Perspective

From the2Organ TraNational MReceived

2014. OrigiAddress c

SVC, DepaMedicalCenchristina.m.Published

Foundationrestrictions0272-638http://dx.d

906

Expanding the Role of Objectively Structured ClinicalExaminations in Nephrology Training

Lisa K. Prince, MD,1 Kevin C. Abbott, MD, MPH,1 Felicidad Green, RN,1

Dustin Little, MD,1 Robert Nee, MD,1 James D. Oliver III, MD, PhD,1

Erin M. Bohen, MD, MPH,2 and Christina M. Yuan, MD1

Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of

none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and

evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that

contains both examination and training features and focuses on management and clinical knowledge of rare

hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane

reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since

June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that

inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows

were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who

subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in

managing the event. The OSCE tested and trained fellows in the recognition and management of rare

hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty

training; however, collaboration between training programs would be necessary to validate such exercises.

Am J Kidney Dis. 63(6):906-912. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

This is a US Government Work. There are no restrictions on its use.

INDEX WORDS: Objective structured clinical examination (OSCE); nephrology fellowship; nephrology

training; hemodialysis emergencies; simulation.

Objectively structuredclinical examinations (OSCEs)are used widely in medical education; however,

we know of none reported that are specifically fornephrology fellowship training.1-4 OSCEs are educationand assessment simulation tools used to inculcate andevaluate a specific skill set required in clinical practice.They are case-based scenarios performed in a structuredlearning environment in which trainees are observedand evaluated with an objective checklist, followed bydirect feedback upon conclusion of the OSCE. OSCEsare among the oldest forms of simulation in medicaleducation and usually consist of a series of clinicalstations at which trained actors portray standardizedpatients.1,2,4 We developed an OSCE with both exam-ination and training features5 focused on managementand clinical knowledge of rare potentially catastrophic

1Nephrology Service, Department of Medicine, andnsplant Service, Department of Surgery, Walter Reedilitary Medical Center, Bethesda, MD.October 8, 2013. Accepted in revised form January 3,nally published online March 11, 2014.orrespondence to Christina M. Yuan, MD, Nephrologyrtment of Medicine, Walter Reed National Militaryter, 8901Wisconsin Ave, Bethesda,MD20814. E-mail:yuan@health.milby Elsevier Inc. on behalf of the National Kidney

, Inc. This is a US Government Work. There are noon its use.6/$0.00oi.org/10.1053/j.ajkd.2014.01.419

hemodialysis emergencies: venous air embolism, bloodleak, dialysis membrane reaction, and hemolysis.6

Upon recognition, all 4 of these situations require thesame initial emergency management: stopping theblood pump, clamping off the blood tubing to and fromthe hemodialysis machine, and disconnecting the pa-tient while not returning the blood in the dialysis tubingset because it likely contains substances that will worsenthe ongoing event.Systemic reactions to dialyzers and dialyzer compo-

nents have become uncommon due to the increased useof biocompatible dialysis membranes and gamma ster-ilization,6 whereas venous air embolism,7 hemolysis,8

and blood leaks have become rare because of standardpreventative mechanical and procedural controls usedduring hemodialysis.9-12 However, such controls can beovercome by human error or mechanical malfunction,and nephrologists must be capable of quickly recog-nizing and decisively managing these life-threateningevents. Because they are unlikely to occur duringroutine medical care by an individual fellow duringthe 2-year training period, we developed an OSCEthat trains and tests the fellow’s immediate clinicalemergency response, followed by a multidisciplinaryteaching component presented by nursing staff,nephrology faculty, and senior nephrology fellows.Because these emergencies rarely occur while thenephrologist is present in the dialysis unit or at thebedside, a telephone-call simulation is used. Thenursing preceptor makes a scripted call reporting and

Am J Kidney Dis. 2014;63(6):906-912

The Dialysis Emergencies OSCE

describing the simulated emergency. Trained actorsand complex simulation equipment are not needed.Thus, the OSCE is simple to perform and low cost.

DESCRIPTION OF DIALYSIS EMERGENCIES OSCE

The OSCE, which is given in the last quarter of thefirst fellowship year, consists of four 20-minute casescenarios, described by a script, and a set of checklistquestions (Box 1; Item S1, available as online sup-plementary material). The scenarios were developed,reviewed, and edited by faculty nephrologists, hemo-dialysis nurses, and technicians. Fellows are informedbeforehand of the general OSCE topic, dialysis emer-gencies, and are directed to read the chapter that dis-cusses dialysis complications in the Handbook ofDialysis.6

The precepting team consists of a hemodialysisnurse (registered nurse or licensed practical nurse), anephrology faculty physician, and a second-yearnephrology fellow who has taken the OSCE previ-ously. Teams are assigned by the program directorand the hemodialysis head nurse. Each is assigned asingle scenario to be given to each examinee, whichthey review at least a week before the exercise. Thenurse preceptor assigned to each scenario is in chargeof the simulation, prepares any necessary props aheadof time, and leads the exercise.

Box 1. Example Scenario Wit

Script for Nurse Preceptor: “Dr _______, I’ve been having trouble

on, and now the venous air alarm is going off and there are bubbles

do you want me to do?”

1. _______ Stop dialysis _______

STOP (F

2. _______ Clamp the lines; don’t give back the blood _______

STOP (F

3. FELLOW WILL BE COMING IMMEDIATELY. Y____ N_____

STOP

4. OK. I’ve already done that. Do you want anything else?

____________ High flow, high % O2.

____________ Put patient on the left side, with the head d

____________ Vitals/EKG monitoring

____________ Crash cart

____________ Other

STOP

Fellow Arrival in the Dialysis Unit at OSCE Station:

Tell the fellow that you have a few more questions about the scen

1. What is the most likely cause of these symptoms and signs?

Venous air embolism; Other: ______________

2. What are some ways that air embolism can be produced duri

Leak into system at catheter (after air detector); failure of air

after disabling air detector

3. Why do you place the patient on the left side with the head d

To keep the air in the right heart (atrium and ventricle) and ou

4. What use are high concentrations of O2?

It allows for faster reabsorption of the air (mostly N2) from the

5. Demonstrate the air detector and air detector alarm.

Abbreviations: EKG, electrocardiogram; OSCE, objectively structu

Am J Kidney Dis. 2014;63(6):906-912

The examinee waits in a private clinic office witha telephone and is called by the nurse preceptor, whobegins the OSCE by presenting the emergency,simulating the real-world situation of an emergencycall from the nurse dialyzing a patient (see Box 1). TheOSCE coordinator (usually the program director orassociate program director) directs the process, makingsure that the scenarios begin and end on time.The graded part of the OSCE consists of a checklist

(Box 1; Item S1) that documents whether the examineedirects the nurse (with prompting, if necessary) to stopdialysis and clamp the tubing without returning theblood and recognizes that the patient must be seenimmediately. Failure to perform these 3 tasks, whichare common to all the scenarios, results in failure forthe scenario. The fellow must correctly navigate 3 ofthe 4 scenarios to pass the OSCE. After the fellowindicates that he or she will come immediately to thedialysis unit, the nurse asks specifically if there are anyother orders and checks off those indicated by thefellow on a scenario-specific checklist. If the examineefails the scenario, he or she is directed to the dialysisunit at the point of failure, where the preceptors discussthe rationale for the correct responses with him or her.After arriving in the dialysis unit, the fellow is

directed to the appropriate OSCE station, wherethe physician and nursing preceptors ask additional

h Checklist: Air Embolism

with Mrs White’s catheter really pulling negative since she got

in the venous trap. She’s a little short of breath and dizzy. What

_ Continue dialysis

atal)

__ Give the blood back

atal)

(Fatal)

own.

ario. Circle the answers given by the fellow.

ng dialysis?

detector; “air rinse” or other intervention which allows infusion

own in this scenario?

t of the pulmonary circulation; Other: ______________

blood; Other: ______________

red clinical examination.

907

Prince et al

questions specific to the scenario, some of whichinvolve props, and document the fellow’s answers.This part of the OSCE is primarily for training pur-poses, although it also is an opportunity for the fellowto demonstrate knowledge about the scenario. Theprecepting team discusses the best answers to thespecific question set with the fellow, gives hands-ontraining to identify machine alarms and detectors,and provides literature about the specific scenarios.The scenarios are as follows:

1. Air embolism (Box 1). Props: demonstration of airdetector and air detector alarm on a prepared he-modialysis machine.

2. Blood leak/membrane rupture (Example2 in ItemS1).Props: demonstration of venous pressure alarm,blood leak detector and alarm, and the dialysiseffluent side of dialyzer.

3. Dialysis membrane reaction (Example 3 in Item S1).Props: none.

4. Hemolysis due to chloramines (Example4 in ItemS1).Props: positive chloramine dipstick after dippinginto tap water.

We retrospectively and anonymously surveyed thefellows who had participated (as preceptors or exam-inees) in the OSCE since it began in June 2010 usingSurveyMonkey (https://www.surveymonkey.com/).Participants were asked to rate their level of confidencein acutely managing air embolism, blood leak,membrane reaction, and hemolysis before and afterthe OSCE. The confidence levels that participantscould choose from for each emergency were “veryconfident,” “confident,” “somewhat confident,” and

Table 1. Trainee Confidence in Ability to Manage Dialysis-Associa

Experience With th

Confidence pre-OSCE (N 5 13)

Very confident

Confident

Somewhat confident

Not confident

Confidence post-OSCE (N5 13)a

Very confident

Confident

Somewhat confident

Not confident

Respondents who observed the complication post-OSCE

Helpfulness of OSCE in managing the subsequent complication

Very much

Some

Not at all

Note: This table is based on an anonymous retrospective survey

Abbreviations: NA, not available; OSCE, objectively structured clinaPost OSCE, respondents were significantly more likely to be “

4 emergencies (51/52 responses) versus pre-OSCE (7/52 response

908

“not confident.” Survey participants also were asked ifthey had subsequently seen a case of air embolism,blood leak, membrane reaction, or hemolysis. If theyhad, they were asked if they thought that the OSCE hadhelped prepare them to correctly recognize and treatthe emergency: the options were “verymuch,” “some,”or “not at all.” Comments about the exercise also wererequested.Fifteen fellows have participated in the OSCE as

preceptors and/or examinees since the first adminis-tration in June 2010. No fellow has failed the exercise.Three fellows have served as preceptors only. Twelvefellows have been examinees, 4 of whom have notserved as preceptors.There were 13 responses (87% response rate) to the

survey. The results are summarized in Table 1. Fellows’confidence in their ability to manage the 4 emergenciessignificantly increased after the OSCE. Subsequently, inclinical practice, 23% of the respondents had seen ahemodialysis-associated air embolism; 15% had seen ablood leak, 31% had seen a membrane reaction, andnone had seen an episode of hemolysis. All respondentsreported that the OSCE experience had been at least of“some” help in managing the complication.

DISCUSSION

This OSCE, containing both testing and trainingcomponents,5 focuses on the acute management of 4rare but immediately life-threatening dialysis emer-gencies: air embolism, blood leak, hemolysis, andmembrane reaction. Nephrologists must be able toimmediately recognize and appropriately treat each ofthese potentially lethal events, but are unlikely to gain

ted Emergencies Before and After the OSCE and Subsequent

e Emergencies

Air Embolism Blood Leak Membrane Reaction Hemolysis

0 0 0 1

2 1 2 1

8 8 9 8

3 4 2 3

6 7 7 5

7 5 6 8

0 1 0 0

0 0 0 0

3 (23%) 2 (15%) 4 (31%) 0 (0%)

1 2 3 NA

2 0 1 NA

0 0 0 NA

performed in July 2013.

ical examination.

very confident” or “confident” of their ability to respond to the

s; P , 0.0001, Fisher exact test).

Am J Kidney Dis. 2014;63(6):906-912

The Dialysis Emergencies OSCE

repeated experience with them during training becauseof their rarity. For such clinical events, simulation(of which OSCEs are an example) is an ideal trainingtool.13-16 The OSCE is designed for adult learnersin that it simulates a real-world clinical situation,is practical and relevant, and uses feedback froma multidisciplinary precepting team that includespeers.17-19 Moreover, the simulation is simple and lowcost. It uses repetition to cement a strong memory ofthe necessary immediate response to these emergen-cies13 that must be initiated at the first suspicion of theevent: stop dialysis and clamp the blood tubing, do notreturn the blood in the dialyzer tubing set, and assessthe patient immediately.As the name indicates, OSCEs are designed to be

objective, be structured, and enable the acquisitionand demonstration of clinical knowledge. As origi-nally described by Hardin et al,1 the OSCE consistedof a series of “procedural stations” followed by“question and answer stations.” Procedural stationsoften use standardized patients, but may feature afocused task (such as interpreting a diagnostic test ordemonstrating a skill using a simulation device).Standardized patients prevent inconvenience anddiscomfort to actual patients and also prevent bias andvariation in the simulation. However, standardizedpatients are not necessary to an OSCE and are amongits more expensive aspects.20 In our OSCE, ratherthan a standardized patient, a standardized nursinginteraction/script is used.OSCEs are “criterion referenced.” They do not

compare examinees against one another, but againstobjective thresholds, and thus assess competency.19

Task homogeneity during the test (ie, focus on oneclinical competency or competency component) in-creases reliability. OSCEs also provide opportunitiesfor formative feedback. Our OSCE uses an objectiveassessment scheme that, like the correct immediateresponse, is the same for each scenario. Trainees areexpected to pass on initial attempts.Simulations, including OSCEs,4 are training exer-

cises that attempt to present clinical problems realis-tically. The trainee interacts with the simulation (eg,an actor, an advanced technical model, or a script) ashe or she would under natural conditions.21,22 High-quality simulations use several important features.They provide feedback, the essential feature of aneffective simulation. They also incorporate repetitiveand deliberate practice, are integrated into the cur-riculum, provide for a measure of outcome, and have“simulation fidelity.”16,22

Our OSCE incorporates feedback and is repetitiveand deliberate. The 3 steps of emergency managementare repeated 4 times during the exercise. The traineealso repeats the OSCE when he or she acts as a pre-ceptor in the second year of training.

Am J Kidney Dis. 2014;63(6):906-912

It is integrated into the curriculum and occurs atthe end of the training year after basic lectures ondialysis technology, membrane biocompatibility, anddialysis water treatment and assigned reading on thesubject.The outcome (passing or failing) is measured using

objective trainee responses, not preceptor impressions.The increased confidence in ability to manage theseemergencies reported by the trainees after theOSCEalsois an independent outcome, but it is retrospective andsubjective. We have no data for the impact of the OSCEon subsequent clinical performance. The number oftrainees who subsequently managed one of these com-plications seems high (Table 1), and it is likely that ep-isodes were observed by more than one nephrologist atone of the small number of medical centers to which ourmilitary nephrology graduates are assigned.We chose to simulate only the initial phase of the

emergency in the OSCE. We believe that it is anaccurate depiction of the brief period on which it isfocused and thus has simulation fidelity.22 Normally,the nephrologist would have to make a decisionabout initial management based on a verbal telephonicdescription by a dialysis nurse. The exercise is designedin part to assess how the fellow responds when con-tacted by the nurse. Renal replacement therapy (RRT)requires close collaboration between nurses and physi-cians. In our opinion, dialysis simulation scenarios mustinclude nurses’ input during both development andimplementation.Training programs with greater technical resources

could consider additional simulation of the bedsidesituation—this might be particularly useful for the sce-nario depicting air embolism (Box 1)—and perhapsinvolve a standardized patient. However, some simu-lation is incorporated subsequent to the initial call andserves a training purpose. This includes recognizingdipstick positivity for chloramines (Example 4, ItemS1)and demonstrating pertinent detectors and alarms (Box1; Examples 2 and 4 in Item S1).Management scenariosfor other rare events that complicate hemodialysis (eg,tetany due to an inappropriately low calcium dialysateconcentration or life-threatening hyperkalemia withelectrocardiogram changes) also could be developedand are being considered by our program.Simulations have been described for nephrology

procedural training in temporary dialysis catheterplacement and kidney biopsy.23,24 Training nurses incontinuous RRT also has been described.25 Sophisti-cated simulation technology may be used, but modelsalso may be simple and inexpensive (eg, the turkeybreast/porcine kidney biopsy simulation tool). In ourown program, we use the dialysis catheter insertionand kidney biopsy simulations referenced, whichhave been shown to improve trainee confidence leveland clinical performance.26,27

909

Prince et al

Not surprisingly, simulations have been compared tonaturalistic theater.28,29 Although striving for fidelity,they are never completely authentic due to cost, tech-nological limitations, and in some cases, ethical con-siderations.21 However, the sophistication of the “set” isnot of key importance, but rather whether teaching andevaluation goals are met. Our dramatic scenario is verysimple, requiring only a nurse, a script, and a telephone.Rather than a blockbuster action movie with computer-generated imagery, our simulation is like a radio play.Because of its simplicity and low cost, this

training OSCE may be readily introduced intonephrology fellowship programs. Our program usesit as a tool to assess progress in the AccreditationCouncil for Graduate Medical Education (ACGME)clinical competencies.30 OSCEs can be implementedsuccessfully and inexpensively by training pro-grams.31 Although OSCEs, and simulations in gen-eral, are excellent and recommended methods offellow training and assessment, the decline infunding for graduate medical education and the timeconstraints of faculty make it imperative that they beefficient, simple, and cost-effective wheneverpossible, allowing smaller programs with fewer re-sources to implement them.32 This constraint alsoapplies to prospective validation of educationalsimulation tools, such as the OSCE.The OSCE significantly increased trainee confi-

dence in managing the dialysis emergencies tested.Other nephrology simulations have used trainee con-fidence as an indicator of effectiveness.24,26 It wouldbe difficult to perform prospective validation in a smalltraining program such as ours. The problem of alimited number of fellows, even when a small numberof programs work together, has been an impediment totimely validation for nephrology procedural simula-tions.23,24,27 Larger numbers of programs would needto cooperate to assess effectiveness. A possible designwould randomly assign programs and/or fellows toeither the OSCE or to usual training alone. At 10months into the first year of fellowship, participantsrandomly assigned to the OSCE arm would beassigned the reading from the Handbook of Dialysis6

and perform the OSCE. Programs randomized to thecontrol arm would assign the reading from the Hand-book of Dialysis6 only. Both groups would rate theirconfidence level at managing the emergencies at12 months into fellowship and take a written exami-nation based on the OSCE assessing medical knowl-edge and patient care components of managementusing online anonymous survey software. It wouldrequire approximately 40 fellows in each arm to detecta 50% versus 80% pass rate, using a 2-sided samplesize calculation with a error of 0.05 and power of 0.80.OSCEs and simulations have great potential to

improve nephrology training, especially in procedure

910

performance (eg, kidney biopsy and temporary hemo-dialysis catheter insertion) and RRT. Testing andtraining scenarios should be developed to document theattainment of specific nephrology competency mile-stones. Potential milestones include the ability to writeRRT orders that address specific patient issues (eg, hy-potension on dialysis or anticoagulation), managementof acute kidney transplant rejection, and competence inurinalysis performance and interpretation.30

Applying simulation to RRT is a special case.Dialysis is prescribed by the nephrologist but physi-cally performed by nursing staff. Because dialysis isa multidisciplinary rather than physician-dominatedprocedure, it should be nurse/physician teams thatdevelop dialysis-related simulations. Dialysis nurseshave insight and hands-on skill that nephrologists donot, and a specific skill that nephrology fellows mustlearn is effective communication with dialysis nurses.With clever and imaginative scenario development,nurses and data may be able to serve as the stan-dardized patient, and advanced technical simulationsof dialysis equipment may be unnecessary.Validating nephrology-specific OSCEs and simu-

lations will require the collaboration of multipleprograms if it is to occur expeditiously. Perhaps aneducational research consortium under the auspicesof our professional societies, the American Board ofInternal Medicine, and the ACGME, could worktogether to validate existing OSCEs and simulationsor those proposed by individual programs with apriori outcome measures.33 The American Society ofNephrology–sponsored in-training examination couldbe leveraged to this purpose. Inexpensive onlinesurvey tools also could be used.Nephrology programs could be stratified and ran-

domized in blocks, and the outcomes could be assessedwith larger numbers of trainees. Thus, evidence-basedOSCEs could be adopted generally and used to assesswhether our trainees are “ready for unsupervisedpractice” in the competency or subcompetencyaddressed by the OSCE. The structure and results ofthe research would be transparent to everyone. More-over, this would not have to be an expensive under-taking, especially if the proposed OSCEs are low costand simple to implement, the selected outcomesare straightforward, and the validation projects aremanaged by our educational professional societies.“Citizen science,” or crowd-sourced science, has

been a very successful approach to problems in areasas disparate as astronomy and ornithology in gatheringlarge data sets designed and analyzed by professionalscientists. It is defined as “the systematic collectionand analysis of data; development of technology;testing of natural phenomena; and the dissemination ofthese activities by researchers on a primarily avoca-tional basis.”34 A population of dedicated enthusiastic

Am J Kidney Dis. 2014;63(6):906-912

The Dialysis Emergencies OSCE

amateurs (eg, birders and amateur astronomers) isinvaluable for this type of research. This model alsocould be effective for nephrology fellowship educationresearch. Working together, nephrology educator“citizen scientists” could quickly and cost-effectivelyvalidate OSCEs, simulations, and other educationaltools. Such programs would benefit our fellows, be asource of academic satisfaction and excitement,and demonstrate professionalism and practice-basedlearning and improvement.

ACKNOWLEDGEMENTSThe views expressed in this article are those of the authors and

do not reflect the official policy of the Department of the Army,Department of the Navy, Department of Defense, or US govern-ment. We thank the nephrology faculty, fellows, and dialysisnursing staff for enthusiastically participating in and helping torefine the dialysis emergencies OSCE.Support: None.Financial Disclosure: The authors declare that they have no

relevant financial interests.

SUPPLEMENTARY MATERIAL

Item S1: Example Scenarios 2-4 with Checklist: Blood Leak,Membrane Reaction, and Hemolysis.Note: The supplementary material accompanying this article

(http://dx.doi.org/10.1053/j.ajkd.2014.01.419) is available at www.ajkd.org

REFERENCES1. Harden RM, Stevenson M, Downie WW, Wilson GM.

Assessment of clinical competence using objective structuredexamination. Br Med J. 1975;1:447-451.

2. Avelino-Silva TJ, Gil LA Jr, Suemoto CK, et al. Imple-menting the objective structured clinical examination in a geriat-rics fellowship program—a 3-year experience. J Am Geriatr Soc.2012;60(7):1322-1327.

3. Berman JR, Lazaro D, Fields T, et al. The New York CityRheumatology Objective Structured Clinical Examination: five-year data demonstrates its validity, usefulness as a unique ratingtool, objectivity, and sensitivity to change. Arthritis Rheum.2009;61(12):1686-1693.

4. Wallenstein J, Heron S, Santen S, Shayne P, Ander D.A core competency-based objective structured clinical examina-tion (OSCE) can predict future resident performance. Acad EmergMed. 2010;17(suppl 2):S67-S71.

5. Brazeau C, Boyd L, Crosson J. Changing an existing OSCEto a teaching tool: the making of a teaching OSCE. Acad Med.2002;77(9):932.

6. Sherman RA, Daugirdas JT, Ing TS. Complications duringhemodialysis. In: Daugirdas JT, Blake PG, Ing TS, eds. Handbookof Dialysis. 4th ed., Philadelphia, PA: Wolters Kluwer Health;Lippincott Williams & Wilkins; 2007.

7. Vanholder V, Hoenich N, Ringoir S. Morbidity and mor-tality of central venous catheter hemodialysis: a review of 10years’ experience. Nephron. 1987;47(4):274-279.

8. De Oliveira RM, de los Santos CA, Antonello I, d’Avila D.Warning: an anemia outbreak due to chloramine exposure in aclean hemodialysis unit—an issue to be revisited. Ren Fail.2009;31(1):81-83.

Am J Kidney Dis. 2014;63(6):906-912

9. Hoenich NA, Ronco C, Levin R. The importance of waterquality and haemodialysis fluid composition. Blood Purif. 2006;24:11-18.

10. Ward DM. Chloramine removal from water used in he-modialysis. Adv Ren Replace Ther. 1996;3(4):337-347.

11. Süm Öz kan G, Ulusoy S. Acute Complications of Hemodi-alysis. In: Goretti Penido M, ed. Technical Problems in Patients onHemodialysis. InTech, Rijeka, Croatia; 2011. http://www.intechopen.com/books/technical-problems-in-patients-on-hemodialysis/acute-complications-of-hemodialysis. Accessed August 6, 2013.

12. Lodi CA, Vasta A, Hegbrant MA, et al. Multidisciplinaryevaluation for severity of hazards applied to hemodialysis devices:an original risk analysis method. Clin J Am Soc Nephrol. 2010;5:2004-2017.

13. Grenvik A, Schaefer JJ III, DeVita MA, Rogers P. Newaspects on critical care medicine training. Curr Opin Crit Care.2004;10(4):233-237.

14. Weinberg ER, Auerbach MA, Shah NB. The use ofsimulation for pediatric training and assessment. Curr OpinPediatr. 2009;21(3):282-287.

15. Andreatta PB, Bullough AS, Marzano D. Simulation andteam training. Clin Obstet Gynecol. 2010;53(3):532-544.

16. Satava RM. The revolution in medical education—the roleof simulation. J Grad Med Educ. 2009;1(2):172-175.

17. Kaufman DM. Applying educational theory in practice.BMJ. 2003;326:213-216.

18. Spencer J, Jordan R. Educational outcomes and leadershipto meet the needs of modern health care. Qual Health Care.2001;19(suppl II):ii38-ii45.

19. Carraccio C, Englander R. The objective structured clinicalexamination: a step in the direction of competency-based evalua-tion. Arch Pediatr Adolesc Med. 2000;154:736-741.

20. Carpenter JL. Cost analysis of objective structured clinicalexaminations. Acad Med. 1995;70:828-833.

21. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL,Scalese RJ. Features and uses of high-fidelity medical simulationsthat lead to effective learning: a BEME systematic review. MedTeach. 2005;27(1):10-28.

22. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ.A critical review of simulation-based medical education research:2003-2009. Med Educ. 2010;44:50-63.

23. Mrug M, Bissler JJ. Simulation of real-time ultrasound-guided renal biopsy. Kidney Int. 2010;78(7):705-707.

24. Barsuk J, Ahya SN, Cohen ER, McGaghie WC,Wayne DB. Mastery learning of temporary hemodialysis catheterinsertion by nephrology fellows using simulation technology anddeliberate practice. Am J Kidney Dis. 2009;54:70-76.

25. Mottes T, Owens T, Niedner M, Juno J, Shanley TP,Heung M. Improving delivery of continuous renal replacementtherapy: impact of a simulation-based educational intervention.Pediatr Crit Care Med. 2013;14(8):747-754.

26. Dawoud D, Lyndon W, Mrug S, Bissler JJ, Mrug M.Impact of ultrasound-guided kidney biopsy simulation ontrainee confidence and biopsy outcomes. Am J Nephrol. 2012;36:570-574.

27. Ahya SN, Barsuk JH, Cohen ER, Tuazon J, McGaghie WC,Wayne DB. Clinical performance and skill retention aftersimulation-based education for nephrology fellows. Semin Dial.2012;25(4):470-473.

28. Unalan PC, Uzuner A, Cifcili S, Akman M, Hancioglu S,Thulesius HO. Using theater in education in a traditional lectureoriented medical curriculum. BMC Med Educ. 2009;9:73.

911

Prince et al

29. Jacobsen T, Baerheim A, Lepp MR, Schei E. Analysisof role-play in medical communication training using a theatricaldevice the fourth wall. BMC Med Educ. 2006;6:51:1-8.

30. Yuan CM, Nee R, Abbott KC, Oliver JD. Milestones fornephrology training programs: a modest proposal. Am J KidneyDis. 2013;62(6):1034-1038.

31. Poenaru D, Morales D, Richards A, O’Connor HM.Running an objective structured clinical examination on a shoe-string budget. Am J Surg. 1997;173(6):538-541.

912

32. Sullivan G, Simpson D, Cooney T, Beresin E. A milestonein the milestones movement: the JCME milestones supplement.J Grad Med Educ. 2013;5(1 suppl 1):1-4.

33. Parker MG. Nephrology training in the 21st century: towardoutcomes-based education. Am J Kidney Dis. 2010;56(1):132-142.

34. Finalizing a definition of “citizen science” and “citizen sci-entists.” OpenScientist Blog. September 3, 2011. http://www.openscientist.org/2011/09/finalizing-definition-of-citizen.html. AccessedDecember 15, 2013.

Am J Kidney Dis. 2014;63(6):906-912