The Acute Dialysis Orders Objective Structured Clinical Examination (OSCE): Fellow Performance on a Formative Assessment of Acute Kidney Replacement Therapy Competence

Clin J Am Soc Nephrol. 2019 Sep 6;14(9):1346-1354. doi: 10.2215/CJN.02900319. Epub 2019 Aug 13.


Background and objectives: Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies.

Design, setting, participants, & measurements: Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey.

Results: A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3-4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing "proficiency in ordering" acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format.

Conclusions: The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development.

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Keywords: Brain Diseases; Certification; Curriculum; Dialysis Solutions; Education; Hyperkalemia; Nephrology; Patient Care; Personal Satisfaction; Physical Examination; Prospective Studies; Sodium Bicarbonate; Surveys and Questionnaires; dialysis; hemodialysis; pericarditis.

MeSH terms

  • Clinical Competence*
  • Education, Medical, Graduate*
  • Humans
  • Nephrology / education*
  • Prescriptions / standards*
  • Prospective Studies
  • Renal Replacement Therapy*