You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


CURRENT STATUS OF NEPHROLOGY TRAINING IN EUROPE
===============================================

Nephrology is a relatively young medical specialty, born in the past century, based mainly on advancing the understanding of renal morphology, histology and physiology \[[@sfy106-B1]\]. Between 1960 and 1970, a number of internationally recognized hospitals established training programmes in nephrology with dedicated 2--3 year nephrology-specific tutoring, which followed a period of 1--3 years of training in internal medicine. The European Renal Association--European Dialysis and Transplant Association (ERA--EDTA) was founded in 1964. In 1958 the Union of European Medical Specialties (UEMS) was founded and 4 years later the specialist sections were created with the aim of coordinating and harmonizing training in the different medical specialties. However, it was not until 1993 that the UEMS Renal Section was established.

For \>4 decades, interest in nephrology expanded and flourished, becoming one of the most attractive and innovative areas of clinical medicine. However, since the turn of the century there has been a worldwide, progressive decline in interest in nephrology as a career choice. The UEMS Renal Section is working to better understand the causes of these negative sentiments towards the specialty in Europe to identify the responsible factors that can be modified to enable us to promote and ignite interest in the specialty of nephrology as a career choice. European Union (EU) directives mandate that a specialist in one state be recognized as such in all states. However, there remains substantial variation in the breadth and quality of training of the nephrology workforce, which takes place mainly in public hospitals across the EU. Multiple systems of governance over nephrology specialist training exist. There is no systematic approach on how to evaluate the quality of teaching of nephrology and there are no universal guidelines on the assessment of nephrology training centres and evaluation of trainees' skills.

Not all countries have a mandatory examination, although many have a system of peer review. In both the UK and Ireland, national colleges oversee the implementation of uniform training schemes in hospitals across the country. In France and Belgium, each university directs its own nephrology scheme and is answerable, ultimately, to the relevant government ministry \[[@sfy106-B7]\]. The UK, Denmark and The Netherlands have adopted competency-based education programmes. Competency-based postgraduate training can bridge the gap between theory and clinical practice \[[@sfy106-B8]\]. A similar strategy has been adopted recently in Spain \[[@sfy106-B9]\]. Using this approach, competence is defined by focusing on the observation of critical clinical activities, and multiple competencies are assessed from serial observations of various activities rather than abstract definitions of competences \[[@sfy106-B8], [@sfy106-B9]\].

It is generally agreed that nephrologists should have a sound basic training in general internal medicine and that countries organize their training programme accordingly. However, there is significant dissimilarity in the length of internal medicine training programmes, ranging from 0 to 5 years across the EU ([Table 1](#sfy106-T1){ref-type="table"}). The duration of nephrology training is also highly variable, ranging from 2 to 4 years, with an average of 3.1 years \[[@sfy106-B7]\]. Table 1.Training years after registration to attain higher specialty certification in nephrology based on a survey of countries represented at the UEMS Renal Section 2015CountryTotal years after registrationGeneral yearsNephrologyAustria633Belgium642Bosnia and Herzegovina532Bulgaria413Croatia532Czech Republic404Denmark734Estonia404Finland633France422Germany633Greece624Hungary624Ireland624Israel642Italy413Kosova523Montenegro752Netherlands642Norway6.53.53Portugal514Romania422Slovakia624Slovenia624Spain413Sweden523Switzerland633Turkey743UK743

The UEMS Renal Section has recently published guidelines outlining the recommended minimum common framework for harmonization of training in nephrology in the EU \[[@sfy106-B10]\]. It is challenging to produce universal recommendations, yet this programme was developed following widespread consultations among the nephrology community across member states. They include a minimum of 2 years in general medicine training, with 6 months nephrology experience desirable, prior to entering a training programme. Nephrology training should be of 3--4 years duration in a recognized teaching hospital, of which at least 3 years should be in clinical nephrology. It is also desirable that trainees undertake a period of structured research, although it is recognized that a more substantial period of research may be undertaken later.

It is recognized that excellent teaching and mentoring are among the most important factors for the satisfaction of nephrology fellows in training \[[@sfy106-B11]\]. Thus each programme should have a named trainer who is responsible for the programme and a written record should be maintained and regular appraisals of the progress should be made by the trainee. The curriculum is suggested to include the following: (i) manifestations and pathophysiology of renal disease, acute kidney injury and chronic kidney disease; (ii) renal replacement therapies and end-of-life care; (iii) knowledge of the major randomized controlled trials and guidelines in the fields of nephrology, dialysis and transplantation and (iv) procedural skills including renal ultrasound, renal biopsy and insertion of central venous catheters. The necessity to acquire competence in procedural skills is a matter of ongoing debate within the nephrology community \[[@sfy106-B12]\]. Which procedures nephrology fellows learn and how they should be attained remains an open question that needs further discussion. However, we must ensure that those who complete training are highly skilled, with expertise that distinguishes nephrologists from other specialties, capable of providing optimal outcomes for patients with kidney disease.

TOWARDS HARMONIZATION AND FEWER BARRIERS: THE ECN
=================================================

As mentioned previously, the UEMS Renal Section and the ERA-EDTA have been working jointly since 2010 to harmonize European nephrology training \[[@sfy106-B10], [@sfy106-B13]\]. The most recent enterprise, with the collaboration of the Federation of the Royal Colleges of the UK and the UK Renal Association, has been the establishment of the ECN. The ECN should ensure that free movement of labour across Europe does not compromise the highest standards of medical care. The first edition of the ECN was in 2017, sharing the same format, and most of the content, of the Specialty Certificate in Nephrology (SCE), developed in the UK in 2009 as a requirement to achieve certification as a renal specialist.

Comprehensively covering the field of nephrology, the examination is designed to test the expected knowledge of a newly qualified specialist and should be taken towards the end of specialty training. However, it is acknowledged that many trainees will consider sitting for the exam at earlier stages of training. The exam does not aim to test detailed subspecialist knowledge, but requires practical knowledge, problem-solving ability and clinical judgement related to what a general nephrologist should be familiar with. The original curriculum was written by the Joint Royal Colleges Training Board, oriented towards practicing clinicians, and is available at <https://www.jrcptb.org.uk/documents/>2010[-renal-medicine-amendment-](http://-renal-medicine-amendment-)2012.

A recent *NDT Digest* report provides complete information about the exam with some good advice regarding how to be successful \[[@sfy106-B12]\]. In brief, the exam consists of two papers of 3-h duration, each comprising 100 extended matching multiple choice questions (the best of five possible choices); there is no negative marking, questions are in English and many of them are based on opinion and best judgement.

The exam is produced following a well-structured and detailed process that involves three groups: the question-writing group, the exam board and the standard-setting group. The question-writing group consists of peer-trained nephrologists (UK and European) who write and review the questions. Five European representatives selected by the UEMS Renal Section and the ERA-EDTA attended the question-writing group in 2017 and 2018. Questions are entered into a question bank from which the exam questions are drawn. In a second step, the exam is reviewed by the exam board, which has two representatives from the UEMS Renal Section. The exam is edited and then reviewed again by the standard-setting group. The blueprint, which determines the distribution of questions, is available at [https://www.mrcpuk.org/sites/default/files/documents/SCE%20Nephrology%20Blueprint%](https://www.mrcpuk.org/sites/default/files/documents/SCE%20Nephrology%20Blueprint%)2020[14%20Final%20.pdf](http://14%20Final%20.pdf).

The standard-setting group, which includes two European representatives, reviews the papers, determines that all questions are suitable and sets the pass mark. The pass mark is derived by the modified Angoff method \[[@sfy106-B14], [@sfy106-B15]\], which estimates what proportion of just passing candidates will answer the question correctly. A *post hoc* correction of the pass mark is applied using the Hofstee compromise \[[@sfy106-B16]\] and then the final pass mark is calculated. For more details visit <https://www.mrcpuk.org/mrcpukexaminations/results/exam-pass-marks>.

The UEMS Renal Section published the 'Updated program for harmonization of training in nephrology in the EU' \[[@sfy106-B8]\], which gives information on the range of knowledge needed for the exam. Although there are no specific courses to prepare for the ECN, more information about useful resources to prepare for the exam, such as the 'Advanced Nephrology Course', can be found in a recent publication \[[@sfy106-B12]\]. Registration for the exam is currently 6--7 weeks, typically between the end of October/early November and the beginning of December. For the 2019 ECN, registration will be from 7 November to 5 December 2018 and the exam will take place on 27 February 2019.

FIRST TWO EDITIONS OF THE ECN: RESULTS AND REFLECTIONS
======================================================

The first two editions of the ECN were held in early 2017 and 2018. In 2017, the exam was taken by 77 candidates from 19 countries, of whom 44 were successful and in 2018 by 45 candidates from 17 countries, 28 of whom were successful. The pass rate and passing numbers by country are detailed in [Figure 1](#sfy106-F1){ref-type="fig"} and [Tables 2](#sfy106-T2){ref-type="table"} and [3](#sfy106-T3){ref-type="table"}. Table 2.Passing and sitting numbers by countryCountry20172018FailPassTotalFailPassTotalAustria101Belgium011Denmark145123Egypt112123Finland112Germany101123Greece8412134Irish Republic011Israel011011Italy202Netherlands112Norway101Poland011Portugal11920448Romania101Spain426202Switzerland4610347Tunisia101112Turkey437246Ukraine101United Kingdom112033Total334477172845Table 3.Pass rates of the ECNYearPass mark (%)Pass rate all candidates (%)201862.162.2(123/198 questions)(28/45 candidates)201760.157.1(119/198 questions)(44/77 candidates)

![Percentage of ECN pass rate by country.](sfy106f1){#sfy106-F1}

Several logistical difficulties were encountered in the first 2 years of the exam, mainly related to the availability of examination centres. For example, due to the large number of applicants, several candidates from Lisbon were allocated examination centres in Porto in the first year.

Exam candidates were surveyed after each exam. For the 2017 exam, the majority of candidates (68.4%) heard about the exam from their national society ([Figure 2](#sfy106-F2){ref-type="fig"}), with colleagues, conferences and training bodies being the other sources of information. About 38% of respondents stated that they sat for the exam, as it would reflect a good benchmark of their knowledge, while 35% felt that success in the exam would help to advance their career.

![Sources of information about the ECN according to the answers of the nephrologists who sat for the ECN exam in 2017.](sfy106f2){#sfy106-F2}

About 35% of survey respondents felt that the exam was too difficult, with the remainder stating that the exam was difficult but fair, or exactly of a standard that they had expected. The results were similar for those who responded to the survey in 2018. When asked whether the exam was relevant to their clinical practice, 74% of respondents agreed or strongly agreed, with only a small percentage strongly disagreeing with this statement. The online application system was deemed satisfactory by 96% of applicants, and respondents were, on the whole, positive about the exam venue (apart from the exceptions mentioned earlier). Conversion charts (for SI to traditional units) were introduced for the 2018 exam. About 57% of candidates used the charts, of whom, 50% found them to be useful.

ROLE OF THE UEMS, ERA-EDTA AND NATIONAL SOCIETIES IN THE SUSTAINABILITY OF THE ECN
==================================================================================

So far, after two editions of the ECN, 122 candidates from 26 countries have sat for the exam, with 72 (59%) having passed. While the numbers taking the exam in 2018 were more modest, the numbers taking the exam in 2017 exceeded initial expectations. On reflection, the exam was promoted more widely in the first year. In order to attract sufficient candidates to the exam, a robust promotional strategy has been designed by the UEMS Renal Section and this article is part of it. Of greater importance, however, is to make the exam more relevant to European nephrology trainees. To date, Switzerland has adopted the exam as their national training assessment; we expect in the near future that other countries will join Switzerland, as it is felt that promoting the exam to national training bodies is the best way to ensure the exam flourishes.

Another important aspect is to increase the academic and professional recognition of the ECN at the national level to have it recognized as a 'relevant merit' and a sign of high-quality training in nephrology to be used for obtaining professional career advantages in the hospital or university environment. It is crucial that the national societies work in this direction, with the idea of promoting the ECN as a mark of excellence that will be useful to obtain better professional positions.

The ERA-EDTA and the national societies play a key role in obtaining these achievements. As stated previously, according to the responses from the 2017 survey, more than two-thirds of the nephrologists who sat for the ECN received information about it through their national societies ([Figure 2](#sfy106-F2){ref-type="fig"}). Furthermore, the involvement of national societies is crucial in another aspect, as in the first two editions of the exam, several societies subsidized young nephrologists, paying or waiving the ECN registration fee and also offered various advantages to successful young candidates.

If the ECN proves advantageous to candidates securing employment or advancing scientific careers, then the number of candidates will increase and the sustainability of the ECN will be guaranteed. Furthermore, if a national training body adopts the ECN as the mandatory exam at the end of training and can guarantee a regular stream of candidates on an annual basis, it may be possible to work towards the possibility of translating the exam into that country's language. Another important aspect of the ECN through European and national recognition is the possibility that it may become a kind of 'passport' to facilitate the mobility of nephrologists among the European countries. This objective was a priority on the list of the main objectives to achieve when the UEMS Renal Section decided to establish the ECN.

FINAL REMARKS AND THE FUTURE OF THE ECN
=======================================

A recent positive development is the pre-agreement between the UEMS Renal Section and Boards, the British Renal Association and the Royal Colleges of the UK to adopt a common pan-European exam in 2020, following the third-pathfinder exam in 2019. The ECN 2019 will be of great importance in deciding the future of the ECN, as the number of registrations in 2019 will provide information about the trend of registrations to ascertain if a pan-European exam would be financially viable. The pan-European exam will unify the current ECN described in this article and the Royal College of Physicians of the UK (RCPUK) specialty certificate exam that has existed since 2009. While the governance of the exam will remain under the RCPUK, the UEMS Renal Section and Boards will have integral roles in the development and delivery of each edition of the exam. If, after the analysis of the results of the ECN 2019, all parties consider that the new initiative will be viable, a new memorandum of understanding will be signed in December 2019, covering a period of 3 years. Therefore success in increasing the number of candidates for the ECN 2019 will play a key role in deciding the future. Two other medical specialties, gastroenterology and endocrinology, signed an agreement in 2018 for a pan-European examination. The support of the national societies in this enterprise is crucial, as they can reach and influence local bodies (hospitals, universities and medical associations) to increase the national professional recognition of the ECN at different practical levels of medical careers.

The authors thank to Dr Natalia Carrillo-López for her contribution in the edition of the paper, Plan de Ciencia, Tecnología e Innovación del Principado de Asturias (GRUPIN) and Red de Investigación Renal-RedInRen from Instituto de Salud Carlos III (grISCIII-RETIC REDINREN RD16/0009).

FUNDING
=======

No funding has been received to produce this paper.

CONFLICT OF INTEREST STATEMENT
==============================

None declared.

[^1]: Jorge B. Cannata-Andía and Talia Weinstein authors contributed equally to this work.