NEPHROLOGY FELLOWSHIP TRAINING PROGRAM

Curriculum

The current curriculum for nephrology fellowship program was approved in 2013 by the “Portaria n.º 300/2013, de 11 de outubro”.

Since the current general regulation of medical fellowship (“Regulamento do Internato Médico”) establishes an obligatory five-year review of the program, there is an urgent need to proceed to its revision.

Nephrology is a rapidly evolving and expanding subspecialty.

In recent years, some special areas of expertise have become increasingly important for the practice of nephrology, so their increased role or inclusion in the nephrology fellowship program should be considered and discussed, as a better preparedness in those topics could be of major importance for the treatment of nephrology patients.

Some of those areas involve home therapies, conservative and palliative treatments, intensive care nephrology, interventional nephrology, onconephrology, cardionephrology and nephrogenetics.

It could be important to entrench renal transplantation in the fellowship training program, as it is the optimal renal replacement therapy available for nephrology patients and should be encouraged.

But nephrologists’ activity should not be confined solely to renal replacement therapy. It’s important that nephrology becomes increasingly outward-looking and open to working with other medical specialities.

That will diversify, broaden horizons and multiply the space and relevance of nephrology in patient care and investigation.

Additionally, nephrology should be at the forefront of health policy in Portugal, as it has always been. Its role is central to designing and implementing sustainable health systems and must not be neglected.

Evaluation

Rigorous and fair evaluation is one of the fundamental cornerstones of any training program.

In recent years, the need to review the nephrology fellowship program evaluation process has become more and more evident. The use of the obtained grade by public hospitals to contract medical staff in a national public competition has led to an expected inflation of the grades given. This is true for not only the final grades, but also for the annual grades of continuous evaluation.

To address the issue, it could be tempting to simplify the classification system, reducing it to a simple attribution of fit or non-fit. However, it is our perception that this would entail a high risk of reducing the importance given not only to the evaluation, but to the training program as a whole. It is the aim of the Nephrology Board to improve the evaluation process by increasing its credibility and not trying to increase its credibility by simplifying it in such a way as to make it worthless. Several options can be discussed.

First, it is necessary to standardize the way in which continuous evaluation is carried out and make it more objective. The disparity of criteria between nephrology departments and its impact on the final grade is far too large and the trend has been to increase the grades in order not to jeopardize their own fellows.

Regarding the final assessment examination, it is not only necessary to rethink its tests, but also to put the make-up of the jury on the table again. It is our opinion that a jury should be kept to three members, and these should consist of its president and two members appointed by the Nephrology Board, with the exclusion of the Training Supervisor.

Regarding the curricular test, the curriculum must be more objective, limiting the content and number of pages. A logbook to record the procedures that fellows must master, and other items related to the training program should be created.

Nephrology fellowship programs need to focus primarily on clinical nephrology training, so we need to rethink the weight given to each of the curricular components, valuing clinical skills more.

Concerning the practical evaluation, the current model is probably too extensive and out of touch, so the discussion of clinical cases could be an alternative or a complement to the current examination.

Finally, the theoretical knowledge test will be no less important , and will necessarily have to become more objective. The best alternative might be to create a multiple-choice written exam.

At the end of the day, with a common written theoretical test, a more objective and limited curriculum and a simplified practical test, it may be possible to have a more transparent, fair and homogenous evaluation.

Suitability and Formative Capacity Assignment

The visits for suitability and formative capacity assignment, by the Nephrology Board of the Portuguese Medical Association, should take place every three years. After the break caused by the SARS-CoV-2 pandemic, and before resuming the visits, this may be the ideal time to proceed with the revision and discussion of the assignment criteria.

The primary goal of training programs is to provide a high-quality education for future nephrologists. So, it is important to ensure the quality of training of all training programs. Quality standards should be established, implemented and audited.

Many departments rely on fellows to fill gaps in the clinical workforce, and that is not a very righteous model.

We must rethink the number of applications and training programs in order to improve the quality and homogeneity of the fellowship training programs for the next generation of practicing nephrologists.

Training programs should have a local program coordinator to serve as an important liaison among the fellows, the director, the Nephrology Board and others involved. Trainers and training supervisors should have solid theoretical preparation and intrinsic leadership characteristics. Trainers’ training courses should be promoted.

PAVING THE WAY TO NEPHROLOGY FELLOWSHIP TRAINING SUCCESS

Many of us chose nephrology out of a desire to understand the physiology of the kidney, vital to our specialty, and an eagerness to improve the lives of patients affected by kidney disease, which is often a devastating condition. We need to recover our sense of value and commitment to compassionate patient care of the highest quality, while transcribing new knowledge into relevant improvements in health care outcomes for patients with kidney disease. To continue pursuing this goal, it is of unsurpassed importance to understand the emergence of new patient needs and update the training program

accordingly. It is also very important to recapture the vibrancy of nephrology, broadening the scope of our speciality to include new areas of expertise. Nephrologists have been among the leading physicians in championing interdisciplinary, value-based care, and that is a strength of our speciality that should be encouraged.

Designing and standardizing a nephrology fellowship training program is challenging, of paramount importance, and cannot be treated lightly. Additionally, no fellowship training program is adequate without a rigorous and equitable evaluation.

A broad debate of the nephrology fellowship training program, involving all the stakeholders, is mandatory and must be started urgently.