- Email: [email protected]
Nephrology Education and Continuing Education in Resource-Limited Settings
Nephrology Education and Continuing Education in Resource-Limited Settings Tushar J. Vachharajani, MD, FASN,* Aminu K. Bello, MD, PhD, FASN,† Rhys Evans, MD,‡ Gavin Dreyer, MD,§ and Quentin Eichbaum, MD, PhD, FCAP|| Summary: Nephrology training programs in high-income countries have transitioned from an apprenticeship model to a well-structured, resource-driven model that supports continual professional development. In contrast, in low- and middle-income countries, medical training and in particular nephrology training has lagged behind owing to resource limitations. Some of the challenges to adequately provide training to health care professionals in low- and middle-income countries include shortage of teaching faculty, difficulty in developing curricula to meet regional needs, and a lack of resources to provide competency-based medical education. The task of providing nephrology education becomes even harder when it comes to training physicians and health care workers to manage patients with complex kidney diseases without adequate infrastructure, government support, or proper health care policies. The nephrology training curriculum for lowand middle-income countries ideally should focus on local and regional needs, implementation of preventive measures for risk modification, education of a multidisciplinary health care workforce, raising general awareness of kidney disease, and optimizing the use of available resources. The ultimate goal being overall better recognition and care for patients with kidney disease. Semin Nephrol 37:224-233 Published by Elsevier Inc. Keywords: Nephrology education, training, low middle income countries, health care, chronic kidney disease
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he World Health Organization reports noncommunicable diseases (NCDs) as a major cause of mortality worldwide with almost three quarters of NCD-related deaths occurring in low- and middleincome countries.1 Almost 38 million deaths occur each year worldwide from the four main NCDs— cardiovascular diseases, cancer, respiratory diseases, and diabetes, although the direct and indirect contributions of kidney disease to global deaths are unknown. NCDs have common modifiable risk factors such as unhealthy diet, insufficient physical activity, overweight/obesity, and harmful use of tobacco and alcohol. Chronic kidney disease, hypertension, diabetes, and cardiovascular disease are often the end result of these uncontrolled risk factors, leading to high health care costs and a negative impact on productivity and growth. A well-trained and educated health
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Division of Nephrology, W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina. † Division of Nephrology and Immunology, University of Alberta, Edmonton, Canada. ‡ Malawi College of Medicine, Chichiri, Blantyre, Malawi. § Department of Nephrology, Barts Health NHS Trust, London, United Kingdom. || Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN. Financial disclosure and conflict of interest statements: none. Address reprint requests to: Tushar Vachharajani, MD, FASN, Division of Nephrology, W. G (Bill) Hefner VA Medical Center, 1601 Brenner Ave, Salisbury, NC 28144. E-mail: [email protected] 0270-9295/ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.semnephrol.2017.02.003
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workforce led by a nephrologist can offer a costeffective intervention to implement preventive measures to modify risk factors, increase awareness about other renal disorders such as acute kidney injury, increase awareness of the augmentation of cardiovascular risk with kidney disease, and implement timely holistic therapeutic interventions to improve overall patient care.1 In developed countries, nephrology training is structured and supported by resources, allowing trainees to maintain their knowledge and skills through continuing medical education programs. Moreover, the availability and affordability of therapeutic options offer an encouraging environment to constantly improve patient care and conduct scientific research. The limited educational resources in low- and middle-income countries (LMICs), along with expensive and unavailable treatment options for kidney diseases, create a challenging situation in designing a meaningful nephrology training curriculum. The current review outlines the conflicts faced by educational experts in planning and implementing a nephrology training curriculum for resourcelimited countries.
KEY CONCEPTS IN MEDICAL EDUCATION IN GLOBAL HEALTH After the momentous changes that Abraham Flexner introduced into the North American medical curriculum in 1910, medical education as a discipline remained static for decades under the domineering influence of basic science. Over the past 2 or 3 decades, however, medical education (and more broadly health professional Seminars in Nephrology, Vol 37, No 3, May 2017, pp 224–233
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education) has grown rapidly into a fully fledged discipline within medical schools with its own philosophical framework of constructivism, specific research methodologies, and standardized education degrees. In contrast, the pace of change in medical education in LMICs, especially in resource-limited settings (RLS), has been slow, mostly because of their resource constraints. In many LMICs, the legacy of colonialism also may have played a role since Western medicine was introduced into these countries during colonialist periods.2 An unpredicted concomitant trend in health professional education in recent decades has been the rapid development of global health as a discipline. This trend has resulted in the explosive growth of health professional schools of associated global health education programs. Applied across geographic and cultural boundaries, this discipline has brought to the center of education debates about the significance of contexts. We now have a better understanding that medicine and allied health professions are practiced and taught in specific contexts, and that these contexts can differ significantly from one another. Although scientific and epidemiologic contexts are apprehended more readily, only more recently are the nuances of social contexts and determinants being recognized and incorporated into health professional education. With regard to global cultural contexts, a major divide to consider is the difference between the cultures of individualist and collectivist settings.3 Individualist cultures, which include the high-income countries of North America and Europe, generally are competitive and value individual autonomy. Collectivist cultures include many LMICs in Africa, South America, and Asia, and generally are oriented toward group (collective) settings and participation. The learning environments of individualist and collectivist settings are different in many respects.3–5 Individualist cultures view learning as something the individual can acquire and apply across contexts and for which the individual can be assessed. Collectivist cultures, on the other hand, view learning as mostly situated in dynamic social contexts and cannot be transferred readily to other contexts. A major development in medical education in recent decades in high-income countries has been the shift toward competency-based medical education (CBME). Competencies are intended to make explicit for learners what they specifically need to know in domains of knowledge, skills and attitudes of their health professional practice. Health institutions and organizations have a tendency to develop their own lists of competency domains and competencies to match their values and training needs. The degree to which such competencies are linked appropriately to specific contexts is currently a topic of debate among educators.4,5 With the advent of the internet in the early 1990s, numerous teaching methodologies emerged when
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electronic platforms became more accessible and userfriendly. Traditional modes of teaching in lecture halls are yielding to novel teaching methods such as teambased learning and flipped classrooms, and to selfdirected learning, which incorporates social media and electronic devices such as mobile devices and tablets and telemedicine.6 In RLS, the utilization of these methods may depend on a host of factors ranging from available local resources such as internet bandwidth, faculty availability, and the willingness of institutional leadership, faculty, and students to adopt these approaches.
CHALLENGES AND OPPORTUNITIES OF HEALTH PROFESSIONAL EDUCATION IN RESOURCE-LIMITED SETTINGS The main challenges facing health professional education in RLS derive mostly from such resource constraints (Fig. 1). Some of the ways these constraints manifest themselves in health professional education are as follows. Teaching Faculty Shortages A general problem in RLS is the shortage of trained health professionals to provide teaching and clinical training at both undergraduate and postgraduate levels. Continuing medical education for practicing professionals is usually not available. Given the lack of postgraduate clinical training programs in LMICs, it may be important for clinical specialties such as nephrology to provide some clinical foundation during undergraduate medical education that may be applicable after graduation. Shortages in teaching faculty have the consequence that employed faculty often are stretched thin with heavy teaching loads, and also may be required to teach subjects in which they have little expertise. At a postgraduate level, salaries of academic faculty may be significantly lower than for colleagues in private practice, resulting in physicians leaving academia or holding dual appointments to supplement salaries while retaining academic privileges. These circumstances challenge the quality of health professional education in RLS. Curriculum Development Given their resource limitations, new health professional schools in RLS often face the unsettling dilemma on how to develop their teaching curricula. The seminal Lancet document of 2010 on "Health Professionals for a New Century" by Frenk et al,7 stresses that curricula should be derived and linked to local health contexts and health needs. With severe faculty shortages, schools in RLS may believe they are constrained in developing their curricula based on local contexts and health needs, and may instead be tempted to take
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Figure 1. Challenges to medical education in RLS. CME, continuing medical education.
easier routes toward curriculum development such as purchasing ready-made curricula, implementing available traditional curricula, or developing hybrid models of traditional and context-specific curricula. The latter solutions generally are problematic in the long term and are difficult to change once accepted in a school. Competency-Based Medical Education The Lancet 2010 document also recommended that education of health professionals preferably should be competency-based rather than deriving solely from set curricula.7 The trend toward CBME has grown steadily in high-income countries over the past 2 decades, but is still in its infancy in LMICs. A major reason for this shortcoming in LMICs pertains to the lack of resources required for adequate assessment of competencies that are outcomes-based and generally require assessment by direct observation.8,9 RLS lack faculty who can perform such intensive assessment of competencies adequately. Moreover, even in high-income countries the extent to which competencies are linked appropriately to specific contexts settings has been questioned.4,10 Moreover, some competencies arise in dynamic social situations and cannot be assessed by traditional observations and psychometric methods. Instead, they require alternate modes of assessment but they often erroneously are subject to the same traditional methods of assessment. Assessment and Accreditation The adequacy of assessment in health professional schools generally is linked to a school’s accreditation because such assessment significantly determines the quality of a school’s graduates. Appropriate assessment and accreditation both require substantial resources in
terms of institutional capacity and expertise. Assessment in RLS often is overly summative, without providing adequate formative feedback opportunities for students and trainees to master learning materials. Appropriate assessment also requires expertise in quality-assured psychometric methodologies that may be lacking in RLS. In high-income countries, the trend toward self-directed assessment requires ongoing iterative feedback that may be too resource-intensive for RLS. This approach of self-directed assessment, however, may be more consonant with collectivist cultures of LMICs, as such, assessment requires input from other group members and coworkers to ensure validity. Accreditation requires interinstitutional consensus in developing standards that are imposed fairly and equitably on schools. To be impartial, accreditation bodies should be independent bodies with officials having no conflicts of interests with health institutions being accredited. The development of such organization requires a sustainable level of funding that may be lacking in RLS, although such bodies slowly are being established initially as collaborative efforts, such as networks of external examiners between schools. Some schools have tried to circumvent their inadequate assessment and accreditation methods by importing question banks for assessment from high-income countries such as those of the CBME, and some have purchased the services of high-income countries’ accreditation bodies. However, because these assessment and accreditation systems were developed for high-income countries, they may be inappropriate for the LMICs, a practice we therefore do not recommend. Admissions Policies Who gets admitted to medical school (and other health professional schools) deserves moral attention in RLS
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given the disparities in education that places applicants from rural areas at a disadvantage. Equitable policies should be in place to ensure that applicants from wealthy urban families, who have had access to the best secondary education, are not given undue advantage compared with rural applicants, especially because some studies have indicated that the latter applicants are more likely to return to practice in these underserved rural areas.11,12
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to new African medical schools by developing southto-south and south-north collaborative partnerships that have resulted in several innovations in curricula development, assessment, and accreditation approaches and admissions policies.14–17 The task ahead for health professional education in RLS therefore at once is fraught with daunting challenges but also laced with exciting opportunities. How nephrology education will meet these challenges and opportunities is a topic we now discuss.
Scientific Research Although few health professional educators would disagree about the importance of promoting scientific research in RLS, in question are the opportunity costs and the readiness of RLS for large-scale promotion of such research. Funding bodies in high-income countries such as the National Institutes of Health in the United States and the Wellcome Trust in the United Kingdom, recently have awarded millions of dollars for establishing scientific research in RLS, particularly in the LMICs of Africa. Although well intentioned, we believe such intensive promotion of basic science research and training in these settings is premature. Not only are the infrastructures insufficient to absorb large numbers of graduating research scientists (with the likely unintended consequence of them leaving for employment in high-income countries), but such funding often comes at the cost of siphoning funds and resources away from much-needed capacity-building health care delivery projects that now are needed more urgently. Although scientific research certainly should be promoted in RLS settings, it should be performed judiciously alongside development of adequate employment opportunities. Jumpstarting scientific research may to some extent work by increasing the numbers of trained scientists, but it also may backfire without appropriate employment infrastructures. As suggested, this heavy emphasis in RLS in Africa may have colonialist roots. Farmer et al13 point out that we have continued to overemphasize the molecular determinants of medicine at the expense of teaching social determinates, resulting in a tendency to ask only biological questions about what are in fact biosocial phenomena. Although these challenges are daunting, they also contain within them the seeds of opportunities. In particular, new health professional schools, unencumbered by tradition and inflexible leadership, may be more agile at leapfrogging and implementing innovations.5 By some estimates more than a hundred new medical schools will be opening in Africa over the next decade, a projection that presents enormous scope for innovative opportunities.14–16 The Consortium of New Sub-Saharan Medical Schools is a consortium catering
CHALLENGES WITH DEVELOPING NEPHROLOGY TRAINING CURRICULUM IN RESOURCE-LIMITED SETTINGS The key purpose of a nephrology education program is to provide the requisite skills and expertise for effective care delivery for patients with kidney diseases.18,19 The spectrum of kidney disease would entail acute kidney injury (AKI), chronic kidney disease (CKD), as well as renal replacement therapy (RRT). A trainee in nephrology should receive training for the identification and prevention of both AKI and CKD, management of disease, and reducing the risk of progression to kidney failure requiring RRT. Although this is a key concept underpinning nephrology education based on global standards, it does not take into consideration regions with varying needs such as the LMIC with limited resources and/or capacity to provide kidney care in its full spectrum. The requisite competence and training required for delivery of kidney care thus would differ across regions based on their needs and circumstances,20–22 without deviation from the global standard and expectations of training or deliverables. In this line, as discussed earlier, there have been concerted efforts to transform medical education including nephrology training to be competency-based, essentially to train and educate based on local needs and circumstances.17,22,23 Nephrology education in resource-poor settings still is based predominantly on Western curriculum and is fraught with a number of problems with content, needs assessment and evaluation, instructional methods and delivery models, limited or lack of integration of important training attributes (professionalism, scholarship, advocacy, and so forth), and a lack of rigorous assessment methodology19,21,24 (Table 1). Thus, there is a mismatch between training objectives and content and the local needs and circumstances. Nephrology training programs in resource-poor settings emphasize training in RRT technology (modern dialysis techniques and transplantation), which is of less relevance and importance considering the limited capacity of the health system to deliver care in these domains, which
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Table 1. Key Thematic Problems With the Current Training Structure and Curricula in Developing Countries Theme/Domain
Key Issues
Potential Solutions
Curriculum content
Emphasis on factual information, memory, and recall (core knowledge content)
Problem-based learning adapted to local circumstances with a background of thorough understanding and disease physiology and pathophysiology Grounding of understanding of disease within the patient’s life to best be able to develop successful management strategies despite the potential absence of sophisticated technology Structure and organization are more the product of Reliable local epidemiology of disease incidence Absence of needs and prevalence as well as understanding of established tradition than of evidence and not in assessment and barriers to delivery/uptake of good kidney care keeping with health system changes and evaluation demand Production of nephrologists not commensurate with the population growth and needs Instructional model Didactic; learning is still opportunistic Introduce and emphasize problem-based learning with close monitoring and mentorship of learners Formal teaching as well as learning by example, Professionalism, collaboration, advocacy, Other core areas of faculty development, interdisciplinary teaching, managerial skills, and scholarship (critical competencies not and other teaching rounds (eg, grand rounds, appraisal skills) are not formally taught included mortality and morbidity reviews, and so forth) Lack of training in critical Other competency domains (eg, scholarship) not Structured training in critical appraisals including journal clubs, requirements to publish (eg, case formalized and developed—low knowledge appraisals and literature reports/series) during training generation and data gathering to inform EBM review methodology practice Assessments (tests and Summative rather than formative (not wellMini-CEX, OSCE, 360-degree feedback in addition examinations) evaluated assessment process) to clinical knowledge, maybe even reflective writing Abbreviations: EBM, evidence-based medicine; Mini-CEX, mini clinical evaluation exercise; OSCE, objective structured clinical examination. Adapted with permission from Okel et al.24
may be critical for some, but not all, settings to have a well-trained workforce to deliver RRT care. However, it is universally important to have people trained in the identification and management of AKI and CKD. For example, the key long-term strategies for optimal CKD care (control of blood pressure and other modifiable risk factors), to delay progression of CKD to end-stage renal disease and reduce adverse events, can be delivered competently by a trained workforce at the primary care level with minimal supervision by a nephrologist. Health Care Workforce Training Training in preventive medicine therefore should be prioritized and extended beyond physician workforce training to other health care workers such as community health workers, community health assistants, pharmacists, and nurses. The health care workforce can be provided with relevant knowledge and skills to identify and treat AKI and CKD in the communityand hospital-based settings (Table 2). However, the best strategy to structure and align nephrology education to meet local needs and circumstances within
the existing competency framework still is unknown. Because countries across the world have unique societal needs and capabilities to deliver kidney care, developing a training curriculum as a one-cap-fits-all principle is challenging. The World Health Organization Global Health Workforce Alliance Framework for health workforce planning could be leveraged to guide the restructuring of nephrology education to meet the unique characteristics of various countries and communities.25 The framework is not specific to nephrology workforce training but is broadly applicable for all countries, specialties, and for all cadre of the health workforce including physicians, nonphysicians groups (nurses, community health officers, pharmacists, and other health professionals), and delivery sectors (public, private, nongovernmental organizations/faith-based). The framework seeks to engage the entire health care workforce for equitable and quality care delivery in their own communities with an emphasis on developing policies to define the scope of practice, accountability and management, continuing education, and professional development, and to integrate public and private sector perspectives.25 A trained nephrologist provides leadership
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Table 2. Key Areas of Focus for Nephrology Training in Low-Resource Settings Disease Training Curriculum Domain AKI
CKD
Delivery Platforms
Target Workforce
Simple education tools (paper charts, pathways, algorithms) Media: podcasts, YouTube videos, messaging Clinical management including RRT Clinical pathways and algorithms (slow dialysis therapies where Lectures and grand available) rounds Local clinical champions Simple education tools Awareness, risk factors, and (paper charts, identification of CKD and pathways, algorithms) prevention Media: podcasts, YouTube videos, messaging Clinical management including RRT Clinical pathways and algorithms (and kidney transplantation where available) Lectures and grand rounds Conservative care Local clinical champions Awareness, risk factors, and identification of AKI in the communities and prevention
Nonphysician personnel (eg, community nurses, pharmacists, health and/or health extension workers, and so forth) working in community-based health outlets and clinics Trained secondary school leaders and community leaders
Physicians Nonphysician personnel (eg, community nurses, pharmacists, health and/or health extension workers, and so forth) working in community-based health outlets and clinics Trained secondary school leaders and community leaders
Physicians
Abbreviations: HD, hemodialysis; PD, peritoneal dialysis.
through a broad knowledge base and requisite competencies, scholarship, and skills in critical appraisal for generating new knowledge and appraising evidence26 (Table 3). The restructuring of nephrology training across all settings also would focus on other aspects of training such as professionalism, collaboration, advocacy, management, and skills in critical appraisal, research, and scholarship26,27 (Table 3). The engagement of relevant stakeholders such as political leaders and policy makers, support from international and regional professional organizations (such as the International Society of Nephrology [ISN]), and institutional collaborations between high-income countries and LMICs is critical for the successful implementation of this training model.28
Medical and Nursing School Curriculum The emphasis on preventive care and risk modification is pivotal in reducing health care costs in LMICs, especially with kidney disease. The curriculum for medical and nursing students can be modified to highlight the importance of adequate blood pressure control, use of renin-angiotensin blockers, reduction of proteinuria, lifestyle modification (weight loss, stop tobacco use, physical activity), tight blood glucose control, and adequate lipid control to prevent or stabilize chronic kidney disease. The goal should be to build a new generation of primary care physicians and health care workers who are tuned into affordable and preventive care strategies to tackle the growing epidemic of CKD.
Table 3. Essential Characteristics of a Nephrologist Based on a Standardized Competency Framework Medical expert: medical knowledge and application of such knowledge in patient care Scholar: skills in knowledge generation and dissemination; education Professional: skills, attitudes, and behaviors expected by patients and society Communicator: effective communication with individual patients and their families and teamwork with other health professions, the scientific community, and the public Collaborator: physicians effectively work within a health care team to achieve optimal patient care Manager: making decisions about allocating resources and contributing to the effectiveness of the health care system Health advocate: physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations The CanMEDS (physician competency framework developed by Royal College of Canada. http://www.royalcollege.ca/rcsite/canmeds/ about/faq-canmeds-e) Initiative, Royal College of Physicians and Surgeons of Canada was used.27
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Similar to CKD, AKI is a poorly recognized disease, often associated with a high risk for progression to CKD. AKI is seen universally in all countries in multiple settings and in all age groups. However, in LMICs, AKI often is secondary to intravascular volume depletion resulting from infectious diseases, childbirth-related complications, and toxins related to herbal and alternative medicines. Morbidity and mortality from AKI in LMICs remains high, although the exact incidence is unknown.29 AKI is preventable in the majority of cases by early recognition, and is easily treatable with simple hydration therapies. In general, a lack of awareness among the general population and allied health care workers is common in LMICs. AKI awareness initiatives from the ISN, such as 0by25, zero preventable deaths from AKI by 2025, if adopted in early medical and allied health care training programs can play a critical role.30 Advanced Training The nephrologists in RLS need to take a leadership role by providing advanced care in tertiary centers and help develop health care policies tailored to the specific needs of the society. These nephrologists should be trained in emerging issues in nephrology such as renal histopathology, RRT, interventional nephrology, managing renal disease in aging patients, palliative care medicine, and so forth. The advanced trainees can be provided opportunities to undertake focused minifellowships in developed countries, supervised handson and simulation-based training from visiting experts arranged by professional organizations such as the ISN, or through government-funded exchange programs.31 Similarly, the nursing and ancillary workforce in tertiary centers can be trained to manage dialysis equipment and dialysis therapies more effectively. In LMICs, establishing a renal transplant program can be challenging and fiscally demanding both for the society as well as for the individual. Training in transplant medicine may be difficult in RLS and is best achieved in a developed country. The infrastructure and support needed to establish a transplant center in RLS can be daunting. A close collaboration between an established center in a developed country and LMICs through initiatives such as the ISN–The Transplantation Society Sister Transplant Centers program can help start a transplant program and provide the necessary tools and resources to train a transplant team.32 Specific Challenges for Training and Treating Kidney Disease The diagnosis and treatment of kidney disease is heavily dependent on laboratory and tissue analysis.
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Frequently, therapy is based on results obtained from blood tests or histopathology results. In RLS, often the resources to analyze and perform simple tests are unavailable, such as processing arterial blood gas analysis to assess for acid-base disorder, work-up for immunologic disorder, drug levels for immunosuppressant used after transplantation, or performing a renal biopsy safely and processing the sample for electron microscopy. These hurdles clearly pose a unique set of challenges not only to train, but also to provide evidence-based therapy. Often, the reliance on clinical judgment and arbitrary use of medications could result in a detrimental outcome. Simulation and case-based training may help understand the pathophysiology but may not necessarily help with therapeutic intervention. Educators may be well placed to advocate strongly for the consistent availability of adequate tools for diagnosis, which would have the simultaneous benefit of improving learning and care delivery.
SUCCESSFULLY TEACHING NEPHROLOGY IN RESOURCE-LIMITED SETTINGS: EXPERIENCES FROM MALAWI Malawi, located in east Africa, has a population of 16.2 million33 and one national medical school in the commercial capital Blantyre with an intake of 80 students per year. There are no qualified Malawian nephrologists in the country: dialysis services traditionally have been overseen by general physicians. Over the past 5 years, Barts Health NHS Trust in the United Kingdom has established a bidirectional educational exchange program through the ISN Sister Renal Centre Program with Queen Elizabeth Central Hospital (QECH)—the University teaching hospital for the Malawi College of Medicine. This partnership has been designed to establish and maintain a highquality nephrology service that eventually will be led by local Malawian clinical staff, trained and supported by this program. Our approach has been to deliver a multilevel education program that will leave a knowledge legacy and internal infrastructure to deliver a high-quality clinical nephrology service and continue training in Malawi by Malawian clinical staff with ad hoc support from visiting UK renal specialists. We have delivered training programs for front-line nursing and medical clinical staff at QECH, an education and awareness program in the surrounding district hospitals, as well as Malawi’s first ever Continuing Medical Education covering acute kidney injury. Training Front-Line Clinical Staff in Malawi Staff from Barts Health in the United Kingdom have spent more than 4 years delivering hands-on practical teaching, mentorship, and clinical supervision to
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Malawian nurses, clinical officers (a cadre broadly equivalent to physician assistants), and doctors at QECH. This training has identified future service leaders in Malawi who have undertaken short-term placements at Barts Health to gain additional training in specialist fields in nephrology as well as leadership and management experience. We have identified that nurses in Malawi need more nephrology training than doctors because there is an under-representation of a nephrology component in the nursing undergraduate curriculum compared with the curriculum for medical students. Accordingly, we delivered a 3-week training program for nurses, specifically to help them identify and manage AKI. The course was designed and delivered by a UK-based AKI specialist nurse and showed a sustained knowledge legacy after the training was completed.34 Acute Kidney Injury Continuing Medical Education In March 2015, we delivered an ISN-endorsed AKI symposium in Blantyre, which was a large renal education event.35 We invited doctors, clinical officers, and nursing staff from district hospitals and health centers across Southern Malawi. One hundred delegates attended, 60% of whom were district health care workers, and an international faculty of 10 AKI specialists from five different countries taught for 2 days. The aim of the course was to raise awareness of AKI and improve the delegates' confidence in managing AKI, as well as highlighting the renal services available at QECH. A precourse survey highlighted significant deficiencies in health care worker education in AKI.36 Fifty percent of all responders had never received dedicated teaching on AKI, and this number was even higher in nurses (61%) and district health care workers (63%). This lack of knowledge was despite 69% of workers reporting that they managed patients with AKI. If teaching occurred, it was usually at an undergraduate level and 98% of all responders (100% of nurses) wanted more support in managing patients with kidney disease. The course was held over 2 days with a mixture of didactic lecture and small group sessions, with case discussions based around real-life examples of AKI from Malawi. Delegates were engaging, enthusiastic, and keen to learn with lively discussions about the practical challenges of managing AKI in a resource-poor setting. Ninety-eight percent of attendees left the course feeling more confident in managing patients with AKI. District Outreach Teaching Program After identifying that renal education and support was particularly lacking in district hospital settings, we
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developed and delivered an AKI outreach education program for district health care workers in the Southern region of Malawi. All district hospitals were offered a half-day AKI teaching session that included lectures and case-based discussions delivered by a member of the nephrology service at QECH. The aim was to enhance confidence in managing AKI, and also to improve understanding of when and who to refer to the tertiary nephrology service at QECH. To date, we have visited 8 hospitals and delivered teaching to 110 clinicians and nurses, with 98% of participants indicating that they had developed increased confidence in the management of AKI in a postcourse survey. After our initial training activities, there has been ongoing demand among the district teams for this program to continue and we also have seen an increase in the number of patients referred in a timely fashion to the renal unit at QECH through a newly devised referral pathway. Challenges Encountered in Malawi Experience We remain sanguine about the potential risks of this approach. Staff turnover was high, internet access was variable, and the program required a considerable amount of time and goodwill on both sides of the partnership. Equally, Malawi, similar to many other resource-limited settings, has a limited infrastructure for diagnosing and managing all aspects of kidney disease. Laboratory resources were scarce and unpredictable and a specialist service such as hemodialysis, although available in limited volume and free at the point of access in Malawi, may not be available in other similar settings. Thus, the teaching sometimes has been challenging to put into practice for the Malawian trainees, which may lead to some erosion of the knowledge legacy. However, over the duration of this educational partnership, there has been a remarkable and sustained growth in knowledge, confidence, and staff retention, as well as dramatic improvements in the quality of patient care for kidney disease.
SUMMARY OF KEY ISSUES FOR NEPHROLOGY EDUCATION IN RESOURCE-LIMITED SETTINGS The delivery of optimal kidney care in resource-poor settings requires a re-orientation of the current approach to development and training of a broader nephrology workforce (Fig. 2). Identification of the local needs and requirements are necessary to focus training on areas that would have a maximal impact on health care outcomes. In places that need nephrologists trained to deliver advanced care including RRT, that training should aim to provide skills and expertise based on the standard competency domains aligned to the local resource and requirement. Ensuring a
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Volunteers to improve general health awareness in the community
Medical pharmacy and nursing students
Community health workers and assistants, social workers
Specialist, primary care physicians, nurses and pharmacists
Prevenve care and risk modificaon
7. Disease detecon and advanced therapy
8. 9.
10. Figure 2. Training needs and responsibilities of the broader health care workforce.
sustainable delivery of high-quality clinical training, contextualized for the local clinical environment and capable of providing an enduring knowledge legacy, are key issues for nephrology training programs. One approach could be to use local clinical knowledge and evidenced-based teaching combined with training delivered by visiting experts. The use of internet and computer-based learning aides as well as hard copies of teaching materials and using free-to-access communication software can be an invaluable mechanism to provide remote support, as was evident in the Malawi experience. The experiences in Malawi could be repeated in other resource-limited settings at a relatively low cost. Finally, the role of regional professional societies, government agencies, and medical and allied health schools cannot be underestimated in improving the overall standard of care. The commitment to improve medical education remains a collective responsibility. The introduction of kidney disorder into the curriculum at a grassroots level can stimulate a change in building an infrastructure that will improve awareness, access to care, diagnostic capacity, and delivery of care. Eventually, over time, the experience gained can be used to draft health care policies ideally suitable to the needs of each country.
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Lameire G, Goldsmith DJ, Winearls CG, Himmefarb J, Remuzzi G editors. Oxford textbook of clinical nephrology. Oxford: Oxford University Press, 2015 Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923-58. Holmboe ES. Realizing the promise of competency-based medical education. Acad Med. 2015;90:411-3. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676-82. Eichbaum Q. Acquired and participatory competencies in global health education: definition and assessment. Acad Med. 2016. in press. Strasser R, Lanphear J. The Northern Ontario School of Medicine: responding to the needs of the people and communities of Northern Ontario. Educ Health (Abingdon). 2008;21: 212. Wilson NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health. 2009;9:1060. Farmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3:e449. Eichbaum Q, Bowa K, Pires P, Vanio O, Nyarango P. Challenges and opportunities for new medical schools in Africa: the Consortium of New Southern African Medical Schools (CONSAMS). Acad Med. 2014;89:S108-9. Eichbaum Q, Hedimbi M, Bowa K, et al. New medical schools in Africa: challenges and opportunities. CONSAMS and value of working in consortia. Ann Glob Health. 2015;81: 265-269. Eichbaum Q, Nyarango P, Bowa K, et al. "Global networks, alliances and consortia" in global health education-the case for south-to-south partnerships. J Acquir Immune Defic Syndr. 2012;61:263-4. Eichbaum Q, Nyarango P, Ferrao J, et al. Challenges and opportunities for new medical schools in Africa. Lancet Glob Health. 2014;2:e689-90. Swanepoel CR, Wearne N, Okpechi IG. Nephrology in Africa– not yet uhuru. Nat Rev Nephrol. 2013;9:610-22. Omaswa F. Human resources for global health: time for action is now. Lancet. 2008;371:625-6. Mani MK. Treating renal disease in India's poor: the art of the possible. Semin Nephrol. 2010;30:74-80. Luyckx VA, Naicker S, McKee M. Equity and economics of kidney disease in sub-Saharan Africa. Lancet. 2013;382:103-4. Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: current situation and strategies for action. Lancet. 2011;378: 1654-1663. Iobst WF, Sherbino J, Cate OT, Richardson DL, Dath D, Swing SR, et al. Competency-based medical education in postgraduate medical education. Med Teach. 2010;32:651-6. Okel J, Okpechi IG, Qarni B, Olanrewaju T, Courtney MJ, Luyckx V, et al. Nephrology training curriculum and implications for optimal kidney care in the developing world. Clin Nephrol. 2016;86:110-3. Rehwagen C. WHO alliance aims to tackle the world's lack of health workers. BMJ. 2006;332:1294. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638-45. Matlow A, Chan MK, Bohnen JD, Blumenthal DM, Sanchez-Mendiola M, de Camps Meschino D, et al. Collaborating internationally on physician leadership education: first steps. Leadersh Health Serv (Bradf Engl). 2016;29:220-30.
Nephrology and continuing education 28. Feehally J, Couser W, Dupuis S, Finkelstein F, Harden P, Harris D, et al. Nephrology in developing countries: the ISN's story. Lancet. 2014;383:1271-2. 29. Lewington AJ, Cerda J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer. Kidney Int. 2013;84:457-67. 30. 0by25 Initiative from International Society of Nephrology. [cited 2016 September 12]. Available from: http://www.0by25.org. 31. The International Society of Nephrology Education Programs. [cited 2016 September 11]. Available from: http://www.theisn. org/programs. 32. ISN-TTS Sister Transplant Centers Program. [cited 2016 September 13]. Available from: http://www.theisn.org/pro grams/sister-transplant-centers-program.
233 33. Malawi census. [cited 2016 September 5]. Available from: http:// www.nsomalawi.mw/images/stories/data_on_line/demography/ mdhs2015_16/Malawi%20DHS%202015-16%20KIR.pdf. 34. Kirwan C, Wright W, Banda P, Chick A, Mtekateka M, Banda E, et al. A nurse led intervention improves detection and management of AKI in Malawi. J Renal Care. 2016;42: 196-204. 35. Available from: http://www.theisn.org/about-isn/isn-blog/item/ 1895-isn-sponsored-aki-symposium-in-malawi. [cited 2016 August 13]. 36. Evans R, Rudd P, Hemmila U, Mtekateka M, Kawale Z, Craik A, et al. Deficiencies in education and experience in the management of acute kidney injury in Malawian healthcare workers. Malawi Med J. 2015;27:106-8.
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he World Health Organization reports noncommunicable diseases (NCDs) as a major cause of mortality worldwide with almost three quarters of NCD-related deaths occurring in low- and middleincome countries.1 Almost 38 million deaths occur each year worldwide from the four main NCDs— cardiovascular diseases, cancer, respiratory diseases, and diabetes, although the direct and indirect contributions of kidney disease to global deaths are unknown. NCDs have common modifiable risk factors such as unhealthy diet, insufficient physical activity, overweight/obesity, and harmful use of tobacco and alcohol. Chronic kidney disease, hypertension, diabetes, and cardiovascular disease are often the end result of these uncontrolled risk factors, leading to high health care costs and a negative impact on productivity and growth. A well-trained and educated health
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Division of Nephrology, W. G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina. † Division of Nephrology and Immunology, University of Alberta, Edmonton, Canada. ‡ Malawi College of Medicine, Chichiri, Blantyre, Malawi. § Department of Nephrology, Barts Health NHS Trust, London, United Kingdom. || Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN. Financial disclosure and conflict of interest statements: none. Address reprint requests to: Tushar Vachharajani, MD, FASN, Division of Nephrology, W. G (Bill) Hefner VA Medical Center, 1601 Brenner Ave, Salisbury, NC 28144. E-mail: [email protected] 0270-9295/ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.semnephrol.2017.02.003
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workforce led by a nephrologist can offer a costeffective intervention to implement preventive measures to modify risk factors, increase awareness about other renal disorders such as acute kidney injury, increase awareness of the augmentation of cardiovascular risk with kidney disease, and implement timely holistic therapeutic interventions to improve overall patient care.1 In developed countries, nephrology training is structured and supported by resources, allowing trainees to maintain their knowledge and skills through continuing medical education programs. Moreover, the availability and affordability of therapeutic options offer an encouraging environment to constantly improve patient care and conduct scientific research. The limited educational resources in low- and middle-income countries (LMICs), along with expensive and unavailable treatment options for kidney diseases, create a challenging situation in designing a meaningful nephrology training curriculum. The current review outlines the conflicts faced by educational experts in planning and implementing a nephrology training curriculum for resourcelimited countries.
KEY CONCEPTS IN MEDICAL EDUCATION IN GLOBAL HEALTH After the momentous changes that Abraham Flexner introduced into the North American medical curriculum in 1910, medical education as a discipline remained static for decades under the domineering influence of basic science. Over the past 2 or 3 decades, however, medical education (and more broadly health professional Seminars in Nephrology, Vol 37, No 3, May 2017, pp 224–233
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education) has grown rapidly into a fully fledged discipline within medical schools with its own philosophical framework of constructivism, specific research methodologies, and standardized education degrees. In contrast, the pace of change in medical education in LMICs, especially in resource-limited settings (RLS), has been slow, mostly because of their resource constraints. In many LMICs, the legacy of colonialism also may have played a role since Western medicine was introduced into these countries during colonialist periods.2 An unpredicted concomitant trend in health professional education in recent decades has been the rapid development of global health as a discipline. This trend has resulted in the explosive growth of health professional schools of associated global health education programs. Applied across geographic and cultural boundaries, this discipline has brought to the center of education debates about the significance of contexts. We now have a better understanding that medicine and allied health professions are practiced and taught in specific contexts, and that these contexts can differ significantly from one another. Although scientific and epidemiologic contexts are apprehended more readily, only more recently are the nuances of social contexts and determinants being recognized and incorporated into health professional education. With regard to global cultural contexts, a major divide to consider is the difference between the cultures of individualist and collectivist settings.3 Individualist cultures, which include the high-income countries of North America and Europe, generally are competitive and value individual autonomy. Collectivist cultures include many LMICs in Africa, South America, and Asia, and generally are oriented toward group (collective) settings and participation. The learning environments of individualist and collectivist settings are different in many respects.3–5 Individualist cultures view learning as something the individual can acquire and apply across contexts and for which the individual can be assessed. Collectivist cultures, on the other hand, view learning as mostly situated in dynamic social contexts and cannot be transferred readily to other contexts. A major development in medical education in recent decades in high-income countries has been the shift toward competency-based medical education (CBME). Competencies are intended to make explicit for learners what they specifically need to know in domains of knowledge, skills and attitudes of their health professional practice. Health institutions and organizations have a tendency to develop their own lists of competency domains and competencies to match their values and training needs. The degree to which such competencies are linked appropriately to specific contexts is currently a topic of debate among educators.4,5 With the advent of the internet in the early 1990s, numerous teaching methodologies emerged when
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electronic platforms became more accessible and userfriendly. Traditional modes of teaching in lecture halls are yielding to novel teaching methods such as teambased learning and flipped classrooms, and to selfdirected learning, which incorporates social media and electronic devices such as mobile devices and tablets and telemedicine.6 In RLS, the utilization of these methods may depend on a host of factors ranging from available local resources such as internet bandwidth, faculty availability, and the willingness of institutional leadership, faculty, and students to adopt these approaches.
CHALLENGES AND OPPORTUNITIES OF HEALTH PROFESSIONAL EDUCATION IN RESOURCE-LIMITED SETTINGS The main challenges facing health professional education in RLS derive mostly from such resource constraints (Fig. 1). Some of the ways these constraints manifest themselves in health professional education are as follows. Teaching Faculty Shortages A general problem in RLS is the shortage of trained health professionals to provide teaching and clinical training at both undergraduate and postgraduate levels. Continuing medical education for practicing professionals is usually not available. Given the lack of postgraduate clinical training programs in LMICs, it may be important for clinical specialties such as nephrology to provide some clinical foundation during undergraduate medical education that may be applicable after graduation. Shortages in teaching faculty have the consequence that employed faculty often are stretched thin with heavy teaching loads, and also may be required to teach subjects in which they have little expertise. At a postgraduate level, salaries of academic faculty may be significantly lower than for colleagues in private practice, resulting in physicians leaving academia or holding dual appointments to supplement salaries while retaining academic privileges. These circumstances challenge the quality of health professional education in RLS. Curriculum Development Given their resource limitations, new health professional schools in RLS often face the unsettling dilemma on how to develop their teaching curricula. The seminal Lancet document of 2010 on "Health Professionals for a New Century" by Frenk et al,7 stresses that curricula should be derived and linked to local health contexts and health needs. With severe faculty shortages, schools in RLS may believe they are constrained in developing their curricula based on local contexts and health needs, and may instead be tempted to take
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Figure 1. Challenges to medical education in RLS. CME, continuing medical education.
easier routes toward curriculum development such as purchasing ready-made curricula, implementing available traditional curricula, or developing hybrid models of traditional and context-specific curricula. The latter solutions generally are problematic in the long term and are difficult to change once accepted in a school. Competency-Based Medical Education The Lancet 2010 document also recommended that education of health professionals preferably should be competency-based rather than deriving solely from set curricula.7 The trend toward CBME has grown steadily in high-income countries over the past 2 decades, but is still in its infancy in LMICs. A major reason for this shortcoming in LMICs pertains to the lack of resources required for adequate assessment of competencies that are outcomes-based and generally require assessment by direct observation.8,9 RLS lack faculty who can perform such intensive assessment of competencies adequately. Moreover, even in high-income countries the extent to which competencies are linked appropriately to specific contexts settings has been questioned.4,10 Moreover, some competencies arise in dynamic social situations and cannot be assessed by traditional observations and psychometric methods. Instead, they require alternate modes of assessment but they often erroneously are subject to the same traditional methods of assessment. Assessment and Accreditation The adequacy of assessment in health professional schools generally is linked to a school’s accreditation because such assessment significantly determines the quality of a school’s graduates. Appropriate assessment and accreditation both require substantial resources in
terms of institutional capacity and expertise. Assessment in RLS often is overly summative, without providing adequate formative feedback opportunities for students and trainees to master learning materials. Appropriate assessment also requires expertise in quality-assured psychometric methodologies that may be lacking in RLS. In high-income countries, the trend toward self-directed assessment requires ongoing iterative feedback that may be too resource-intensive for RLS. This approach of self-directed assessment, however, may be more consonant with collectivist cultures of LMICs, as such, assessment requires input from other group members and coworkers to ensure validity. Accreditation requires interinstitutional consensus in developing standards that are imposed fairly and equitably on schools. To be impartial, accreditation bodies should be independent bodies with officials having no conflicts of interests with health institutions being accredited. The development of such organization requires a sustainable level of funding that may be lacking in RLS, although such bodies slowly are being established initially as collaborative efforts, such as networks of external examiners between schools. Some schools have tried to circumvent their inadequate assessment and accreditation methods by importing question banks for assessment from high-income countries such as those of the CBME, and some have purchased the services of high-income countries’ accreditation bodies. However, because these assessment and accreditation systems were developed for high-income countries, they may be inappropriate for the LMICs, a practice we therefore do not recommend. Admissions Policies Who gets admitted to medical school (and other health professional schools) deserves moral attention in RLS
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given the disparities in education that places applicants from rural areas at a disadvantage. Equitable policies should be in place to ensure that applicants from wealthy urban families, who have had access to the best secondary education, are not given undue advantage compared with rural applicants, especially because some studies have indicated that the latter applicants are more likely to return to practice in these underserved rural areas.11,12
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to new African medical schools by developing southto-south and south-north collaborative partnerships that have resulted in several innovations in curricula development, assessment, and accreditation approaches and admissions policies.14–17 The task ahead for health professional education in RLS therefore at once is fraught with daunting challenges but also laced with exciting opportunities. How nephrology education will meet these challenges and opportunities is a topic we now discuss.
Scientific Research Although few health professional educators would disagree about the importance of promoting scientific research in RLS, in question are the opportunity costs and the readiness of RLS for large-scale promotion of such research. Funding bodies in high-income countries such as the National Institutes of Health in the United States and the Wellcome Trust in the United Kingdom, recently have awarded millions of dollars for establishing scientific research in RLS, particularly in the LMICs of Africa. Although well intentioned, we believe such intensive promotion of basic science research and training in these settings is premature. Not only are the infrastructures insufficient to absorb large numbers of graduating research scientists (with the likely unintended consequence of them leaving for employment in high-income countries), but such funding often comes at the cost of siphoning funds and resources away from much-needed capacity-building health care delivery projects that now are needed more urgently. Although scientific research certainly should be promoted in RLS settings, it should be performed judiciously alongside development of adequate employment opportunities. Jumpstarting scientific research may to some extent work by increasing the numbers of trained scientists, but it also may backfire without appropriate employment infrastructures. As suggested, this heavy emphasis in RLS in Africa may have colonialist roots. Farmer et al13 point out that we have continued to overemphasize the molecular determinants of medicine at the expense of teaching social determinates, resulting in a tendency to ask only biological questions about what are in fact biosocial phenomena. Although these challenges are daunting, they also contain within them the seeds of opportunities. In particular, new health professional schools, unencumbered by tradition and inflexible leadership, may be more agile at leapfrogging and implementing innovations.5 By some estimates more than a hundred new medical schools will be opening in Africa over the next decade, a projection that presents enormous scope for innovative opportunities.14–16 The Consortium of New Sub-Saharan Medical Schools is a consortium catering
CHALLENGES WITH DEVELOPING NEPHROLOGY TRAINING CURRICULUM IN RESOURCE-LIMITED SETTINGS The key purpose of a nephrology education program is to provide the requisite skills and expertise for effective care delivery for patients with kidney diseases.18,19 The spectrum of kidney disease would entail acute kidney injury (AKI), chronic kidney disease (CKD), as well as renal replacement therapy (RRT). A trainee in nephrology should receive training for the identification and prevention of both AKI and CKD, management of disease, and reducing the risk of progression to kidney failure requiring RRT. Although this is a key concept underpinning nephrology education based on global standards, it does not take into consideration regions with varying needs such as the LMIC with limited resources and/or capacity to provide kidney care in its full spectrum. The requisite competence and training required for delivery of kidney care thus would differ across regions based on their needs and circumstances,20–22 without deviation from the global standard and expectations of training or deliverables. In this line, as discussed earlier, there have been concerted efforts to transform medical education including nephrology training to be competency-based, essentially to train and educate based on local needs and circumstances.17,22,23 Nephrology education in resource-poor settings still is based predominantly on Western curriculum and is fraught with a number of problems with content, needs assessment and evaluation, instructional methods and delivery models, limited or lack of integration of important training attributes (professionalism, scholarship, advocacy, and so forth), and a lack of rigorous assessment methodology19,21,24 (Table 1). Thus, there is a mismatch between training objectives and content and the local needs and circumstances. Nephrology training programs in resource-poor settings emphasize training in RRT technology (modern dialysis techniques and transplantation), which is of less relevance and importance considering the limited capacity of the health system to deliver care in these domains, which
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Table 1. Key Thematic Problems With the Current Training Structure and Curricula in Developing Countries Theme/Domain
Key Issues
Potential Solutions
Curriculum content
Emphasis on factual information, memory, and recall (core knowledge content)
Problem-based learning adapted to local circumstances with a background of thorough understanding and disease physiology and pathophysiology Grounding of understanding of disease within the patient’s life to best be able to develop successful management strategies despite the potential absence of sophisticated technology Structure and organization are more the product of Reliable local epidemiology of disease incidence Absence of needs and prevalence as well as understanding of established tradition than of evidence and not in assessment and barriers to delivery/uptake of good kidney care keeping with health system changes and evaluation demand Production of nephrologists not commensurate with the population growth and needs Instructional model Didactic; learning is still opportunistic Introduce and emphasize problem-based learning with close monitoring and mentorship of learners Formal teaching as well as learning by example, Professionalism, collaboration, advocacy, Other core areas of faculty development, interdisciplinary teaching, managerial skills, and scholarship (critical competencies not and other teaching rounds (eg, grand rounds, appraisal skills) are not formally taught included mortality and morbidity reviews, and so forth) Lack of training in critical Other competency domains (eg, scholarship) not Structured training in critical appraisals including journal clubs, requirements to publish (eg, case formalized and developed—low knowledge appraisals and literature reports/series) during training generation and data gathering to inform EBM review methodology practice Assessments (tests and Summative rather than formative (not wellMini-CEX, OSCE, 360-degree feedback in addition examinations) evaluated assessment process) to clinical knowledge, maybe even reflective writing Abbreviations: EBM, evidence-based medicine; Mini-CEX, mini clinical evaluation exercise; OSCE, objective structured clinical examination. Adapted with permission from Okel et al.24
may be critical for some, but not all, settings to have a well-trained workforce to deliver RRT care. However, it is universally important to have people trained in the identification and management of AKI and CKD. For example, the key long-term strategies for optimal CKD care (control of blood pressure and other modifiable risk factors), to delay progression of CKD to end-stage renal disease and reduce adverse events, can be delivered competently by a trained workforce at the primary care level with minimal supervision by a nephrologist. Health Care Workforce Training Training in preventive medicine therefore should be prioritized and extended beyond physician workforce training to other health care workers such as community health workers, community health assistants, pharmacists, and nurses. The health care workforce can be provided with relevant knowledge and skills to identify and treat AKI and CKD in the communityand hospital-based settings (Table 2). However, the best strategy to structure and align nephrology education to meet local needs and circumstances within
the existing competency framework still is unknown. Because countries across the world have unique societal needs and capabilities to deliver kidney care, developing a training curriculum as a one-cap-fits-all principle is challenging. The World Health Organization Global Health Workforce Alliance Framework for health workforce planning could be leveraged to guide the restructuring of nephrology education to meet the unique characteristics of various countries and communities.25 The framework is not specific to nephrology workforce training but is broadly applicable for all countries, specialties, and for all cadre of the health workforce including physicians, nonphysicians groups (nurses, community health officers, pharmacists, and other health professionals), and delivery sectors (public, private, nongovernmental organizations/faith-based). The framework seeks to engage the entire health care workforce for equitable and quality care delivery in their own communities with an emphasis on developing policies to define the scope of practice, accountability and management, continuing education, and professional development, and to integrate public and private sector perspectives.25 A trained nephrologist provides leadership
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Table 2. Key Areas of Focus for Nephrology Training in Low-Resource Settings Disease Training Curriculum Domain AKI
CKD
Delivery Platforms
Target Workforce
Simple education tools (paper charts, pathways, algorithms) Media: podcasts, YouTube videos, messaging Clinical management including RRT Clinical pathways and algorithms (slow dialysis therapies where Lectures and grand available) rounds Local clinical champions Simple education tools Awareness, risk factors, and (paper charts, identification of CKD and pathways, algorithms) prevention Media: podcasts, YouTube videos, messaging Clinical management including RRT Clinical pathways and algorithms (and kidney transplantation where available) Lectures and grand rounds Conservative care Local clinical champions Awareness, risk factors, and identification of AKI in the communities and prevention
Nonphysician personnel (eg, community nurses, pharmacists, health and/or health extension workers, and so forth) working in community-based health outlets and clinics Trained secondary school leaders and community leaders
Physicians Nonphysician personnel (eg, community nurses, pharmacists, health and/or health extension workers, and so forth) working in community-based health outlets and clinics Trained secondary school leaders and community leaders
Physicians
Abbreviations: HD, hemodialysis; PD, peritoneal dialysis.
through a broad knowledge base and requisite competencies, scholarship, and skills in critical appraisal for generating new knowledge and appraising evidence26 (Table 3). The restructuring of nephrology training across all settings also would focus on other aspects of training such as professionalism, collaboration, advocacy, management, and skills in critical appraisal, research, and scholarship26,27 (Table 3). The engagement of relevant stakeholders such as political leaders and policy makers, support from international and regional professional organizations (such as the International Society of Nephrology [ISN]), and institutional collaborations between high-income countries and LMICs is critical for the successful implementation of this training model.28
Medical and Nursing School Curriculum The emphasis on preventive care and risk modification is pivotal in reducing health care costs in LMICs, especially with kidney disease. The curriculum for medical and nursing students can be modified to highlight the importance of adequate blood pressure control, use of renin-angiotensin blockers, reduction of proteinuria, lifestyle modification (weight loss, stop tobacco use, physical activity), tight blood glucose control, and adequate lipid control to prevent or stabilize chronic kidney disease. The goal should be to build a new generation of primary care physicians and health care workers who are tuned into affordable and preventive care strategies to tackle the growing epidemic of CKD.
Table 3. Essential Characteristics of a Nephrologist Based on a Standardized Competency Framework Medical expert: medical knowledge and application of such knowledge in patient care Scholar: skills in knowledge generation and dissemination; education Professional: skills, attitudes, and behaviors expected by patients and society Communicator: effective communication with individual patients and their families and teamwork with other health professions, the scientific community, and the public Collaborator: physicians effectively work within a health care team to achieve optimal patient care Manager: making decisions about allocating resources and contributing to the effectiveness of the health care system Health advocate: physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations The CanMEDS (physician competency framework developed by Royal College of Canada. http://www.royalcollege.ca/rcsite/canmeds/ about/faq-canmeds-e) Initiative, Royal College of Physicians and Surgeons of Canada was used.27
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Similar to CKD, AKI is a poorly recognized disease, often associated with a high risk for progression to CKD. AKI is seen universally in all countries in multiple settings and in all age groups. However, in LMICs, AKI often is secondary to intravascular volume depletion resulting from infectious diseases, childbirth-related complications, and toxins related to herbal and alternative medicines. Morbidity and mortality from AKI in LMICs remains high, although the exact incidence is unknown.29 AKI is preventable in the majority of cases by early recognition, and is easily treatable with simple hydration therapies. In general, a lack of awareness among the general population and allied health care workers is common in LMICs. AKI awareness initiatives from the ISN, such as 0by25, zero preventable deaths from AKI by 2025, if adopted in early medical and allied health care training programs can play a critical role.30 Advanced Training The nephrologists in RLS need to take a leadership role by providing advanced care in tertiary centers and help develop health care policies tailored to the specific needs of the society. These nephrologists should be trained in emerging issues in nephrology such as renal histopathology, RRT, interventional nephrology, managing renal disease in aging patients, palliative care medicine, and so forth. The advanced trainees can be provided opportunities to undertake focused minifellowships in developed countries, supervised handson and simulation-based training from visiting experts arranged by professional organizations such as the ISN, or through government-funded exchange programs.31 Similarly, the nursing and ancillary workforce in tertiary centers can be trained to manage dialysis equipment and dialysis therapies more effectively. In LMICs, establishing a renal transplant program can be challenging and fiscally demanding both for the society as well as for the individual. Training in transplant medicine may be difficult in RLS and is best achieved in a developed country. The infrastructure and support needed to establish a transplant center in RLS can be daunting. A close collaboration between an established center in a developed country and LMICs through initiatives such as the ISN–The Transplantation Society Sister Transplant Centers program can help start a transplant program and provide the necessary tools and resources to train a transplant team.32 Specific Challenges for Training and Treating Kidney Disease The diagnosis and treatment of kidney disease is heavily dependent on laboratory and tissue analysis.
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Frequently, therapy is based on results obtained from blood tests or histopathology results. In RLS, often the resources to analyze and perform simple tests are unavailable, such as processing arterial blood gas analysis to assess for acid-base disorder, work-up for immunologic disorder, drug levels for immunosuppressant used after transplantation, or performing a renal biopsy safely and processing the sample for electron microscopy. These hurdles clearly pose a unique set of challenges not only to train, but also to provide evidence-based therapy. Often, the reliance on clinical judgment and arbitrary use of medications could result in a detrimental outcome. Simulation and case-based training may help understand the pathophysiology but may not necessarily help with therapeutic intervention. Educators may be well placed to advocate strongly for the consistent availability of adequate tools for diagnosis, which would have the simultaneous benefit of improving learning and care delivery.
SUCCESSFULLY TEACHING NEPHROLOGY IN RESOURCE-LIMITED SETTINGS: EXPERIENCES FROM MALAWI Malawi, located in east Africa, has a population of 16.2 million33 and one national medical school in the commercial capital Blantyre with an intake of 80 students per year. There are no qualified Malawian nephrologists in the country: dialysis services traditionally have been overseen by general physicians. Over the past 5 years, Barts Health NHS Trust in the United Kingdom has established a bidirectional educational exchange program through the ISN Sister Renal Centre Program with Queen Elizabeth Central Hospital (QECH)—the University teaching hospital for the Malawi College of Medicine. This partnership has been designed to establish and maintain a highquality nephrology service that eventually will be led by local Malawian clinical staff, trained and supported by this program. Our approach has been to deliver a multilevel education program that will leave a knowledge legacy and internal infrastructure to deliver a high-quality clinical nephrology service and continue training in Malawi by Malawian clinical staff with ad hoc support from visiting UK renal specialists. We have delivered training programs for front-line nursing and medical clinical staff at QECH, an education and awareness program in the surrounding district hospitals, as well as Malawi’s first ever Continuing Medical Education covering acute kidney injury. Training Front-Line Clinical Staff in Malawi Staff from Barts Health in the United Kingdom have spent more than 4 years delivering hands-on practical teaching, mentorship, and clinical supervision to
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Malawian nurses, clinical officers (a cadre broadly equivalent to physician assistants), and doctors at QECH. This training has identified future service leaders in Malawi who have undertaken short-term placements at Barts Health to gain additional training in specialist fields in nephrology as well as leadership and management experience. We have identified that nurses in Malawi need more nephrology training than doctors because there is an under-representation of a nephrology component in the nursing undergraduate curriculum compared with the curriculum for medical students. Accordingly, we delivered a 3-week training program for nurses, specifically to help them identify and manage AKI. The course was designed and delivered by a UK-based AKI specialist nurse and showed a sustained knowledge legacy after the training was completed.34 Acute Kidney Injury Continuing Medical Education In March 2015, we delivered an ISN-endorsed AKI symposium in Blantyre, which was a large renal education event.35 We invited doctors, clinical officers, and nursing staff from district hospitals and health centers across Southern Malawi. One hundred delegates attended, 60% of whom were district health care workers, and an international faculty of 10 AKI specialists from five different countries taught for 2 days. The aim of the course was to raise awareness of AKI and improve the delegates' confidence in managing AKI, as well as highlighting the renal services available at QECH. A precourse survey highlighted significant deficiencies in health care worker education in AKI.36 Fifty percent of all responders had never received dedicated teaching on AKI, and this number was even higher in nurses (61%) and district health care workers (63%). This lack of knowledge was despite 69% of workers reporting that they managed patients with AKI. If teaching occurred, it was usually at an undergraduate level and 98% of all responders (100% of nurses) wanted more support in managing patients with kidney disease. The course was held over 2 days with a mixture of didactic lecture and small group sessions, with case discussions based around real-life examples of AKI from Malawi. Delegates were engaging, enthusiastic, and keen to learn with lively discussions about the practical challenges of managing AKI in a resource-poor setting. Ninety-eight percent of attendees left the course feeling more confident in managing patients with AKI. District Outreach Teaching Program After identifying that renal education and support was particularly lacking in district hospital settings, we
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developed and delivered an AKI outreach education program for district health care workers in the Southern region of Malawi. All district hospitals were offered a half-day AKI teaching session that included lectures and case-based discussions delivered by a member of the nephrology service at QECH. The aim was to enhance confidence in managing AKI, and also to improve understanding of when and who to refer to the tertiary nephrology service at QECH. To date, we have visited 8 hospitals and delivered teaching to 110 clinicians and nurses, with 98% of participants indicating that they had developed increased confidence in the management of AKI in a postcourse survey. After our initial training activities, there has been ongoing demand among the district teams for this program to continue and we also have seen an increase in the number of patients referred in a timely fashion to the renal unit at QECH through a newly devised referral pathway. Challenges Encountered in Malawi Experience We remain sanguine about the potential risks of this approach. Staff turnover was high, internet access was variable, and the program required a considerable amount of time and goodwill on both sides of the partnership. Equally, Malawi, similar to many other resource-limited settings, has a limited infrastructure for diagnosing and managing all aspects of kidney disease. Laboratory resources were scarce and unpredictable and a specialist service such as hemodialysis, although available in limited volume and free at the point of access in Malawi, may not be available in other similar settings. Thus, the teaching sometimes has been challenging to put into practice for the Malawian trainees, which may lead to some erosion of the knowledge legacy. However, over the duration of this educational partnership, there has been a remarkable and sustained growth in knowledge, confidence, and staff retention, as well as dramatic improvements in the quality of patient care for kidney disease.
SUMMARY OF KEY ISSUES FOR NEPHROLOGY EDUCATION IN RESOURCE-LIMITED SETTINGS The delivery of optimal kidney care in resource-poor settings requires a re-orientation of the current approach to development and training of a broader nephrology workforce (Fig. 2). Identification of the local needs and requirements are necessary to focus training on areas that would have a maximal impact on health care outcomes. In places that need nephrologists trained to deliver advanced care including RRT, that training should aim to provide skills and expertise based on the standard competency domains aligned to the local resource and requirement. Ensuring a
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Volunteers to improve general health awareness in the community
Medical pharmacy and nursing students
Community health workers and assistants, social workers
Specialist, primary care physicians, nurses and pharmacists
Prevenve care and risk modificaon
7. Disease detecon and advanced therapy
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10. Figure 2. Training needs and responsibilities of the broader health care workforce.
sustainable delivery of high-quality clinical training, contextualized for the local clinical environment and capable of providing an enduring knowledge legacy, are key issues for nephrology training programs. One approach could be to use local clinical knowledge and evidenced-based teaching combined with training delivered by visiting experts. The use of internet and computer-based learning aides as well as hard copies of teaching materials and using free-to-access communication software can be an invaluable mechanism to provide remote support, as was evident in the Malawi experience. The experiences in Malawi could be repeated in other resource-limited settings at a relatively low cost. Finally, the role of regional professional societies, government agencies, and medical and allied health schools cannot be underestimated in improving the overall standard of care. The commitment to improve medical education remains a collective responsibility. The introduction of kidney disorder into the curriculum at a grassroots level can stimulate a change in building an infrastructure that will improve awareness, access to care, diagnostic capacity, and delivery of care. Eventually, over time, the experience gained can be used to draft health care policies ideally suitable to the needs of each country.
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