Daniel Landry

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Background: Home hemodialysis (HHD) prevalence is low in the United States; thus, nephrology fellows may have limited HHD clinical experience and be hesitant to counsel suitable patients. We describe a formative HHD counseling simulation scenario, part of a previously described nephrology-specific formative Objective Structured Clinical Examination (OSCE) that assesses fellow counseling skills using validated assessment instruments. Methods: During a 20-minute simulation, fellow performance was assessed by a standardized patient using the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS) and by faculty using an HHD-specific Mini-Clinical Evaluation Exercise (Mini-CEX). Overall, EEC-GRS and Mini-CEX scores were the primary outcome measures. After the simulation, fellows were surveyed anonymously regarding satisfaction with the scenario and HHD clinical experience/education. Program directors reported HHD curriculum components. Fellow performance was analyzed by training year. Results: Four programs (19 fellows: 10 first-year, nine second-year) participated. All had an HHD curriculum. Three offered HHD training courses but no HHD clinic. One had a longitudinal HHD clinic (two first-year and two second-year fellows) but did not offer a training course. There were no significant differences in overall EEC-GRS or Mini-CEX scores between first- and second-year fellows. No fellow had an unsatisfactory overall score. On the post-OSCE survey (37% response rate), six of seven (86%) responding fellows agreed/strongly agreed that the simulation increased their “comfort in discussing HHD with a patient.” Conclusion: This educational, formative HHD counseling scenario, part of a previously described OSCE, is a low-risk opportunity for fellows to practice patient communication skills and appears to increase fellow comfort in discussing HHD.

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Key Points: Because of low patient numbers and uneven geographical distribution, nephrology fellows may not have experience caring for home hemodialysis (HHD) patients. We developed and preliminarily validated a formative HHD objective structured clinical examination. The objective structured clinical examination may be used to assess HHD curriculum and basic HHD clinical skills in individual fellows. Background: The Accreditation Council for Graduate Medical Education requires graduating nephrology fellows demonstrate competence in home hemodialysis (HHD). Because low patient numbers may lead to training gaps, clinical experience may be enhanced using simulation. We designed and preliminarily validated a formative objective structured clinical examination (OSCE) assessing clinical care of an uncomplicated patient initiating HHD, using a unified model of construct validity. Methods: The OSCE was developed by a nephrology fellow and five faculty (three practicing HHD). The nine-member test committee (five in HHD practice; one HHD care partner) assessed test item difficulty/relevance and determined passing scores. The final test consisted of 27 items (31 possible points); seven were evidence-based/standard-of-care questions (9.5 possible points). Passing score was 20 of 31 points (65%). Median relevance for all items was “important” or “essential.” Content validity index was 0.84. On preliminary validation by 11 board-certified volunteers (four practicing HHD), overall mean±SD score was 27.5±2 (100% passing), kappa=0.83 (95% confidence interval, 0.67 to 0.99). Validator evidence-based question score was 9.0±0.6. Results: Thirty-eight fellows (9 programs, 21 first-year; 17 second-year) were tested. Seventy-one percent passed (Cronbach α=0.70). Fellows' mean±SD scores were lower than validators: 21.5±4.0 versus 27.5±2, P < 0.001, as were their scores on evidence-based questions: 7.4±1.4 versus 9.0±0.6, P < 0.001. Eighty-eight percent of evidence-based/standard-of-care questions were answered correctly by validators versus 62% by fellows (P < 0.001). Forty-two percent of fellows were able to name four potential benefits and two risks associated with HHD; 79% recognized that the primary risk of buttonhole cannulation was infection. Seventy-four percent correctly identified minimum single pool Kt/V for thrice-weekly hemodialysis, and 29% knew the minimum standard weekly Kt/V target. Eighty-eight percent of fellows surveyed (22 of 25) agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Conclusions: The OSCE may be used as a formative assessment of fellow proficiency in prescribing HHD.

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