INTRODUCTION: EDITOR¿S NOTE
The 1st Meeting of Tutors in Nephrology, organised by the National Nephrology Commission and the Spanish Society of Nephrology, was held on October 7, 2007 in the Ministry of Health and Consumer Affairs in Madrid. Dr. Francisco Ortega Suárez, Chairman of the National Commission of the Specialty of Nephrology, and Dr. Ángel Luis Martín de Francisco Hernández, Chairman of the Spanish Society of Nephrology (SEN), welcomed attendants and explained the rationale and objectives of the meeting. Mr. Miguel Javier Rodríguez Gómez, Underdirector of Professional Planning of the Ministry of Health, subsequently analysed the status of specialised medical training in Spain and the legal and analysis actions being taken by the Ministry. In the afternoon, Dr. Fernando Caballero Martínez, Teaching and Research Coordinator in Madrid health area 6 and member of the National Commission of the Specialty of Family and Community Medicine, spoke about evaluation systems and the pilot experiences on this subject being conducted by this society.
However, the central part of the meeting was a wide discussion and exchange of views of attendants about two previously conducted surveys:
1. A survey to nephrology tutors about the training status in the specialty.
2. A survey to nephrology residents. Since the number of responses to the initial survey was insufficient and obviously not representative, a decision was taken to prolong the recruitment period until the end of February 2008.
The complete results of both surveys may be found in the SEN web site (http://www.senefro.org/). A summary of the most significant results and the multiple contributions by nephrology tutors during the meeting is given below.
The analysis done is limited to these sources and is therefore not intended to be comprehensive or to answer the multiple problems faced. We do think however that this is an excellent material for supporting a collective reflection on the subject that cannot be postponed. We invite you all to such a reflection, and offer our Letters to the Editor section for all of you ho want to make a public contribution to the analysis of the subject or any of its aspects.
MAIN RESULTS OF THE SURVEY TO NEPHROLOGY TUTORS (OCTOBER 2007) SUMMARY AND COMMENTS
Response rate
Forty-five of the 70 tutors consulted (64.3%) answered the survey. The lack of response could be due in a number of cases to technical problems (absence of tutor when survey was made, change in mail address, disagreement with survey methodology, and so on). In other cases, however, tutors may not have been motivated by the topic examined.
Data on nephrology tutors (figs. 1 and 2)
Our survey showed that most nephrology tutors (80%) were associated physicians, males (60%), and with a wide professional experience (more than 10 years of practice in 77% of cases). They also had been carrying out this function for a long time (49% for more than 5 years, and 18% for more than 10 years).
Data on the teaching unit (figs. 3, 4, and 5)
Teaching units of nephrology were characterised by their heterogeneity both as regarded the population seen in their health area (area size may have an influence on the variety of renal diseases that may be seen during a residency period) and the number of nephrologists forming them.
A high number of tutors reported (in survey remarks or interventions at the meeting) a precarious care situation in many nephrology teaching units (severe staff shortage, duties, facilities, etc.) that represents one of the most important negative factors influencing teaching activity.
All units have a hospital haemodialysis unit, and there are associated outpatient units in more than 80% of cases. CAPD is available in 93% of responding units, but the number of patients cared for in almost half of them (43%) is small (less than 25 in 43% of cases). A little over half of teaching units (55%) have a kidney transplant programme with a variable number of transplants per year, but all other units (45%) lack this activity.
Renal biopsies are performed by physicians not belonging to the nephrology department in 40% of teaching units, and indication and control of extracorporeal clearance techniques depend on a nephrologist in only 44% of cases.
Finally, approximately one half of tutors surveyed reported the existence of an accredited experimental research unit dependent from or related to the department.
Several tutors underlined that in many teaching units there is a training imbalance in favour of haemodialysis techniques and a deficit in peritoneal dialysis, kidney transplantation, and clinical nephrology. This observation was confirmed by the survey to residents, as will be seen later.
Data on organisation of the teaching unit (figs. 6, 7, and 8)
Responses show a significant variability in this regard. Most departments (62%) are accredited to train a single resident per year, but the maximum training capacity is often not fulfilled.
Questions as to whether a teaching protocol exists specifying the teaching organisation of the department or formal meetings are held to address topics related to teaching activity were answered negatively in 23% and 31% of cases respectively, or were not answered.
There is a wide variability in the departments through which rotations are made during R1, and in the time of specific rotations thereafter (R2-R4). Many centres (62%) have agreements with other units to complete training of their residents (kidney transplant, CAPD, clinical nephrology, special haemodialysis techniques, paediatric nephrology, pathology, etc.) and an optional rotation period outside the department (66%).
With regard to teaching sessions, most tutors surveyed state that clinical nephrology sessions are organised, but with a highly variable frequency, less than once per week (every two weeks or every month, or no answer was given) according to 36% of responses. In 27% of departments there are no nephropathological sessions, and 36% have no programme stating the subject matters or seminars planned for the staff.
In order to reduce this heterogeneity in teaching organisation, several tutors thought that it would be useful that the SEN and NNC prepared a consensus teaching protocol, or that the NNC document on teaching requirements for the specialty contained more specific and updated information.
Others think that the NNC should play a much more active role to ensure that teaching requirements are met at teaching units and that these (particularly the smallest ones) are protected from the demands of the care system that are against these teaching needs.
Data on the tutor function (fig. 9)
Most units (89%) have a single tutor, but 11% have two or more tutors. Most tutors have no specific time for discharging their function (80%) or think the time they have is not sufficient (an additional 16%).
Only 18% report that they have previously scheduled formal meetings with residents to evaluate target achievement and to detect any problems. Procedures to record resident activity are also widely variable, but most tutors use some such recording procedure. Approximately half the tutors use some type of resident book (51%), while the rest (48%) ask residents to write an annual activity report.
Tutor contributions and remarks in the survey appear to show a wide agreement in that social recognition of the tutor position by the department, hospital and scientific society is needed. According to many, this does not only involve formal recognition of their work with provision of the necessary means (authority, time, and resources), but also a financial compensation.
Considerations about the efficacy of the teaching system (fig. 10)
Despite the above considerations, almost all tutors think that the system provides a good (64%) or excellent (15%) training as clinical nephrologists, and only one (2%) rates training as poor. However, many tutors (44%) think that the current average training level is lower that 10 years ago (while a similar proportion, 42%, think it is better).
When tutors saying that current training is worse are asked what could be the reasons for such impairment, 35% state that current residents are less motivated for training, and 24% that this also occurs among staff physicians.
When asked about the current resident evaluation system, more than half the tutors said they disagreed with it.
Several tutors pointed to the need for standardising resident training in nephrology throughout Spain to achieve minimum requirements in all teaching units. They think that an efficient system for accreditation, and particularly re-accreditation, of these units is one of the crucial elements for ensuring a minimum quality in teaching to intern and resident physicians. However, this requires a State and autonomic political, organisational, and resource framework that is not easy to achieve.
Considerations about training in research
In this regard, half the tutors state that collaboration of residents with research work at the unit, but without developing their own research lines (which is considered desirable by only 9%), is a defined objective.
More than half the tutors consider a defined objective that all residents submit papers to congresses of the specialty, and most of them do. Twenty-two percent say that one objective is that residents collaborate during their residency in some publication of the department, and 38% state they do it, though this is not an obligate objective.
Other issues
Tutor opinion about two issues of great interest was explored:
1. Duration of training: a little over half the tutors (58%) felt that it would be convenient to increase to 5 years the specialisation period, but a significant proportion (42%) thought that the current 4-year model should be maintained.
2. Examination at the end of the specialty. Only 11% of tutors think that an examination should not be done in any case, 40% think that it should be mandatory, and 33,5% that it should only be done voluntarily.
SUMMARY OF THE SATISFACTION SURVEY TO RESIDENTS
Response rate
Only surveys to residents of the final years (3 and 4), accounting for 36% and 64% respectively of the sample, have been considered. A high response rate was obtained, which supports the consistency and validity of results.
Rotations
As shown by the tutor survey, there is a certain dispersion in the type of rotation, particularly in rotations outside the department. However, the NNC requirements are met in all cases.
Achievement of teaching objectives (fig. 11)
Among surveyed residents, 51.5% report good or very good achievement of training objectives in rotations outside nephrology, and 8% a poor achievement.
With regard to organisation of rotations within the department, 47.5% say that teaching is well or perfectly regulated, while 16% think that teaching is poorly or not regulated. Ninety-two percent of residents state that the rate of acquisition of care responsibilities is good or very good, and only 2% report it as poor or very poor. Forty-two percent rate the work supervision level as good or very good, and 27% as poor or very poor.
When asked whether a regulated training programme exists, 21.8% say that no programme exists or there is a low compliance with the existing programme (an additional 13.9%). When available, the programme is good or very good in 44.5% of cases.
Learning of procedures (fig. 12)
Thirty seven percent of residents say that they have not performed any renal biopsy during their residency, and 44% have performed 5 or more biopsies.
Sixty percent say that they have never inserted a peritoneal catheter, while 17% have inserted catheters more than 5 times.
They all have inserted some time a Shaldon catheter, 89% more than 5 times.
Kidney transplant. Eighteen percent report no experience in kidney transplant, and an additional 5% a very inadequate experience (23%). Training in this area was rated as good or very good by 52.6% of residents.
Peritoneal dialysis. Twenty-four percent report no experience in peritoneal dialysis, and an additional 10 % a very inadequate experience (34 %). Training in this procedure was rated as good or very good by 34.7 % of residents.
Training sessions (fig. 13)
Session frequency in the department is, according to the resident survey, one or more weekly sessions in 50% of cases, while sessions are less frequent (every two weeks, every month) in 44% of cases. According to the survey, no sessions are performed in 6% of departments accredited for teaching. Session quality is rates as good or very good in 55.4% of cases, and as poor or very poor in 11% of cases. No pathological sessions are organised in 25% of teaching units.
Other aspects
With regard to specialty duties, 94% of residents say that these always require them to stay at the department, while 1% only require residents to be easy to get hold of, and in 5% of cases either of these modalities may be used.
Interestingly, there were few answers to the question attempting to analyse the scientific activities of residents, with proportions of DK/DAresponses ranging from 64% and 67%.
When residents where asked to make an overall assessment of teaching at their departments, 36.5% rated it as good or very good, 38.6% as neither good nor bad, and 14% as bad or very bad (fig. 14).
CONCLUSIONS
These conclusions, drawn from the analyses of surveys and opinions given by tutors, were outlined at the end of the tutor meeting held in October 2007 and were also discussed at the NNC meeting in April 2008.
However, this is only a preliminary analysis of a subject of vital importance for Spanish nephrologists that is enormously complex. A more in-depth analysis would require the contribution of many other opinions and collaboration by all parties. While there are multiple significant issues, the most important points to consider include:
1. Nephrology teaching units have widely varying staff and material resources.
¿ This would be no problem, but an indication of a varied offer, if the existing facilities and staff would guarantee a specialised training of quality. However, an inadequate number of nephrologists to cover care needs sometimes becomes the main obstacle for adequate teaching progress of residents. All nephrology teaching units should have available adequate human resources for covering not only care needs, but also resident teaching requirements, in accordance with the commitment they undertake when they are accredited for teaching.
¿ Residents should be part of the care mechanism, because patient care is the key element that defines training of healthcare specialists. However, in order to ensure system efficiency and patient protection, adequate supervision of resident work and gradual assumption of responsibilities should be ensured.
2 Nephrology teaching units also have widely variable levels of organisation and achievement of teaching objectives.
¿ According to the most recent legal provisions (Royal Decree 183/2008, of February 8), all teaching departments or units should have a teaching guide or protocol detailing the characteristics and the teaching and care staff and organisation of the department. Commitments to intern and resident training involved in this document should be respected at all times.
¿ All units must have available a procedure to record resident activity (a training resident book or annual activity report by the resident) and the annual evaluations conducted. All these documents will be requested by the NNC in the event of any intervention related to teaching at the department for which it is consulted.
¿ The NNC, in concert with the SEN, will consider preparation of a document to record resident activities providing uniform criteria for such activities at the different nephrology teaching units.
¿ Teaching unit accreditation and re-accreditation activities would have a decisive role for ensuring a minimum quality of specialised training. However, legal actions in this regard are still pending and should be taken by different authorities (at state, regional, and local levels).
3. Tutorship is currently a voluntary and poorly recognised work.
¿ New legal provisions address this issue, advocating formal recognition of the work of tutors and the time they should devote to it either by allowing tutors to devote part of their care time to teaching management or using other formulas to pay them for such time.
¿ An action for supporting the function of tutors is promotion of exchange of problems and solutions between them and the NNC by promoting meetings and training courses.
4. Dependence of specialist training activities from several regulatory authorities (central or autonomic governments, centres, etc.) and lack of definition of many issues represent barriers for training activities.
¿ However, in addition to its legal possibilities, the NNC will state its opinion and will attempt to use its moral authority to influence health authorities in any conflicts that may arise.
5. The surveys and the tutor meeting demonstrate that there are other deep and complex problems, such as reconsideration of training duration, whether or not a final examination is needed at the end of residency, and what actions could be taken to make the specialty more attractive to students, in the face of the continued decrease in the rank number of the specialty in the preferences of physicians entering the intern and resident training system.
6. The status of specialist training in Spain is of vital importance for the future of our specialty, and a reflection is required from all of us, and particularly our institutions, to find ways to improve it.
