Assessing achievement in nephrology training: using clinic chart audits to quantitatively screen competency

Area of Science:

• Medical Education
• Nephrology Fellowship Training
• Competency-Based Assessment

Background:

• Entrustable Professional Activities (EPAs) are crucial for assessing physician competency and trainee development.
• Managing a nephrology outpatient clinic has been proposed as a key EPA for nephrology fellowship training.

Purpose of the Study:

• To evaluate the longitudinal performance of nephrology fellows in managing an outpatient clinic using a chart audit tool.
• To determine if clinic management can be quantitatively assessed as an EPA and identify areas for improvement.

Main Methods:

• Retrospective cohort study analyzing outpatient encounter chart audits from 2008-2013.
• A validated chart audit tool assessed performance, with a median of 7 attending nephrologists auditing an average of 1,686 charts annually.
• 18 fellows were audited, with 12 participating in both their first and second training years.

Main Results:

• Chart audit deficiencies significantly decreased from the first to the second training year (17.3% vs 5.4%, P<0.001).
• Deficiencies also declined within the first year (22.2% vs 12.3%, P=0.002), primarily due to omission errors.
• Fewer quality indicator deficiencies in hypertension and anemia management were observed in the second year. Yearly deficiencies ≥5% correlated with lower In-Training Examination (ITE) scores for second-year fellows (P=0.03).

Conclusions:

• Managing a nephrology outpatient clinic serves as a valid EPA, with performance improving longitudinally.
• The chart audit tool effectively identifies deficiencies across multiple competencies, enabling quantitative assessment and remediation.
• This approach moves beyond assessing only medical knowledge to evaluating broader clinical skills essential for nephrologists.