When we recently asked a room full of internal medicine residents rotating through the medical intensive care unit (MICU) what “CVVH” stood for, most of them could not answer. A few years ago, as an internal medicine resident, I also did not understand basics of renal replacement therapy (RRT), despite taking care of patients receiving various RRTs almost daily.
RRT indications and modalities may not be the most highly prioritized topics during internal medicine training, perhaps due to their absence on the internal medicine board exam. As a result, trainees may remain unfamiliar with the indications and basic mechanisms of dialysis and may struggle when trying to initiate informed discussions with patients and their families regarding the risks and benefits of initiating RRT.
To understand housestaff’s perceptions of RRT at our institution, we conducted a survey of internal medicine trainees. Of the 44 respondents (an even split across three years of trainees), 85% indicated that they cared for patients on RRT either “daily” or “multiple times per week.” Despite this significant RRT exposure, when asked to rank their understanding of RRT on a 1-5 scale (5 indicating the most thorough understanding), 80% of respondents answered 3 or less. These data suggest that despite caring for patients receiving RRT on a regular basis, our trainees are not receiving optimal education from these encounters. Unfortunately, there seems to be a discrepancy between time spent caring for RRT patients and impactful learning and experience that results from this time.
As nephrology fellows, we should feel responsible for promoting familiarity with RRT modalities and indications among medical students and residents. To achieve this goal, the fellows at our institution have implemented a monthly, 30-minute “RRT Basics” lecture, that is delivered by senior fellows and now part of the official MICU curriculum. The talk begins with a discussion regarding the indications for RRT and then progresses to a brief overview of RRT modalities, covering core concepts of RRT including diffusion, convection, and access options. Attendees are also introduced to dialyzers and RRT machines. Medical students, critical care fellows, and even ICU attendings often attend the lectures in addition to residents.
Early feedback from post-lecture surveys indicate an overwhelmingly positive response to the sessions. Residents seem to view the lectures as a valuable supplement to their clinical experience. They note that they feel more comfortable discussing patients with the nephrology fellows and attendings and that these interactions have become more productive and collegial.
I was inspired to see that this educational offering spurred by a perceived gap in knowledge added value to trainees regarding the fundamental concepts and indications for RRT. Potential positive results from incorporating a formal RRT curriculum into internal medicine training programs include improved professional relationships, better communication, efficient consulting, and ultimately better patient care. I encourage more fellows to become involved in championing educational initiatives.
Gary Romaka, DO (@garyromakable)
2nd year fellow, Icahn School of Medicine at Mount Sinai (@ISMMSKidney)