Overview

1. Training time - 2 vs 3 core years

2. Rural vs metropolitan training - ? mandate rural

3. Should acute Tx be mandatory?

4. Is there enough LKDTx exposure?

5. What else do trainees need?

Demographics of trainees

• 2005 Lane et al Nephrology training in Australia: Is there a problem?

• 2003 survey of 42 ATs (37 adult, 5 pediatric)• Average age 31, 17 married or de facto, 7 had children, 65% male, average working hours

42hrs, average of 7.5 years post graduate.

• 2013 ANZSN survey of trainees – 86ATs

• Average age 35, (M 36.1yrs, F 33.9yrs), 45% male, Average working hours 44.4hrs

Lane CA, Holt J, Brown MA. Nephrology training in Australia: is there a problem? Nephrology (Carlton) 2005; 10: 106–8. Beaton J, Krishnasamy R, Toussaint N. et al. Nephrology training in Australia and New Zealand: A survey of outcomes and adequacy. Nephrology 2016

1. Training time

Nephrology 2017; 1: 35-42

• UK– 3 year program post MRCP. Competitive, multi station interview. 3 core years (minimum 3/12 in acute Tx). • Successful completion of the Specialty Certificate Examination (SCE) mandatory

to receive the Certificate of Completion of Training (CCT)

• Ireland combines nephrology with general medicine in a 5 year program.

• USA – 2 year fellowship with 12 months of mandated clinical training, ½ day of ambulatory care clinic per week in second year.

International comparisons

Brown RS. AJKD 2012

Concern that current training involves less clinical care, less complete patient examinations than in the past

“The expansion of information over the years has raised the minimum base of clinical medical knowledge beyond the scope of the time currently allotted to trainees for patient contact”

Should core nephrology training be 36 months?

a. Yes, for all trainees with no exceptions.

b. Yes in general, exceptions may be made for exceptional trainees (? How to determine this) wishing to undertake a higher degree.

c. No, 24 months core is sufficient time to gain clinical competence in nephrology.

d. No – other reason

2. Rural vs metro training sitesBenefits

• Broaden spectrum of exposure to clinical cases – unique issues and patient demographics

• Challenges of working in resource poor health service district/facility cf major tertiary metropolitan center

• Rotation from tertiary metropolitan center may allow peripheral units to have the benefit of an advanced trainee even if they don’t have the work to support a trainee for a 6 or 12 month period.

• Paediatric trainees currently mandated for rural training

Challenges

• Supervision and training

• Access to research projects and resources

• Case mix

• Patient numbers

Rural and interstate/overseas training

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Rural training should be mandatory

Nephrology 2017; 1: 35-42

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Should rural training be mandated in some form?

a. Yes.

b. Yes but it should be included as a rotation from a metropolitan center.

c. No, not mandated but encouraged.

d. No, Trainees should have all training in metropolitan centers.

3. Mandated acute transplant exposure

• Acute renal transplantation is defined as participation in the peri-operative and early outpatient (first three months) care of transplant recipients.

• Acute transplant: participation in 12 acute renal transplants over twoyears of core training (pre-2014 trainees) or 3 years of core training(trainees starting in or after 2014).

• Chronic transplantation: 48 episodes of contact with a minimum of24 different chronic (more than three months post-transplantation) renal transplant recipients.

Acute transplant – survey results

Change to current mandate may lead to:

• Impact on referral for consideration of transplantation

• Potential for disadvantage to more borderline potential recipients

• Reduced experience with/ understanding of process, challenges & complications occurring peri-procedurally that may impact on patient care when recipients return from transplant center

• Impaired relationship building with transplanting nephrologists and transplant center as a source for advice/dialogue about patient care

Should acute transplant exposure (<3/12) continue to be mandated for trainees?

a. Yes, the requirements should remain unchanged.

b. Yes, but mandated LKDTx should also be added to the curriculum requirements.

c. No, get rid of it entirely!

d. No, not mandated but encouraged.

4. Exposure to LKDTx• 44% of trainees in 2010 working in

transplanting hospitals. (Amos et al)• 17 transplanting sites in Australia as of

Dec 2016 • Living donor rates relatively stable

since 2011• Training in Ax of live kidney donors and

potential Tx recipients less adequate than training in acute/chronic DDRTx recipients. (Beaton et al. )

• Training critical to ensure patients receive early access to transplantation with the associated survival benefits and cost benefit to wider community.

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2016 ANZDATA Annual Report, Figure 0.5

Australia 2011-2015

Living and deceased donor transplants

Living donor

Deceased donor

Amos L, Toussaint ND, Phoon RK et al. Increase in nephrology advanced trainee numbers in Australia and associated reduction in clinical exposure over the past decade. Intern. Med. J. 2013; 43: 287–93.

ANZDATA Registry. 39th Report, Chapter 1: Incidence of End Stage Kidney Disease. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. 2017. Available at: http://www.anzdata.org.au

5. What else do trainees think they need?

• Managerial skills

• Research skills

• Enhanced communication and relationship building• Mentorship

• State based trainee representative to report on local issues to the national trainee representative to the SAC.

Reported training adequacy (a) and importance to current practice (b) of managerial skills for ANZ nephrologists awarded Fellowship from 2003-2014 (n=98)

Higher degree

Reported training adequacy (a) and importance to current practice (b) of research skills for ANZ nephrologists awarded Fellowship from 2003-2014 (n=98)

Should management training be incorporated into advanced training?

a. No, this can and should be done in a self directed fashion.

b. No, good idea but there’s no time in the program

c. Yes, in the form of an RACP lecture series/resources aimed at AT’s in all specialities

d. Yes in the form of online tutorials specific for the nephrology workforce

e. Other.

Summary - Proposals

• Continued mandate for acute transplant exposure including LKDTx

• Further consideration of ways to incorporate managerial and research skills into training program

• Mentorship program

• Enhancing communication from local/state based trainee groups to national SAC