Monday, October 14, 2013

I took the nephrology recertification exam this past Thursday.

It was hard. It was harder than I expected.

The Test

Many of the questions were second derivative type questions. They would describe a renal disease and then ask a question that required you to know what the hidden diagnosis was and then some additional bit of knowledge about the disease, i.e. diagnosis, treatment or prognosis.

I felt the test was hard and initially complained that I thought it was unfair but with some more time I feel that it was actually a pretty fair test. One complaint I heard among my fellow test takers was that the test did not reflect their practice. There was essentially no peritoneal dialysis. There was very little chronic hemodialysis and I felt that chronic kidney disease was under emphasized. There was a lot of electrolytes, acid-base and secondary hypertension.

One aspect of the test that bothered me was how the test seemed to have no clue how a modern, networked, doctor actually works. For example, there were questions that asked about a specific drug look the correct dose up on my phone. I am not arguing that drug dosing in renal failure questions are irrelevent in the era of the networked doc but the relevent fact is not what the dose is, but which drugs need to be dose adjusted. Provide a list of drugs and ask me which ones need to be dose adjusted in renal failure. Give me a list of drugs and ask in which ones are drug levels not indicative of biological activity. Adapt the question to be relevant in today's connected world.

Similarly, regarding rare diseases in nephrology. Do not ask me how to treat Fabry's disease. I have never seen a case of Fabry's. I need to be able to diagnose the condition, and then the correct next step is not to reach back in the recesses of your memory for how to treat this one in a million disease. The right answer is to hit the books and brush up on the disease. Recognizing the pattern of symptoms and making the diagnosis is what is important. Treatment can wait for the practitioner to review the latest data. The best time to get up to date on a disease is right when you suspect it so you have the latest knowledge. Forcing people to memorize treatments of rare conditions de-inforces the better habit of hitting the books when something rare comes up (and by books I really mean UpToDate).


The Prep

To prepare for the recertification test I put all my wood behind the ASN Board Review Class. My results are not back, so it may be a bit premature to make a recommendation but, as of today, I feel that it is an excellent way to prepare.

  • The breadth and depth of the lectures was right in line with what I saw on the test.
  • I feared that the ASN would try to get the biggest names in nephrology rather than an all-star bench of great teachers. They did not fall into this trap. They found some really big names in nephrology who are also really good lecturers.
  • They provide a wealth of resources to help you extend your learning beyond the week at the conference.
    • practice test
    • paper syllabus with copies of all the slides
    • CD-ROM with all the slides
    • Audio synched to the slides for online review


I went to the lectures in Chicago and was an active learner by live tweeting the lectures for eAJKD (coverage provided by the excellent uKidney).

After the week in Chicago I carefully went through the practice exam provided by the ASN BRC. One hundred fifty questions with answers and good explanations. I loved this tool and only wish they were a bit more indulgent with the answers (in other words love it, just give us more). I feel that questions and answers I think are one of the best ways to prepare for the test.

In the weeks leading up to the test I listened to hours of the ASN BRC lectures on my computer. The online component has audio synched to the slides, so it really is a way to relive the Chicago experience. The site is a bit balky to navigate but this resource is worth its weight in gold. Tremendous value.

You know how you memorized all the fibrillary diseases as a fellow. Here's a great chart to memorize it again. Joy.
From the ASNBRC who got it from Brenner and Rector*.


* I do not know who the Rector from that duo is but I do wonder if he gets a lot of "Rector? I barely met her!"

In terms of the quality of the lectures, I am a connoisseur of good lectures and a lecture snob when it comes to poor lectures. When I go to Kidney Week or other conference I usually feel that most lectures are actually pretty bad. However, ASN BRC broke mold with excellent lecture after excellent lecture. They had had a few clunkers and the bade ones looked even worse because the bar was set so high by the other speakers. What a crew they assembled.

The one weak point of the course is when the organizers tried to provide some alternative learning strategies. The organizers were not very forthcoming with the motivations for the afternoon interactive sessions but my guess is it goes something like this:
Every year the primary criticisms they get when they look at feedback is the sheer number of hours in lecture is both mind and butt numbing.
The directors response to this is small group, interactive learning sessions. An attempt to flip the class room. Their attempt at this was stymied either by poor planning or limited by physical space. They were able to divide the 500 odd participants into a group of about 100 and a group of 400. Neither of these qualifies as small groups. They did some case based questions but they really were just lectures in disguise. The professors read a question, did the audience-response thing, then proceeded to give a short lecture, sometimes with up to a dozen slides.
Despite inviting audience interaction there was not enough time or an appropriate venue for meaningful audience participation.

A small black mark on an otherwise impressive and highly recommended nephrology review.
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