A Dialysis Medical Director Rotation for Nephrology Fellows: A Single Center’s 10-Year Experience

Abstract

Rationale & Objective

Many nephrology fellows will eventually become dialysis unit medical directors, yet few receive formal training on the responsibilities of this position. This study reports on our 10-year experience conducting a dedicated medical director rotation for nephrology fellows.

Study Design

An observational longitudinal study of a month-long medical director rotation designed to prepare nephrology fellows for leadership roles in dialysis facilities.

Setting & Participants

From 2014 to 2023, 36 nephrology fellows at the Mayo Clinic in Rochester, MN completed the rotation.

Quality Improvement Activities

Fellows were surveyed before and immediately after the rotation. Postgraduation surveys assessed the rotation’s effect on the fellows’ clinical practice.

Outcomes

The study evaluated how well the rotation improved fellows’ understanding of the medical director role, its influence on their clinical practice, and the importance of incorporating this training into fellowship programs.

Analytic Approach

Quantitative and qualitative survey responses from fellows before and after the rotation and postgraduation were analyzed.

Results

Before the rotation, only 5% of fellows had a strong understanding of the medical director’s role, increasing to 100% after completion. None felt well prepared for the role before rotation, whereas 81% reported feeling well prepared afterward. Among graduated fellows, nearly half served as a dialysis facility medical director, 70% found the rotation valuable to their practice, and 30% found it somewhat valuable. Additionally, 85% considered it very important to include a medical director rotation in fellowship training.

Limitations

Single-center study.

Conclusions

A structured medical director rotation within a general nephrology fellowship effectively prepares fellows for leadership roles in dialysis facilities and could serve as a model for other institutions.

Plain Language Summary

The increasing prevalence of patients with kidney failure has expanded the role of dialysis facility medical directors, yet many nephrology fellows receive little formal training for this leadership position. To address this gap, our fellowship program introduced a dedicated medical director rotation in 2014. We surveyed current and graduated fellows to assess the rotation’s effect. Results showed that participation significantly improved fellows’ understanding and preparedness for the role. Graduates found the rotation highly beneficial, though they identified areas for improvement, such as financial management training. Our study highlights the importance of a structured medical director education in nephrology fellowships, demonstrating that such training enhances leadership, operational, and clinical skills, ultimately improving dialysis facility management and patient care.

With the projected increase in the prevalence of patients with kidney failure,^1,2 the demand for trained dialysis facility medical director is increasing. As this need grows, the role of the dialysis medical director has evolved and expanded.³ Responsibilities now encompass safety monitoring,^4,5 infection control, quality improvement,⁴ population management, leadership,⁶ supervision, education,^3,5,7 medico-legal management, and conflict resolution,^8,9 among others. Many nephrology fellows will eventually become dialysis medical directors, but most fellowship programs do not provide formal training on the specific responsibilities of this position.⁶ To assess this gap, we surveyed 5 current or recent dialysis facility medical directors who did not have a dedicated medical director rotation during their fellowship. Three reported receiving no training on the role, whereas 2 reported minimal training. Notably, 4 out of 5 believed that a structured rotation during fellowship would have been helpful. Their insights on how such a rotation might have helped them are listed in Table S1.

Recognizing the evolving role of dialysis facility medical directors and the need for targeted education, our nephrology fellowship program initiated a medical director rotation for general nephrology fellows in 2014. The goal was to provide a comprehensive exposure to the diverse responsibilities of a medical director, including administrative duties.¹⁰ This study details our experience in implementing this dedicated rotation, designed to prepare fellows for the critical yet often underemphasized role of a medical director in a dialysis facility.

Methods

Survey Design and Administration

All 36 fellows in training from July 2014 to June 2023 were surveyed about their understanding of the role of a medical director at the start and immediately after the rotation. Graduated fellows were surveyed from December 2023 to March 2024 about the effect of the medical director rotation on their practices, how well the rotation prepared the fellows for the responsibilities of a dialysis unit medical director, and the use of point-of-care ultrasonography (POCUS) in outpatient hemodialysis units. The clarity of the survey for graduated fellows was assessed and finalized beforehand by administering it to 2 colleagues. The questionnaires for these surveys are included in the Supplementary Materials (Items S1-S3).

The Institutional Review Board approval and informed consent was not required as the study was determined to be “Not Research” by the Mayo Clinic Institutional Review Board. The electronic survey questionnaire was distributed through official email by the project administrator to ensure secure and reliable delivery. Participants returned the completed questionnaires to the project administrator, and the researchers collected and analyzed the responses. To uphold the confidentiality of participants, strict anonymity measures were implemented throughout the survey process, preventing any identification of individual respondents.

Design of the Dialysis Medical Director Rotation

The dialysis unit where fellows do the rotation is a 24-bed, nonprofit hemodialysis unit that conducts 2 shifts of patient care 6 days a week and is owned and managed by Mayo Clinic in Rochester, MN. The rotation occurs during the final year of the general nephrology fellowship and is a required rotation. The “Deliberate Practice” and “Automaticity and Skill Expertise” conceptual frameworks were primarily used in the course design.11, 12, 13 Specifically, the dialysis unit medical director designed a curriculum focused on simulation and procedural skills.

Before the rotation, the fellow meets with the rotation supervisor, who is the dialysis facility’s medical director, to discuss goals and expectations and the roles and responsibilities of a medical director, many of which are unique to the rotation (Table 1). The fellow collaborates with key facility personnel, including the nurse supervisor and administrator, and actively participates in the facility’s monthly interdisciplinary team and quality assurance and process improvement meetings. Additionally, the fellow attends the dialysis system’s monthly medical directors’ meeting and delivers a presentation on a dialysis-related topic at the facility’s monthly staff meeting. As part of hands-on training, the fellow evaluates dialysis accesses, performs at least one POCUS examination each day,14, 15, 16 instructs a staff member on POCUS use for assessing an arteriovenous fistula or graft, prepares a dialysis machine, cannulates an arteriovenous fistula or graft, responds to a mock emergency, and participates in a simulated facility inspection (Table 2).¹⁴ Although there are no formal didactic sessions, the fellow meets daily with the rotation supervisor to discuss interesting cases and dilemmas. Each week, the fellow reviews an article from the CJASN series on the Role of the Medical Director and engages in a discussion about the article with the rotation supervisor.¹⁷ Surveys of fellows in training were analyzed to gather feedback for improving the rotation, and, over time, several enhancements were implemented based on their suggestions.

Table 1.

Role and responsibilities of the Nephrology Fellow during the Medical Director Rotation

Role	Responsibilities
Safety	•Respond to a mock emergency •Respond to a mock inspection
Infection control	•Overseeing water processing plan •Discuss blood stream infection prevention plan •Discuss infection control precautions
Quality assurance	Quality improvement-related responsibilities •Attend the dialysis facility’s monthly interdisciplinary team and quality assurance improvement meeting •Propose a quality improvement project Patient care-related responsibilities •Evaluate patients needing care •Examine patients arteriovenous accesses •Write dialysis orders and prescriptions for new patients •See all patients and write notes at the facility in one day •See patients at an outreach dialysis facility •Participate in care plan conferences Procedure-related responsibilities •Cannulate at least one arteriovenous fistula or graft •Perform at least one POCUS examination each day •Set up a dialysis machine for use
Education	•Instruct facility staff members on POCUS use for arteriovenous access evaluation and cannulation •Speak on a dialysis-related topic at the facility’s monthly staff meeting •Select a journal article for discussion during the hemodialysis continuity clinic monthly
Supervision	Supervise junior fellows and medical students who rotate in dialysis unit
Leadership	•Meet with the facility’s nurse supervisor and administrator •Meet with the facility’s charge nurse daily •Meet with the dialysis system’s regulatory expert •Notify the facility’s providers changes in patients’ care •Attend the dialysis system’s medical directors meeting

Table 2.

Various Mock Emergencies and Inspections Responded to by Fellows During the Rotation

Emergencies	Inspections
Blizzard approaching	Discuss responsibilities of a med director during an inspection
Tornado approaching	Discuss infection control precautions
Massive rainstorm caused flooding	Discuss tuberculosis prevention and control plan
Power outage following a storm	Discuss blood stream infection prevention plan
Fire in facility	Discuss care plan policies
Shooter	Review quality assurance and process improvement methods used in unit
Chloramine-positive tests	Discuss policy on involuntary discharge of patients
Work planned on water main	Discuss water room policies
Agitated patient	Discuss how patient concerns are handled
Patient fell in parking lot	Discuss patient fall prevention plan
Patient with hemolysis	Review how kidney transplantation is promoted
Patient with air embolism	Discuss how education is provided to nurses and technicians
Patient needing CPR
Patient with chest pain
Fistula bleeding

Abbreviations: CPR, cardiopulmonary resuscitation.

A central component of the rotation involves the daily management of outpatient hemodialysis patients. The fellow meets with the dialysis facility’s charge nurse each morning and maintains ongoing communication throughout the day to identify patients requiring evaluation and intervention. The fellow coordinates care changes with the facility’s advanced practice provider or attending nephrologists. The fellow evaluates patients on an as needed basis, but on one designated day the fellow assesses all the patients at the facility, to enable training for the fellow on how to practice efficiently. For patients initiating dialysis, the fellow evaluates the patient and adjusts the dialysis prescription and medications as needed. On 1 or 2 designated days the fellow sees patients at another dialysis facility, to broaden the fellow’s exposure to dialysis practices.

The rotation ends with an oral examination conducted by the medical director, encompassing multiple components that assess the fellow’s knowledge and decision-making skills. The examination begins in the water processing room, where the fellow answers questions about the water purification processes and the equipment. The fellow then evaluates and discusses possible care adjustments for 3 separate patients who have one of the following clinical issues: uncontrolled phosphorus levels, the presence of a hemodialysis catheter rather than a permanent hemodialysis access, and a dialysis prescription of less than 4 hours. Next, the fellow meets individually with 6 nurses or hemodialysis technicians, engaging in discussions about questions related to 6 core responsibilities of a medical director: safety, infection control, quality assurance, leadership, supervision, and education. The final component involves case discussions requiring medical director-level decision-making, including topics such as end-of-life care, infection control, patient behavior management,⁹ and care coordination during natural disasters.¹⁸ To successfully complete the examination, the fellow must demonstrate competence in each section.

Data Analysis

Descriptive analysis was primarily used in this study. We analyzed fellows' attitudes toward the dialysis medical director rotation before and after participation, feedback from graduated fellows, the rotation’s effect on their practices, their suggestions for improving fellowship training for future medical directors, and recommended changes to the rotation. Additionally, the effectiveness of the medical director rotation in preparing graduated fellows for their responsibilities was assessed using a 4-point scale (0-3): 0 indicates “not at all,” 1 indicates “little,” 2 indicates “some,” and 3 indicates “much.” The study reports the average score based on these responses.

Results

Fellows’ Attitudes About the Rotation Before and After Participation

Of the 36 fellows, 21 (58%) completed both the pre- and postrotation surveys (Table 3). Before the rotation, only 1 (5%) had a strong understanding of the medical director’s role, whereas 16 (76%) had a partial understanding, and 4 (19%) had little to no understanding. After completing the rotation, all fellows reported a clear understanding of the medical director’s role. Regarding preparedness, none of the fellows initially felt fully ready to serve as a medical director, 17 (81%) felt partially prepared, and 4 (19%) felt unprepared. After the rotation, all fellows felt prepared, with 17 (81%) reporting they were well prepared and 4 (19%) feeling partially prepared. Notably, the percentage of fellows expecting to pursue a medical director role were similar before and after the rotation (71% vs 76%).

Table 3.

Attitudes of Fellows in Training Toward Dialysis Medical Director Rotation Before and After Rotation

Questionsa	Responses	Before Rotation n (%)	After Rotation n (%)
How well do you understand the role and responsibilities of a medical director?	Very well	1 (5)	21 (100)b
	Somewhat	16 (76)	0 (0)
	Not much	4 (19)	0 (0)
How prepared are you to work as a medical director?	Well prepared	0 (0)	17 (81)c
	Partially prepared	17 (81)	4 (19)
	Not prepared	4 (19)	0 (0)
Do you expect to work as a medical director?	Yes	15 (71)	16 (76)d
	Maybe	4 (19)	5 (24)
	No	2 (10)	0 (0)

^aA subjective survey conducted before and after the medical director rotation to evaluate fellows in training on their understanding of the role, level of preparedness, and interest in pursuing a position as a dialysis unit medical director.

^bBefore the rotation, only 5% of fellows understood the roles and responsibilities of a medical director, whereas after the rotation, all fellows demonstrated a clear understanding.

^c81% reported feeling well prepared to serve as a medical director postrotation, compared with none before the rotation.

^dThe percentage of fellows expecting to pursue a medical director role remained unchanged before and after the rotation (71% vs 76%).

Feedback from Graduated Fellows About the Rotation

Of the 36 fellows, 27 (75%) responded to the postgraduation survey, with 26 completing it in full (Table 4). Among respondents, 46% had worked as a medical director. All found the rotation beneficial to their practice: 70% reported it was highly helpful and 30% found it somewhat helpful. Additionally, all agreed on the importance of incorporating a medical director rotation into fellowship training, with 85% considering it very important and 15% viewing it as somewhat important. The medical director rotation affected the practices of graduated fellows by enhancing their clinical and technical skills; preparing them for medical directorship; developing leadership, administrative, and quality improvement competencies; and providing practical experience with workflow and operations (Table 5). The unedited narrative responses detailing how the rotation benefited their practices are provided in Table S2.

Table 4.

Attitudes of Graduated Fellows Toward the Medical Director Rotation

Questionsa	Responses	n (%)
Have you worked as a hemodialysis unit medical director?	Yes	12 (46)b
	No	14 (54)
How much did the medical director rotation help your clinical practice overall?	Much	19 (70)c
	Some	8 (30)
	Not much	0 (0)
How important is it for a fellowship to include a rotation to prepare fellows to serve as a hemodialysis unit medical director?	Very important	22 (85)d
	Somewhat important	4 (15)
	Not important	0 (0)

^aA subjective survey conducted among graduated fellows who completed the medical director rotation to evaluate its effect on their clinical practice and their perspectives on the importance of incorporating the rotation into a nephrology fellowship program.

^bAmong graduated fellows who completed the medical director rotation, nearly half (46%) went on serve as medical director of hemodialysis unit.

^c70% reported that the rotation significantly benefited their overall clinical practice.

^dThe majority (85%) emphasized the importance of incorporating the medical director rotation into fellowship training.

Table 5.

Effect of the Medical Director Rotation on the Practices of Graduated Fellows who Had Medical Director Rotation

Themes	Key Points of Each Response
Learning Clinical and Technical Skills	No 4: Better understanding of the inner workings and technical aspects of dialysis.
	No 8: Learned water treatment, contingency planning, team roles, machine setup, QAPI, and infection control.
	No 12: Learned quality control, safety, infection control, and patient management issues.
	No 13: General workflow, responsibilities, and effective organization in dialysis practice.
Preparation for Medical Directorship	No 1: Equipped with skills to manage dialysis issues because of comprehensive rotation training.
	No 3: Insights into medical director duties and optimal patient care.
	No 5: Envisioned the role of a medical director. Gained insights into water treatment, emergency planning, and patient meetings.
	No 7: Increased comfort with dialysis complications and unit management. Better prepared for practice.
	No 9: Understanding the responsibilities and roles of medical directorship.
	11: Provided context on future responsibilities and addressing challenges.
	No 14: Rotation focused on leadership, administrative skills, and resource management.
	No 15: Hands-on experience managing teams, adherence, and complexities of dialysis practice.
	No 16: Multi-tasking and leadership skills for nephrology practice.
	No 17: Realized the value of fellowship rotation in developing directorship skills.
Leadership, Administrative, and Quality Improvement	No 2: Water management systems, monthly meetings, and quality improvement projects.
	No 6: Shaped QAI meetings and collaborated with dialysis unit members.
	No 10: Exposure to real-world dialysis operations and team responsibilities. Learning about for-profit dialysis units’ workflows.
	No 18: Experience with QAPI, water treatment, and mentorship in real-world settings.
	No 20: Gained insights into medical director roles despite not practicing directorship currently.
Practical Experience and Workflow Insights	No 10: Suggested exposure to for-profit dialysis workflows. Learned about team responsibilities.
	No 19: Learned to handle situations as the first responder rather than as a second-line contact.

Abbreviations: QAI, Quality Assurance International; QAPI, Quality Assurance and Improvement Program.

Suggestions and Recommendations from Graduated Fellows for Improving the Rotation

Graduated fellows were surveyed on how well the medical director rotation prepared them for 14 crucial responsibilities of a medical director, including communication, safety, education, leadership, quality, supervision, emergency management, infection control, psychosocial aspects, water processing, administration, patient concerns, regulatory surveys, and finance (Fig 1). The rotation was most effective in preparing fellows for communication with the dialysis team, receiving the highest average score of 2.88, with 88% of respondents feeling well prepared in this area (Fig 1, Table S3). Conversely, fellows felt least prepared for financial management, psychosocial issues, and handling patients’ concerns, which had the lowest average scores of 2.0, 1.96 and 1.96, respectively. Only 9%, 10%, and 10% respondents reported feeling well prepared for these aspects.

Figure 1.

Evaluation of how well the medical director rotation in preparing graduate fellows for medical director responsibilities. (A) The percentage of fellows selecting each response across 14 different categories. (B) Responses were assessed using a four-point scale (0-3): 0 = “Not at all,” 1 = “Little,” 2 = “Some,” and 3 = “Much.” The average score is reported for each category.

Regarding how a fellowship could better prepare current fellows for a medical director role, graduated fellows suggested improvements in several areas, including financial and regulatory training, leadership and administrative skills, hands-on experience in diverse settings, and curriculum enhancements (Table 6, Table S4). Graduated fellows recommended various changes and additions to the medical director rotation, including adjustments to its structure and duration, expanded practical experiences and observations, enhanced administrative and financial education, increased participation in meetings, opportunities for collaborative learning, training in crisis and ethical decision-making, and improvements in teaching methods (Table 7, Table S5).

Table 6.

Suggestions from Graduated Fellows on How a Fellowship could Prepare Current Fellows to Serve as a Medical Director

Themes	Key Points of Each Response
Financial and Regulatory Aspects	No 1: Comprehensive experience in financial management and regulatory adherence.
	No 2: Understanding the financial aspects of medical directorships during monthly meetings.
	No 5: Include insight into financial understanding of running a unit.
	No 7: More focus on financial aspects during the rotation.
	No 8: More involvement in administrative and financial aspects.
	No 15: Include CMS guidelines, expectations, and dialysis visit compensation models.
	No 20: Lectures on financial considerations and challenges faced by medical directors
Leadership and Administrative Skills	No 4: Include organizational leadership courses and work productivity management.
	No 18: Training in addressing policy issues and staff performance.
	No 12: Focus on psychosocial issues, managing difficult patients, and building experience in business aspects.
	No 3: Continuing medical director rotation for skill development.
	No 10. Fellows actively participate in monthly meetings and real-world problem-solving scenarios.
	No 13: A formal curriculum to complement hands-on experiences.
Practical, Real-Life Experience in diverse settings	No 9: Rotations in units caring for underserved patients and for-profit units.
	No 14: Practical exposure in working with dialysis companies.
	No 20: Rotating through satellite units to broaden real-world understanding.
	No 6: Understanding responsibilities like monthly paper reviews and alarm triggers.
	No 11: Participating in QAPI and real-life meetings even before rotations.
	No 16: More hands-on training in emergency response.
	No 18: Addressing quality metrics and questions from staff.
Curriculum Enhancements	No 13: Formalize curriculum during the rotation.
	No 20: Record lectures on top challenges faced by medical directors.
	No 10: Extend exposure to patient issues that develop over months.
	No 7: Retain the focus on the water facility aspect.
	No 5: Balance between autonomy and responsibility in current rotations.

Abbreviations: CMS, Center for Medicare & Medicaid Services; QAI, Quality Assurance International; QAPI, Quality Assurance and Improvement Program.

Table 7.

Changes and Additions Recommended for the Medical Director Rotation by Graduated Fellows

Themes	Key Point of Each Response
Structure and Duration of the Rotation	No 1: Increase focus on medical director roles by extending the rotation or distributing participation throughout the fellowship.
	No 12: Extend the rotation to 2 months and include education on access management.
	No 2: Introduce nephrology fellows to medical director roles early in the first year and provide more exposure in the third year.
Practical Experiences and Observations	No 6: Rotate in a dialysis clinic outside the Mayo Clinic system to experience differences.
	No 10: Observe for-profit units because many graduates will work with them.
	No 15: Spend more time physically in dialysis units to understand everyday issues and resource needs.
	No 3: Rounding with the inpatient dialysis administration team.
	No 13: Round with another dialysis doctor to observe diverse approaches.
Administrative and Financial Education	No 11: Provide structured training in administrative skills, including telemedicine integration and emergency preparedness.
	No 14: Learn about policy implementation and take on a direct role in running QAPI.
	No 5: Education on finances, water processing, reimbursement, and insurance issues.
	No 7: Involvement and education on joint ventures and financial issues for job selection.
Meetings, Collaborative Learning, and Crisis and Ethical Decision-Making	No 4: Attend QAPI meetings in the last 3 months of training to gain familiarity.
	No 9: Participate in monthly dialysis staff meetings for troubleshooting experience.
	No 16: Include interactive modules on crisis management, ethical decision-making, and mentorship opportunities.
Teaching Methods and Enhancements	No 8: Practical Problem-Solving: Incorporate more examples of how to address and solve complex situations.
	No 11: Advanced Learning Techniques: Explore advanced technology like AI-driven analytics and emphasize wellness and burnout prevention.
	No 16: Interactive and Mentorship-Based Learning: Encourage hands-on learning through mentorship with experienced medical directors.

Abbreviations: QAI, Quality Assurance International; QAPI, Quality Assurance and Improvement Program.

POCUS Use in the Dialysis Facility

Regarding POCUS uses in the hemodialysis unit among 26 graduated fellows, 3 (12%) reported frequent use, 4 (15%) used it occasionally, 7 (27%) used it rarely, and 12 (46%) did not use it at all.

Discussion

Over a 10-year period from 2014 to 2023, 36 nephrology fellows at the Mayo Clinic in Rochester, MN completed a month-long medical director rotation. Before the rotation, only 5% of fellows reported a strong understanding of the medical director’s responsibilities, whereas all fellows demonstrated a clear understanding afterward. Our study found that nearly half of graduated fellows later served as medical directors of hemodialysis units. Follow-up surveys of graduated fellows further underscored the long-term value of this training, with 85% emphasizing the importance of incorporating a dedicated medical director rotation into nephrology fellowship programs to adequately prepare fellows for the role of a dialysis medical director.

This rotation encompasses broader leadership and operational duties than what a fellow might experience in a continuity clinic for dialysis patients. Beyond patient assessments, fellows are responsible for implementing safety protocols within the dialysis unit, overseeing all patients in the unit, maintaining continuous communication with dialysis staff, including nurse leader, managing initial enrollment visits for new patients, and addressing the psychosocial aspects of dialysis care. Operational engagement extends to overseeing the water treatment plan, responding to emergency drills from within and outside the unit, and collaborating with the dialysis facility administrator and dialysis systems regulatory expert. Quality improvement is another key component, requiring participation in interdisciplinary and quality assurance meetings, leading process improvement initiatives, and contributing to quality improvement projects. Teaching and mentorship are integral to the role, with fellows guiding junior nephrology colleagues and second-year medical students when they see patients and leading discussions on high-impact dialysis-related journal articles.

Designing the rotation posed significant challenges, as it needed to comprehensively encompass the diverse and complex responsibilities of a medical director. Our approach was to create an experience that closely mirrored the daily activities and decision-making processes inherent to the role. Given the critical contributions of all staff members to the functioning of a dialysis unit, the rotation was structured to foster frequent and meaningful interactions between fellows and staff. The rotation actively integrated fellows into care decisions, with attending nephrologists facilitating their involvement. A highlight of the rotation has been the extensive opportunities for fellows to engage with the dialysis team. This integration has been well received, with staff consistently expressing appreciation for the fellows' contributions during the rotation. We believe this emphasis on interactions and communications during the rotation facilitated graduated fellows’ communication skills when in practice.

A significant development in nephrology practice has been expanding role of the dialysis facility medical director.¹⁹ Most graduates indicated that the rotation provided substantial preparation for nine of 14 key responsibilities surveyed, with an average score exceeding 2.5 (maximum 3.0). Fellows felt best prepared for communication within the dialysis team, as discussed above.^20,21 Graduates felt least prepared for responding to facility surveys and inspections, conducting financial planning, managing psychosocial issues and patient concerns, all of which received average scores below 2.0. To address these gaps, graduates suggested several enhancements to the rotation, including more education on financial matters, increased participation in quality assurance meetings, and additional patient encounters in a variety of diverse dialysis unit settings. While discussions on those topics are included in the rotation, simulating real-world scenarios, particularly financial planning and regulatory inspections, remains a challenge.²² To improve financial preparedness, we plan to introduce case-based scenarios focused on financial management and incorporate mid-rotation meetings with dialysis operations staff and the medical director for deeper insight. Fellows consulting with social workers will also provide valuable perspectives on insurance and financial considerations. To enhance fellows’ readiness for facility surveys and inspections, the mock inspection component will be expanded to include more personnel, such as the facility’s nurse supervisor and other staff directly involved in regulatory responses.

We acknowledge that a key limitation of our study is its single-center design, However, our decade-long experience provides compelling evidence in favor of the integration of similar rotations into nephrology fellowship programs nationwide. We hope this work encourages further exploration and broader adoption of these training initiatives at other institutions. Our general nephrology fellowship spans 3 years, with 2 years dedicated to clinical training and one year focused on research. In 2-year fellowship programs, incorporating a full-length medical director rotation may present challenges. However, a condensed version of the rotation, spanning one or 2 weeks, could be structured to fit within the existing fellowship curriculum while still providing valuable exposure to the medical director’s key responsibilities. In addition, another limitation of the study is that some of the benefits graduates attributed to the medical director rotation may also arise from other training experiences, but the surveys were constructed to limit that effect.

In conclusion, the role of a dialysis facility medical director is a vital aspect of nephrology practice. A well-structured medical director rotation can be implemented within existing dialysis facility practices and procedures to provide fellows with the essential skills needed for this leadership role. By equipping nephrology fellows with the knowledge and experience necessary to excel as medical directors, such rotations not only support their professional development but also contribute to the advancement of the field. Given the increasing demand for well-prepared dialysis unit medical directors, our findings hold significant relevance for the nephrology community. The rotation outlined in this study can serve as a model for other institutions seeking to enhance their fellowship training programs and address a key gap in nephrology education.

Supplementary Materials

Supplementary File (PDF)

Items S1-S3; Tables S1-S4.