Training of Surgeons in Peritoneal Dialysis Catheter Placement in the United States: A National Survey

Discussion

Although many factors contribute to the low PD prevalence in the United States, the problem of inadequate training of surgeons in PDCs has not been investigated (1,2,10,16,25,26). This study is the first attempt to evaluate surgical residency training in PDC placement. Timely PDC placement and minimization of complications are necessary to encourage use of PD (5–9,17,18,27,28). Inadequate residency training, resulting in a shortage of surgeons skilled or interested in placing PDCs, may be an underrecognized contributor to PD underutilization and why PDC complications remain a leading cause of technique failure.

In HD, surgeon expertise, willingness, and availability to perform access procedures are viewed as essential (11–15). The Fistula First Initiative, a national effort to improve HD access and outcomes (11–15), embodies this belief. In the Dialysis Outcomes and Practice Patterns Study (DOPPS), the rate of primary fistula failure was substantially lower for surgeons who performed a higher number of fistula procedures during residency (15). Moreover, the likelihood of surgeons placing a fistula was strongly related to case load and degree of emphasis on vascular access during residency (15). In contrast, the importance of surgical training in PD access and how this might influence outcomes and practice has not been studied.

Intuitively, surgeons with adequate training should feel more comfortable placing PDCs and experience fewer complications. However, as shown in Appendix 1, PDC placement may be relegated to the least-experienced trainees with no provision to maintain this skill later in residency. Furthermore, the attitude among some surgeons that PDC placement is an entirely straightforward procedure not requiring much technical skill or special attention is at odds with expert recommendations (5,6,18,28). Better PDC education must be provided to surgeons to correct these misconceptions (5,6,27).

Repetition of procedures during residency is needed for surgical proficiency (24,29). Although no studies have defined the number of PDC insertions needed by surgeons to attain competence, surgical residents may require 20 to 40 patients before reaching an acceptable level of skill in many abdominal surgeries (5,29). We found that most residents placed 2 to ≤5 PDCs during training. This represents a major obstacle to adequate education. Given that 77% of U.S. PD programs start 10 or fewer patients yearly, it is highly improbable that surgery programs can provide enough patients for all residents to be adequately trained in PDCs (5,20). Low PD utilization seems to be the major factor driving inadequate PDC training, a sentiment shared by most program directors.

Approximately half of U.S. programs rely on one specific surgeon to place most PDCs. Given the role of a single designated PDC surgeon in supporting many PD programs, the loss of this one individual could be disastrous if no other similarly skilled or interested surgeon is available. It seems logical that if we do not train more surgeons to place PDCs, fewer will be available to ensure the growth and stability of PD programs. However, training all surgeons in PDCs would be impractical and inefficient given low case volumes and the fact that many surgeons will not be interested in PDCs, regardless of the opportunity. There should be a focus on PDC training only when there is an interest and ability to do so. Ideally, each center should designate two surgeons to perform and teach PDC placement. This would ensure adequate surgical support in case one surgeon is unavailable or leaves. Concentrating efforts on a designated few would help compensate for low referrals and would provide enough patients for these surgeons to maintain expertise and teach PDC placement to trainees.

To accomplish this, we first must address the barriers identified in this study. Attempts to improve training will fail if nephrologists do not refer more patients to PD. Nephrologists must take the initiative to educate surgeons about the negative clinical and economic effect of PDC complications, including the need for HD catheters and hospitalization. A standardized, high-quality PDC training curriculum must be established and made available to interested residents (6). Trainees in surgical specialties with ties to nephrology (e.g., vascular or transplant surgery) should also be encouraged to participate. This curriculum would be accompanied by regular, multidisciplinary audits of PDC outcomes by nephrologists and surgeons together to ensure performance and quality of care (6). If surgeons have better insight into the needs of PD patients and receive regular feedback about their results, there will be impetus for improvement. The current situation in the United States leaves far too much of this to chance.

Other factors in addition to residency training may influence a surgeon's willingness to place PDCs. Because PDCs will at best comprise only a small part of surgical practice, it may be viewed as a poorly reimbursed, time-consuming activity, particularly by private practice surgeons. The observation that only 25% of private centers participated versus nearly 50% of academic centers may support this notion. Thus, arguments for changing payment schemes to create financial incentives for surgeons to place PDCs make sense (5). Surgeons in practice, much like nephrologists, could benefit from sponsored activities such as Peritoneal Dialysis University (PDU) to compensate for lack of PD knowledge. An inaugural surgeon PDU will take place in November 2010 and could represent an important first step in establishing a national forum for surgical PDC training (personal communication, Dr. John Crabtree, March 2010).

What about nephrologists assuming more responsibility for PDC placement (22,27)? Centers using interventional nephrologists to place PDCs have reported excellent outcomes and improved PD utilization, particularly in areas where surgical expertise is unavailable or unsatisfactory (30–33). PDC placement by interventional nephrologists can be accomplished with fewer delays, which may encourage PD utilization by reducing wait times (27,30–33). The American Society of Diagnostic and Interventional Nephrology (ASDIN) has established criteria for certification in PDC insertion to ensure minimum competency for nephrologists (34).

However, relying on the recent generation of nephrologists to place PDCs may have serious limitations. Only 14% of U.S. nephrology fellowship programs provide instruction in PDC placement, and only 9% of nephrology programs teach interventional nephrology using standards suggested by the ASDIN (5,21,22). Although PDC placement by nephrologists can be very successful, the fact remains that only 20.3% of recent U.S. nephrology graduates felt training in PDC placement was important to their career or practice, and only 3.8% of those trained felt competent enough to place PDCs (35).

The ASDIN requires six supervised and ten unsupervised PDC insertions to attain certification (34). Nephrology trainees in one study required at least 23 PDC insertions to reach acceptable skill (36). It remains a challenge then for nephrologists and surgeons to obtain sufficient case volume for PDC training. One consideration when referrals are limited is that technical skills derived from performing other procedures may help surgeons become proficient in PDCs faster than nephrologists (5). Another argument favoring surgical PDC placement is that even with training nephrologists may not attain skill or outcomes comparable to surgeons, particularly if laparoscopic techniques are used (5,18,22).

The strengths and limitations of our study design merit discussion. Because PDC placement is not considered part of the surgical curriculum, performance of this procedure by residents is not routinely reported to ACGME (personal communication, ACGME, August 2008). Furthermore, the lack of specificity of the Current Procedural Terminology (CPT) code 49421 for PDC placement (which includes all types of peritoneal catheters and drains) precluded accurate analysis of the ACGME database (personal communication, ACGME, August 2008). Thus, in the absence of existing data, we felt that surveying program directors would provide the best available account of resident PDC training. Because program directors are responsible for implementing and modifying curriculum, we felt their responses would reflect a program's involvement and willingness to train residents in PDCs. We did not specifically target surgeons who placed PDCs because they likely do so based on their skill or interest and would likely be biased.

Substantial effort was made to encourage participation. Each program director received personalized e-mails and was phoned directly. Both of these strategies have been shown to increase responses, and our rate of 38% is similar to other survey studies (25,27,35,37). Nearly 50% of U.S. academic programs participated, and the sizes of responding versus nonresponding programs appeared similar. Still, nonresponse bias remains a concern. It is likely that responding program directors had more interest in PDC placement. Centers with little experience with PDC placement were probably less inclined to respond. Responses were not verified, so recall bias could be present. Therefore, our results likely overestimate the extent of and support for surgical PDC training. Nonetheless, there seems to be support at a sizeable number (n = 56) of surgery programs for more PDC training, highlighting existing opportunities for collaboration with surgeons.

In conclusion, although many surgery programs train residents in PDC placement, this training appears inadequate and may affect a surgeon's willingness and ability to perform this procedure. Although low PD use by nephrologists is the primary problem, we postulate that inadequate surgical PDC training leads to more frequent complications, further discouraging PD referrals. Fewer referrals prevent surgeons from ever gaining enough experience in PDCs, perpetuating a vicious cycle of mediocre outcomes, dissatisfaction with PD, and low PD utilization.

Nephrologists should develop coordinated efforts with surgeons and institutions to prioritize and support PDC training for designated surgeons and trainees who want to learn this procedure. Related quality improvement measures are also needed to monitor performance, provide feedback, and encourage surgeon accountability for PDC outcomes (6). In areas without surgical interest, interventional nephrologists need to assume responsibility for placing PDCs. Given federal mandates encouraging the use of PD, the availability of PDC expertise in future years becomes even more pertinent (38). This problem deserves more attention and should be considered when discussing strategies to address the trend of declining PD use in the United States.