Twenty percent of Canadian nephrology fellows in the aforementioned Clark et al. survey performed no catheter insertions over a six month time period [9]. It should not be believed that this represents a lack of opportunity for catheter insertions, as there are many temporary insertions happening at teaching centres. For example, in Ontario in 2013, at the four teaching centres (Hamilton, Kingston, London, and Ottawa), there were over 650 temporary hemodialysis catheter insertions (Ontario Renal Network, unpublished data). It could be that lack of catheter insertions by fellows represents a decreased emphasis and willingness to teach this skill. Consultants in academic centres need to take an increased leadership role here. The lack of “opportunity” should not be considered a valid reason for removing this skill as training core competency.
Nephrologist should not be dependent on other services such as interventional radiology (IR) for catheter insertion for a number of reasons: First, at most centers, the IR service is not always available, which is problematic if dialysis is needed urgently (e.g. overdose, hyperkalemia). Second, it is possible that IR would not prioritize temporary hemodialysis catheter insertion, resulting in longer wait times or hospitalizations for patients waiting for catheter insertions. Third, there may be reduced complications for insertions performed by nephrologists. Significantly longer wait times, hospitalization times and worse safety outcomes have been noted for paracentesis when performed by IR versus medicine [19].
Nephrologists do not want to develop a culture of dependency as this could cripple our ability to provide urgent dialysis, a life saving therapy. If the Royal College was to remove this as a requirement of training, then which service would take ownership over temporary hemodialysis catheters insertions? In order to ensure hemodialysis remains under the sole purvey of nephrology, nephrologists must be able to provide dialysis in an emergency setting. Nephrologists cannot and should not leave temporary catheter insertions in the hands of any other service.
The data demonstrates that if an individual is trained appropriately using SBML and USG, they will have minimal difficulty inserting catheters. This is important for two reasons. First, in the authors experience, once you have been trained appropriately you will maintain an appropriate level of comfort and competence in inserting catheters even if you insert catheters only once every few years. There is no increased risk to the patient, because USG helps mitigate against complications. Further, nephrologists with a low frequency of insertion could maintain their competence by occasionally attending an SBML training program, if needed.
Second, for even those trainees who are not “procedurally oriented”, the use of SBML and USG levels the playing field (all trainees who attended Clark et al’s training achieved the passing score [12]). Catheter insertion no longer becomes a procedure which is done by “feel”. Rather, it becomes a technical skill which can easily be mastered. Therefore, even the weakest trainees can be certified as competent operators. However, it would be necessary for all nephrology training programs to have access or provide access to SBML training environments and have an ultrasound available for all insertions.
Nephrology fellowship programs should not be focused solely on training people who are destined for academia. Instead, they should prepare fellows to practice anywhere in Canada. This means that fellows must be competent in temporary dialysis catheter insertion. A trainee’s career path and centre where they will practice is never a certainty and may even change mid-career, it is essential that they learn this skill to maintain their marketability. Given the poor job prospects in nephrology in Canada, no fellow should be closing doors.
