Throughout their academic experience and professional careers, nephrologists learn within the context of an educational continuum for internal medicine. This nearly 50-yr continuum includes four distinct phases. First, in U.S. medical schools, the average third-year internal medicine clerkship lasts 10.5 wk. Given the breadth and depth of internal medicine, it is not surprising that the exposure of medical students to career options in nephrology is limited.
During the second phase, internal medicine residency programs are required to include a “clinical experience in each of the subspecialties of internal medicine”; however, “it is not necessary that each resident be assigned to a dedicated rotation in every subspecialty” (1). It is only during the third phase of learning, the 2- to 3-yr nephrology fellowship, an in-depth understanding of the broad discipline of the kidney in health and disease unfolds.
The fourth phase is by far the longest and, historically, least structured part of the continuum. Postgraduate education (PGE) or continuing medical education (CME), terms used interchangeably, refer to the educational experiences of a nephrologist during the rest of their 30- to 40-yr careers. One may estimate approximately 80% of a nephrologist's learning occurs after 9 to 10 yr of formal training. The American Society of Nephrology (ASN) has a responsibility, therefore, to make every aspect of PGE/CME as high quality as possible for all nephrologists, regardless of career focus, level of experience, or learning style.
The centerpiece of the ASN educational enterprise always has been, and always will be, its prestigious national meeting. In the early 1990s, ASN enhanced the learning opportunities for practicing clinicians during what is now called “Renal Week.” The initial step in turning the ASN meeting into Renal Week was the brainchild of former ASN President C. Craig Tisher, MD, who developed “the short courses.”
Robert G. Narins, MD
Enter Robert G. Narins, MD, whose dual focus was to “provide clinicians with an appreciation for science and pathophysiology, and for basic scientists to have an appreciation for clinical nephrology.” During Dr. Narins’ tenure at ASN (1994–2006), PGE/CME blossomed into a remarkable portfolio of educationally valuable, financially viable, and, at times, wildly entertaining offerings.
A well-established educator who had held academic positions at several prestigious institutions, he mentored many students, residents, and fellows. Dr. Narins also served and chaired the American Board of Internal Medicine's (ABIM's) Nephrology Board for many years.
During a 12-yr span, Dr. Narins is credited with creating the Annual Board Review Course and Update (BRCU); adding one- and two-day PGE programs to the beginning of Renal Week, which finally made the ASN annual meeting a weeklong educational experience; replaced the short courses with the more extensive Clinical Nephrology Conferences; devised and chaired the “Renal WeekEnds.” The latter were created so that clinicians who were unable to attend Renal Week could benefit from a distilled version of the meeting. Because the simultaneous nature of Renal Week's presentations limits accessibility to many attractive sessions, those who attend the annual meeting also greatly benefit from subsequent Renal Weekend Reviews.
To complement all of this synchronous learning (learners and teachers are in the same place at the same time), Dr. Narins proposed the creation of the Nephrology Self-Assessment Program (NephSAP). Working with former ASN President Richard J. Glassock, MD, Dr. Narins ensured that NephSAP spanned the spectrum of current nephrology topics in an 18-mo (now 2-yr) cycle and allowed participants to garner 80 points from ABIM for maintenance of certification (MOC). ASN was one of the first specialty societies to develop such a self-assessment program, and NephSAP provides an ideal platform for new initiatives related to ABIM and MOC.
As a result of Dr. Narins, education at ASN is on a dynamic trajectory. With his retirement in 2006, a new model emerged that exemplifies the adage that, when a most capable leader leaves, it takes three people to assume his or her tasks. The model for directing the educational activities of the ASN has evolved from a permanent director who works in the ASN office in Washington, DC, to a distributed model with an ASN Education Director for Renal Week (Mark E. Rosenberg, MD), BRCU (Patrick T. Murray, MD, until August 31, 2008), and Renal WeekEnds (Jerry Yee, MD).
Each of these educational directors remains at his home institution and reports to the ASN Education Committee, which reports to the ASN Council. This structure closely resembles the model of the Editors-in-Chief of ASN′s journals (Journal of the American Society of Nephrology, Clinical Journal of the American Society of Nephrology, and NephSAP), who work from their home institutions and report to the ASN Publications Committee, which reports to the council.
As with the journals, there are a number of advantages to the distributed model in education. Each ASN Education Director brings a unique expertise, understanding, and personality to his specific activity. A firewall now exists between the educational activities and efforts to market the programs for corporate support. The dynamic among the council, the education committee, and the education directors also provides an opportunity to expand the current educational activities and create new ones.
In his role as ASN Education Director for Renal Week, Dr. Rosenberg is responsible for PGE/CME activities at Renal Week as well as other educational activities that take place throughout the year. He chairs the ASN PGE Committee, which is responsible for developing the one- and two-day PGE courses that take place during the first two days of Renal Week; the Clinical Nephrology Conferences, which are held from 10:00 a.m. to 12:00 noon and 2:00 p.m. to 4:00 p.m. during the third, fourth, and fifth days of Renal Week; and the Official Symposia, which occur during breakfasts, lunches, and dinners during the meeting.
Members of the PGE Committee serve staggered 3-yr terms and represent a number of different organizations, content areas, and ASN advisory groups. The committee reviews potential topics in nephrology with an emphasis on integrating current information into the existing knowledge base, rather than presenting the more cutting-edge offerings of the clinical science symposia.
Official Symposia are sponsored by industry, but the PGE Committee determines the topics, content, and speakers. Strengthening this separation between content development and industry sponsorship is a high priority for the committee and the Society. Working together, Dr. Rosenberg, the committee, and the council have developed strict policies governing the relationship between ASN and industry to ensure the educational programs meet the standards set forth by the Accreditation Council for Continuing Medical Education (ACCME).
Moving forward, the PGE Committee is committed to soliciting broad input from ASN members into the planning of Renal Week 2009. The process will involve formal solicitation of program suggestions from the Society's committees and advisory groups as well as from the ASN membership.
A major long-term goal is to repackage the excellent programs presented at Renal Week to allow for multiple opportunities for asynchronous learning. Through its website, ASN can disseminate programs based on Renal Week to ASN members and others. Potential learning tools include webinars, audio files, and streaming video. As with the sessions during Renal Week, asynchronous learning must provide nephrologists CME credits (to maintain state licensure) and MOC points (to complete recertification by ABIM).
Busy nephrologists, with ever-increasing demands on their time, may not have the opportunity to attend Renal Week. Under Dr. Yee's leadership, Renal WeekEnds provide a compendium of the distillates of new advances in six nephrology disciplines: clinical nephrology, bone and mineral metabolism, parenchymal disorders, hypertension, end-stage renal disease, and transplantation. Topic-specific lectures are interspersed between mealtime sessions.
From the beginning, Renal WeekEnds have attracted outstanding faculty recognized as experts in their respective fields. The amount of material distilled by each speaker is staggeringly comprehensive yet even further refined into crystalline pearls of wisdom for those in attendance. Imagine trying to compress Renal Week into one and one-half days! From the audience's standpoint, participating in one Renal WeekEnd earns 12 CME credits. For Nephrology fellows, Renal WeekEnds provide focus for the seemingly unfathomable breadth of material.
In 2008, Renal WeekEnds traversed seven cities across North America and were hosted by local co-chairs. These co-chairs helped coax the best from the speakers, especially with their incisive queries during the postlecture question-and-answer sessions. In this regard, Renal WeekEnds have not changed substantially from their inception under Dr. Narins. The content remains superlative and will always mirror “the best of the best” from ASN Renal Week.
After only a few years, Renal WeekEnds has already fulfilled its mission of providing Renal Week content for those who missed the ASN meeting. Equally important, however, the weekends have become a unique experience for participants, including those who also attended Renal Week. The reality of Renal WeekEnd's time constraints will force Dr. Yee and the co-chairs to incorporate more modern methods of learning in the future.
Moving into the digital era, for example, ASN will continue to refine the organization of Renal WeekEnds, which will increase the interaction among participants, speakers, and co-chairs. As with Renal Week, Renal WeekEnds will provide opportunities for asynchronous learning through downloading digital files from the ASN website. The days of scrawled notes in the syllabus, which are often forgotten, will become a thing of the past.
Annual Board Review Course and Update
The 13th Annual ASN BRCU took place at the Palace Hotel in San Francisco, California in August 2008. Much of the course remains as it was originally conceived by Dr. Narins. As ASN Education Director BRCU, Dr. Murray has continued to make sure that the course provides a superb update in nephrology as well as prepares nephrologists for either the initial certification or MOC examinations by ABIM. After nearly 15 yr, the course now includes a growing number of repeat participants.
Moving forward, ASN remains cognizant of the need to serve those who attend BRCU for an update. The course's faculty makes a point of separating “Pearls for the Boards” from more evolving, and sometimes controversial “Updates.” ASN is increasing the quality of content testing material used during BRCU, both for the purposes of providing updates and preparing for ABIM examinations. Similarly, the answer key to the BRCU practice examination will be expanded to include a detailed discussion of the rationale supporting the correct answers. Taken together, these changes will further strengthen the educational experience in this already successful course.
In parallel with other ASN educational activities, BRCU will begin to develop a presence on the Society's website. This material will allow ASN members to fully leverage the wealth of educational material and expertise available at BRCU. In combination with the talented faculty who give generously of their time to participate in the BRCU, the expanded use of diverse educational resources and digital technology will help to ensure that the course remains a premier offering.
ASN as Portal for MOC
ABIM, ACCME, and the Federation of State Medical Boards (FSMB) are responsible for evaluating the quality of nephrologists during PGE/CME. FSMB licenses physicians to practice in their respective states, districts, or territories in the United States. To remain licensed, physicians must pursue CME throughout their careers. ACCME is responsible for accrediting CME providers, such as ASN and most other specialty societies.
ABIM evaluates general internists and nephrologists after they complete residency and fellowship training, respectively. Since 1990, ABIM has required general internists and nephrologists to renew their certificates through the MOC program every 10 yr. To complete MOC, a nephrologist must maintain an unencumbered medical license through FSMB; demonstrate self-evaluation of medical knowledge; pass “a secure, computer-based, cognitive examination” administered by ABIM; and measure aspects of his or her practice, reflect on these results, and systematically consider how he or she can improve based on this feedback (2).
ASN partners with ABIM to help nephrologists complete part 2 (self-evaluation of medical knowledge) and part 4 (self-evaluation of practice performances) of MOC. To complete part 2, nephrologists have relied on NephSAP. NephSAP “consists of a series of challenging, oriented questions based on case vignettes and a detailed syllabus that reviews recent publications” (2). Taken together, the vignettes and syllabi are intended to assist nephrologists in the self-assessment of their strengths and weaknesses in nephrology.
During a 2-yr period, the editors of NephSAP address 12 distinct topics in nephrology. Eight of these issues, such as chronic kidney disease, are core aspects of nephrology, whereas four issues cover variable topics, such as renal imaging. In 2008, ASN created audio versions of NephSAP. Some nephrologists will use the audio versions to offset “windshield” time between dialysis centers and hospitals.
In addition to NephSAP, part 2 of MOC can also be achieved by attending the 2-d recertification review course that is part of Renal Week. Advances in Internal Medicine and Nephrology are reviewed using ABIM developed update modules. Case vignettes followed by questions are reviewed by an expert panel.
To complete part 4 of MOC, nephrologists use ABIM's Practice Improvement Modules (PIMs). According to ABIM, a PIM is a “web-based evaluation and improvement tool focused in a clinical area relevant to the physicians’ practice, such as diabetes, hypertension, or hospital-based care” (2). PIMs help nephrologists “review their own patient data from medical charts, hospital performance reports, and/or surveys of their patients and peers.” In addition, PIMs help nephrologists “assess their own practice system or their hospital's system through a comprehensive questionnaire that examines the infrastructure needed to support information management, access to care, and patient safety.”
Currently, ABIM offers PIMs in seven areas, including chronic conditions, prevention, and communication. ASN has started to work with ABIM to develop PIMs in areas of greatest interest to nephrologists, such as chronic kidney disease and dialysis. Ideally, the directors of nephrology fellowship training programs will also consider using nephrology-relevant PIMs as teaching and evaluation tools for fellows.
ASN is committed to helping ABIM develop PIMs (and related tools) for nephrologists, producing self-assessment material for nephrologists (particularly to help nephrologists meet the requirements of part 2 of MOC), and providing nephrologists credit for CME through the Society's educational activities. In addition, ASN will continue to ensure the organizations responsible for evaluating the quality of PGE/CME (ABIM, ACCME, and FSMB) will think creatively about assessment tools that work in the real world for every nephrologist.
Challenges and Opportunities
The ASN educational enterprise currently includes synchronous (Renal Week, Renal WeekEnds, and BRCU) and asynchronous (NephSAP) learning opportunities for the Society's members. In addition to continuing to improve these activities, ASN is adding asynchronous learning to Renal Week, Renal WeekEnds, and BRCU; create audio versions of NephSAP; and develop as many mechanisms as possible for helping nephrologists earn CME credits and MOC points.
At the same time, ASN must develop a strategy for overcoming, and benefiting from, several challenges. For example, ASN must produce educational material that is relevant for all types of nephrologists, such as those interested in acute kidney injury, dialysis, or transplantation. Each subspecialty within nephrology is well represented by organizations that only attempt to meet the needs of that constituency. As a result, ASN′s educational offerings must appeal to general nephrologists and every subspecialist within nephrology as well as link the renal community from an educational perspective.
In addition to this balkanization within nephrology, ASN must address efforts to centralize, and possibly homogenize, the first three phases of the educational continuum (medical school, internal medicine residency, and nephrology fellowship). Today's physicians-in-training must master the six core competencies required by the Accreditation Council for Graduate Medical Education (which accredits residency and fellowship programs) and the American Board of Medical Specialties (of which, ABIM is a member). Four of these competencies (medical knowledge, patient care, professionalism, and interpersonal skills and communications) are familiar to previous generations of physicians. However, the competencies of systems-based practice and practice-based learning and improvement are relatively new. Despite these new expectations of physicians-in-training, the Accreditation Council for Graduate Medical Education in 2003 limited the work week for residents and fellows to 80 h.
The fourth phase of the educational continuum (PGE/CME), therefore, will have greater responsibility for helping to ensure the competence of nephrologists. This accountability, in turn, means that ASN must use every mechanism to provide high-quality educational opportunities to every type of nephrologist. ASN must balance this responsibility to help all nephrologists meet the expectations for CME and MOC through their careers with the need to appeal educationally to the myriad subspecialists within nephrology.
ASN offers premiere educational programs, cutting-edge science, and multiple avenues for nephrologists to learn. Nephrologists and other providers who wish to learn about the kidney will always know that ASN provides content that best suits each individual's needs, learning style, and schedule. Through this vision, which was first articulated by Dr. Narins nearly 20 yr ago, ASN will help nephrologists become life-long learners.