title: Perception of indications for nephrology referral among internal medicine residents: a national online survey.
abstract: OBJECTIVE
  Many patients with chronic kidney disease (CKD) are seen by primary care physicians who may not be aware of indications or benefits of timely nephrologist referral. Late referral to a nephrologist may lead to suboptimal pre-end stage renal disease care and greater mortality. It is not known whether current postgraduate training adequately prepares a future internist in this aspect of CKD management.
  
  
  METHODS
  The authors performed an online questionnaire survey of internal medicine residents in the United States to determine their perceptions of indications for nephrology referral in CKD management.
  
  
  RESULTS
  Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution of 166 PGY 1,187 PGY 2 and 126 PGY 3. Few residents chose nephrology referral for proteinuria (45%), uncontrolled hypertension (64%), or hyperkalemia (26%). Twenty-eight percent of the residents considered consulting a nephrologist for anemia of CKD, whereas 45% would do so for bone disorder of CKD. Most of the residents would involve a nephrologist at glomerular filtration rate (GFR) <30 ml/min/1.73 m(2) (90%) and for rapid decline in GFR (79%). Many residents would refer a patient for dialysis setup at GFR 15 to 30 ml/min/1.73 m(2) (59%); however, 18% would do so at GFR <15 ml/min/1.73 m(2). Presence of CKD clinic experience or an in-house nephrology fellowship program did not considerably change these perceptions.
  
  
  CONCLUSIONS
  Results show that internal medicine residents have widely differing perceptions of indications for nephrology referral. Educational efforts during residency training to raise awareness and benefits of early referral may improve CKD management by facilitating better collaboration between internist and nephrologist.
authors.affiliation: Department of Internal Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA. varunagrawal1996@yahoo.com
authors.forename: Varun
authors.initials: V
authors.lastname: Agrawal
authors.forename: Amit K
authors.initials: AK
authors.lastname: Ghosh
authors.forename: Michael A
authors.initials: MA
authors.lastname: Barnes
authors.forename: Peter A
authors.initials: PA
authors.lastname: McCullough
mesh_terms: D001291:Attitude of Health Personnel; D001364:Awareness; D002908:Chronic Disease; D002983:Clinical Competence; D003299:Cooperative Behavior; D003430:Cross-Sectional Studies; D004503:Education, Medical, Graduate / Q000706:statistics & numerical data; D005919:Glomerular Filtration Rate; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D006947:Hyperkalemia / Q000209:etiology; D006973:Hypertension / Q000209:etiology; D033183:Interdisciplinary Communication; D007388:Internal Medicine / Q000193:education / Q000706:statistics & numerical data; D020407:Internet; D007396:Internship and Residency / Q000706:statistics & numerical data; D007674:Kidney Diseases / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology; D009398:Nephrology / Q000193:education / Q000706:statistics & numerical data; D010465:Perception; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011507:Proteinuria / Q000209:etiology; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology