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Fellowship Program Guide


 Division of Nephrology


University of Utah Health
    Sciences Center



       2006-20...
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                 University of Utah Nephrology Fellowship Program
                                                      ...
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1. Introduction

    The University of Utah Nephrology Fellowship Program is dedicated to providing the highest quality
...
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  ♦ Instructions on how to apply for the program through the Electronic Residency Application Service
    (ERAS)
  ♦ A s...
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3. Division of Nephrology Faculty Members

  Name                                      Research Interests
  Srinivisan B...
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Christof Westenfelder, M.D.               Stem cells in renal injury
Professor                                 Renal ac...
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4. Nephrology Fellowship Program Training Sites

  A. Inpatient sites
     (1) University Hospital (UH) - This is a tert...
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University Hospital rotation (4 months yearly)

            Monday               Tuesday          Wednesday     Thursday...
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Outpatient nephrology and research rotation (4 months yearly)

              Monday              Tuesday        Wednesda...
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Core competencies

    (1) Patient care – Fellows must be able to provide patient care that is compassionate, appropriat...
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      • demonstrate a commitment to ethical principles pertaining to provision or withholding of
         clinical care...
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    p. Renal cystic diseases without a recognized genetic basis
    q. Nutritional management of general nephrologic di...
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         e. Acute and chronic hemodialysis
         f. Continuous renal replacement therapies
     (6) Understanding in...
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  2) Nature of supervision - A faculty member facilitates discussion of the assigned material during the
     didactic ...
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     general nephrology. In addition, genetic diseases are prevalent in this region providing a
     tremendous learnin...
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        fellows receive a series of 4 lectures on biostatistics. Finally, 4 sessions each year are devoted
        to N...
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       behaviors. Fellows review these orally with the attending and both individuals sign the review
       form. If t...
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               interventions assessed. This is reviewed every 6 months with the Program Director and
               the...
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General Nephrology Table

Competency     Competency objectives       General Nephrology objectives relevant to competen...
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Medical     Demonstrate         Demonstrate investigatory and analytic thinking about clinical general       Attending...
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Practice-based    Analyze own       Fellow will hold up a mirror to themselves to document, assess,        Attending t...
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Professionalism   Demonstrate       Demonstrate respect, compassion, and integrity                   Role models      ...
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C. Transplant

1) Goal
   Fellows will become competent in caring for renal transplant patients and patients with renal...
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     a. Handouts - At the beginning of the Fellowship, Fellows are given the Handbook of Renal
        Transplantation ...
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        under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with
        particu...
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Transplant Table

Competency     Competency             Transplant objectives relevant to competency                   ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
Fellowship Program Guide Division of Nephrology University of ...
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Fellowship Program Guide Division of Nephrology University of ...

  1. 1. 1 Fellowship Program Guide Division of Nephrology University of Utah Health Sciences Center 2006-2007
  2. 2. 1 University of Utah Nephrology Fellowship Program Table of Contents 1. Introduction……………………………………………………………………………………..……… 2 2. Fellow Selection Policy/Process……………………………………………………..……………… 2 3. Division of Nephrology Faculty Members…………………………………………………..……… 4 4. Nephrology Fellowship Program Training Sites………………………….……………………….. 6 A. Inpatient sites……………………………………………………………………………………… 6 B. Outpatient sites……………………………………………………………………………………. 6 5. Nephrology Training Program Schedule…………………………………………………….…….. 6 A. Two Year Schedule……………………………………………………………………...………… 6 B. Monthly Schedule (1) University Hospital Rotation………………………………………………………………..… 7 (2) VA Hospital Rotation………………………………………………………………………..... 7 (3) Outpatient Nephrology and Research Rotation…………………………………….……….. 8 6. Nephrology Clinical Training Program Curriculum - Overview………………………………….. 8 A. Clinical Curriculum Introduction…………………………………………………………………. 8 B. Overview of Clinical Program Goals and Objectives………………………………………….. 8 7. Full Clinical Curriculum…………………………..…………………………………………….……. 12 (1) Renal Structure and Function………………………………….…..……………………..… 12 (2) General Nephrology……………………………………………………………………….…. 13 (3) Renal Transplant………………………………………………………………………………. 22 (4) Dialysis and Extracorporeal Therapy………………………………………………………... 29 (5) Special Areas…………………………………………………………………..……………... 37 (6) Assessment and Evaluation of Attendings by Fellows……………………………………. 37 8. Nephrology Research Training Program…………………………………………………………... 38 9. Dealing with Unsatisfactory Fellow Performance…………………………………………………. 40 10. Nephrology Fellowship Work, Moonlighting and On-Call Policy……………………..………… 40 11. Nephrology Fellow Stipend and Benefits…………………………………………….…………… 42 12. Faculty Research Interests..................................................................................................... 42 13. Publications by Nephrology Faculty 2001-06……………………………………………........…. 47 14. Nephrology Fellows Since 1997………………………………………........................................ 58 15. Conference Schedules for 2006-07 (Appendix)
  3. 3. 2 1. Introduction The University of Utah Nephrology Fellowship Program is dedicated to providing the highest quality clinical and research training in the subspeciality of Nephrology. It is accredited by the Graduate Medical Education Committee of the University of Utah and by the Residency Review Committee of the ACGME. There are two programs: 1) The two year clinical program is based at the University Hospital and the Salt Lake Veterans Affairs Medical Center. Upon completion, Fellows are Board Eligible in Nephrology. This program provides primarily clinical training, however, in addition to excellent clinical training, the University of Utah Nephrology Clinical Fellowship Program is designed to provide experience in clinical research. Fellows are placed into on-going faculty clinical research projects and given an opportunity to develop related research interests of their own. 2) The three year research program. The program involves one year of clinical training and two years of basic or clinical research. The clinical year may be done at the beginning or the end of the fellowship and is structured identical to the clinical experience of a year in the two year clinical fellowship. The two years of research are spent under the direction of a faculty member within the Division of Nephrology. This guide provides comprehensive information about all aspects of the Program, including: ♦ Goals and objectives ♦ Nature of sites where training is performed ♦ Types of clinical encounters ♦ Patient case-mix characteristics ♦ Procedures and services ♦ Educational activities and resources, including didactic training and conferences ♦ Nature of supervision and evaluation of Fellow’s performance ♦ Faculty research activities ♦ Fellow research opportunities and policies ♦ On-call and vacation policies ♦ Former Fellow information ♦ Fellow selection policy 2. Fellow Selection Policy/Process 1. To be eligible for a Fellowship in the Division of Nephrology at the University of Utah School of Medicine, an applicant must: ♦ Be a graduate of a U.S. or Canadian medical school accredited by the Liaison Committee on Medical Education (LCME) and have three years residency in an ACGME-approved program, OR ♦ Be a graduate of a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA) and have three years residency in an ACGME-approved program, OR ♦ Be a graduate of a medical school outside of the United States who meets one or more of the following qualifications: 1. Has a currently valid ECFMG certificate plus at least one year training in an ACGME approved program, OR 2. Has a full and unrestricted license to practice medicine in a US licensing jurisdiction plus at least one year training in an ACGME-approved program, OR 3. Is a graduate of a medical school outside the United States who has completed a Fifth Pathway program provided by an LCME-accredited medical school. ♦ Be eligible for American Board of Internal Medicine prior to the time they begin training 2. The Division of Nephrology will send an applicant (upon request): ♦ Introduction letter from the Division Chief and/or the Program Director ♦ General information about the Salt Lake City area
  4. 4. 3 ♦ Instructions on how to apply for the program through the Electronic Residency Application Service (ERAS) ♦ A statement that “The University of Utah School of Medicine does not discriminate on the basis of sex, face, age, religion, color, national origin, disability, or veteran’s status”. 3. The Division of Nephrology requires the following documentation for application: ♦ Completed Fellowship application through ERAS ♦ Curriculum Vitae and Personal Statement through ERAS ♦ Three letters of recommendation through ERAS ♦ International Medical Graduates must include the following in addition to the above: - Copy of green card, visa (J-1), or documentation of U.S. citizenship - Valid ECFMG certificate with Clinical Skills Assessment certification - Evidence of previous training in the United States 4. Selection Criteria for Interviewing Applicants - The Nephrology faculty, in a joint meeting, reviews applicants who meet the criteria. Based on the quality of the application and academic credentials, the applicant is subsequently invited for an interview. On the interview day, applicants receive an information packet and interview with members of the Division of Nephrology and the Nephrology Fellows. At the conclusion of the interview, the interviewers complete a standard evaluation form for each applicant they interviewed. The results are tallied and form the basis of the preliminary rank order. Letters or calls are then made to the top applicants offering the position of Nephrology Fellow. 5. The Guide to the Nephrology Fellowship Program is given to applicants on interview day and includes: ♦ Examples of the Fellow rotation schedule, the monthly call schedule, and the monthly conference schedule ♦ Program Curriculum, including evaluation procedures ♦ Work hours and supervision policy ♦ Vacation/Absence policy ♦ Stipend information ♦ Insurance coverage information ♦ Benefits summary ♦ University policies pertinent to Fellows with regard to sexual harassment 6. The University of Utah Graduate Medical Education Committee requires that Fellows have a Utah Medical License and ACLS certification. Fellows who are not currently certified in ACLS must become so within six months of commencing their training.
  5. 5. 4 3. Division of Nephrology Faculty Members Name Research Interests Srinivisan Beddhu, M.D. Predictors of dialysis outcomes Assistant Professor Wayne A. Border, M.D. Renal fibrosis Professor Diabetic nephropathy Alfred K. Cheung, M.D. Optimization of dialysis Professor Lipids in ESRD patients Scott Eppich, M.D. Clinical care in Provo, UT Staff Physician Alexander Goldfarb, M.D. Statistical models of outcomes Assistant Professor Dialysis and transplant outcomes Tom Greene, Ph.D. Statistical analysis of multicenter trials Research Professor Martin C. Gregory, M.D. Alport Syndrome Clinical Professor Yufeng Huang, M.D., Ph.D. Diabetic nephropathy Research Assistant Professor Renal fibrosis Carl Kablitz, M.D. Dialysis outcomes Clinical Assistant Professor Dialysis delivery technology Bellamkonda Kishore, Ph.D. Adenosine actions in the nephron Research Associate Professor Models of acute renal failure Donald E. Kohan, M.D., Ph.D. Thrombotic microangiopathies Chief and Training Program Director Hypertension and volume balance Professor Polycystic kidney disease Ken Leypoldt, Ph.D. Peritoneal transport characteristics Research Professor Nancy Noble, Ph.D. Renal fibrosis Research Professor Diabetic nephropathy Abinash Roy, M.D. Clinical care in St. George, UT Clinical Assistant Professor Fuad Shihab, M.D. Chronic cyclosporine nephropathy Clinical Professor Renal transplantation outcomes Kevin Strait, Ph.D. Renal autacoids Research Assistant Professor Regulation of renal transport Christi Terry, Ph.D. Dialysis outcomes Research Assistant Professor
  6. 6. 5 Christof Westenfelder, M.D. Stem cells in renal injury Professor Renal actions of erythropoietin Chief, Renal Section, VA Medical Center Tianxin Yang, M.D., Ph.D. Macula densa signaling Research Associate Professor Collecting duct signaling
  7. 7. 6 4. Nephrology Fellowship Program Training Sites A. Inpatient sites (1) University Hospital (UH) - This is a tertiary care facility with 330 operating beds located on the University of Utah Health Sciences Center Campus. It contains surgical, neurosurgical, burn, and medical intensive care units; a newly remodeled 3-station acute dialysis unit with support for hemodialysis, peritoneal dialysis, and continuous renal replacement therapies; radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging; electron microscopy for renal biopsy material; biochemical and serologic laboratories; a nutrition support service; and relevant social services. A close working relationship exists with other services including surgery, urology, obstetrics, gynecology, pediatrics and psychiatry. (2) Salt Lake Veterans Affairs Medical Center (VAMC) – This is a tertiary care facility with 117 operating beds located adjacent to the University of Utah Lower Campus and approximately one-half mile from University Hospital. It contains surgical and medical intensive care units, a 10-station newly remodeled dialysis unit that performs acute and chronic hemodialysis and supports continuous renal replacement therapies and peritoneal dialysis, radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging, electron microscopy for renal biopsy material, biochemical and serologic laboratories, a nutrition support service, and relevant social services. A close working relationship exists with other services including surgery, urology and psychiatry. B. Outpatient sites (1) University Hospital Renal Clinic – Located on the A level of the University Hospital, this 11-room clinic is the site for all general nephrology, nephrolithiasis, peritoneal dialysis, post-transplant and pre-transplant patients associated with the University of Utah. (2) VAMC General Nephrology Clinic – Located on the 4th floor of Building 1 (main hospital building) at the VAMC, this clinic is the site of ambulatory care for VA general nephrology and post-transplant patients. (3) VAMC Dialysis Clinic – Located within the dialysis unit, this clinic is the site of outpatient follow- up of VA hemodialysis and peritoneal dialysis patients. 5. Nephrology Training Program Schedule The two year clinical fellowship and the one clinical year of the research fellowship are comprised of three major rotations that cycle throughout the year. The following schedules are based on the Program’s current policy of having three fellows doing clinical service together. A. Yearly schedule for fellows on clinical service (only 1 year for research fellows) Year 1 (1 block = 4 weeks) Block 1 2 3 4 5 6 7 8 9 10 11 12 13 U A C B A C B A C B A C B A VA B A C B A C B A C B A C B OP C B A C B A C B A C B A C Year 2 (1 block = 4 weeks) Block 1 2 3 4 5 6 7 8 9 10 11 12 13 U C B A C B A C B A C B A C VA A C B A C B A C B A C B A OP B A C B A C B A C B A C B
  8. 8. 7 University Hospital rotation (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am Ward duties Ward duties Ward duties Didactic General (all day) (all day) (all day) conference 9 am nephrology Ward duties 10 am continuity clinic 11 am (starts at 8:30) Noon 1 pm Transplant Transplant Pathology interdisciplinary interdisciplinary conference rounds rounds 2 pm Ward duties 3 pm U PD Rounds (Monthly) 4 pm Clinical conference 5 pm Research conference VA Hospital rotation (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am Ward duties Ward duties Ward duties Didactic General (all day) (all day) (all day) conference 9 am nephrology Monthly Ward duties 10 am continuity clinic hemodialysis/ (all day) PD rounds 11 am (starts at 8:30) Noon 1 pm Monthly VA general Monthly Pathology hemodialysis nephrology hemodialysis conference 2 pm rounds clinic (starts rounds 3 pm at 12:30 pm) U PD Rounds 4 pm Ward duties Clinical (Monthly) (all day) conference 5 pm Research conference
  9. 9. 8 Outpatient nephrology and research rotation (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am RESEARCH RESEARCH General Post- DAY DAY 9 am nephrology transplant Pre-transplant continuity clinic clinic clinic 10 am (starts at 8:30) 11 am Noon 1 pm Renal stones Pathology clinic (every conference other month) 2 pm 3 pm PD clinic at U Didactic U PD Rounds ( twice/month) conference (Monthly) 4 pm Clinical conference 5 pm Research conference 6. Nephrology Clinical Training Program Curriculum - Overview A. Clinical Curriculum Introduction The Nephrology Fellowship Clinical Training Program is designed to provide individuals with the opportunity to achieve the fundamental knowledge, procedural skills, practical experience, and professional and ethical behavior necessary for the subspeciality of Nephrology. Fellows care for patients with the full spectrum of renal disorders at all stages of the disease process. Efforts are made at every point to emphasize the integration of fundamental medical knowledge, disease prevention, social, psychological, and economic issues. This section describes the clinical curriculum. The first part presents an outline of the Clinical Program goals and objectives. Subsequently, the full clinical curriculum is described, relating Clinical Program goals and objectives to the manner in which they are achieved. B. Overview of Clinical Program Goals and Objectives The Nephrology Fellowship Clinical Training Program is structured around goals and objectives derived from three major sources: 1) the ACGME Core Competencies; 2) the ACGME subspecialty requirements for Nephrology training programs; and 3) additional input derived from University of Utah Nephrology faculty. These various components are combined to achieve an integrated set of goals and objectives that cover all aspects of the training program. In this first section, an overview of the training program’s goals and objectives is presented, broken down by the six core competencies and then the specific Nephrology areas. This should be reviewed so that Fellows understand each of these components. The following section, devoted to the detailed curriculum, then combines the core competencies and specific nephrology issues into an integrated and comprehensive set of goals and objectives.
  10. 10. 9 Core competencies (1) Patient care – Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to: • communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families • gather essential and accurate information about their patients • make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment • develop and carry out patient management plans • counsel and educate patients and their families • use information technology to support patient care decisions and patient education • perform competently all medical and invasive procedures considered essential for the area of practice • provide health care services aimed at preventing health problems or maintaining health • work with health care professionals, including those from other disciplines, to provide patient-focused care (2) Medical knowledge - Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to: • demonstrate an investigatory and analytic thinking approach to clinical situations • know and apply the basic and clinically supportive sciences which are appropriate to their discipline (3) Practice-based learning and improvement – Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to: • analyze practice experience and perform practice-based improvement activities using a systematic methodology • locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems • obtain and use information about their own population of patients and the larger population from which their patients are drawn • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness • use information technology to manage information, access on-line medical information; and support their own education • facilitate the learning of students and other health care professionals (4) Interpersonal and communication skills - Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Fellows are expected to: • create and sustain a therapeutic and ethically sound relationship with patients • use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills • work effectively with others as a member or leader of a health care team or other professional group (5) Professionalism - Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
  11. 11. 10 • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities (6) Systems-based practice - Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are expected to: • understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice • know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources • practice cost-effective health care and resource allocation that does not compromise quality of care • advocate for quality patient care and assist patients in dealing with system complexities • know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance Specific renal competencies - Fellows will acquire expertise in: (1) An understanding of normal renal biology including: a. Renal anatomy and histology b. Renal physiology, including in the elderly c. Fluid, electrolyte and acid-base regulation d. Mineral metabolism e. Blood pressure regulation - normal and abnormal f. Renal drug metabolism and pharmacokinetics, including drug effects on renal function and including in the elderly g. Renal function in pregnancy h. Basic immunologic principles, including mechanisms of disease and diagnostic laboratory testing relevant to renal diseases i. Medical genetics (2) Prevention, evaluation, and management of general nephrologic disorders including: a. Acute renal failure b. Chronic renal failure c. End-stage renal disease d. Fluid, electrolyte, and acid-base disorders e. Disorders of mineral metabolism including nephrolithiasis and renal osteodystrophy (including use of lithotripsy) f. Urinary tract infections g. Hypertensive disorders h. Renal disorders related to pregnancy i. Primary and secondary glomerulopathies including infection-related glomerulopathies. This also entails a basic understanding of immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis. j. Diabetic nephropathy k. Tubulointerstitial nephritis including papillary necrosis l. Genetic and developmental renal diseases including renal cystic diseases, hereditary glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma. m. Vascular diseases including atheroembolic disease n. Disorders of drug metabolism and renal drug toxicity o. Renal disorders associated with the elderly including altered drug metabolism
  12. 12. 11 p. Renal cystic diseases without a recognized genetic basis q. Nutritional management of general nephrologic disorders (3) Pre- and post-renal transplant care including: a. Pre-transplant selection, evaluation and preparation of transplant recipients and donors b. Immunosuppressant drug effects and toxicity c. Immediate postoperative management of transplant recipients d. Immunologic principals of types and mechanisms of renal allograft rejection e. Clinical diagnosis of all forms of rejection including laboratory, histopathologic and imaging techniques f. Prophylaxis and treatment of allograft rejection g. Recognition and medical management of nonrejection causes of allograft dysfunction including urinary tract infections, acute renal failure, and others h. Understanding major causes of post-transplant morbidity and mortality i. Fluid, electrolyte, mineral and acid-base regulation in post-transplant patients j. Long-term follow-up of transplant recipients in the ambulatory setting including economic and psychosocial issues k. Principles of organ harvesting, preservation and sharing l. Renal disease in liver, heart and bone marrow transplant recipients (4) Dialysis and extracorporeal therapy including: a. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies b. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options c. Drug dosage modification during dialysis and other extra-corporeal therapies d. Evaluation and management of medical complications in patients during and between dialyses and other extra-corporeal therapies, and an understanding of their pathogenesis and prevention e. Long-term follow-up of patients undergoing chronic dialysis including their dialysis prescription modification and assessment of adequacy of dialysis f. An understanding of the principles and practice of peritoneal dialysis including the establishment of peritoneal access, the principles of dialysis catheters, and how to choose appropriate catheters. g. An understanding of the technology of peritoneal dialysis including the use of cyclers h. Assessment of peritoneal dialysis efficiency using peritoneal equilibration testing and the principles of peritoneal biopsy i. An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy j. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis k. An understanding of the complications of peritoneal dialysis including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, plural effusions and other less common complications and their management l. An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient m. An understanding of the psychosocial, economic and ethical issues of dialysis n. An understanding of dialysis water treatment, delivery systems and dialyzer reuse o. An understanding of end-of-life care and pain management in the care of patients undergoing chronic dialysis. (5) Personally conducting the following procedures: a. Urinalysis b. Percutaneous biopsy of native and transplanted kidneys c. Peritoneal dialysis d. Placement of temporary vascular access for hemodialysis and related procedures including use of vascular ultrasound guidance
  13. 13. 12 e. Acute and chronic hemodialysis f. Continuous renal replacement therapies (6) Understanding indications, complications (if relevant), and interpretation of the following procedures: a. Placement of peritoneal catheters b. Renal imaging - ultrasound, CT, IVP, MRI, angiography, and nuclear medicine studies c. Therapeutic plasmapheresis d. Radiology, angioplasty and declotting of vascular access (7) Special areas in the management of patients of renal diseases including: a. Psychosocial and economic issues confronting patients with renal disease b. Ethical issues relevant to care of patients with renal disease c. Optimizing the relationship of the nephrologist with other health care providers d. Optimizing mechanisms towards achieving life-long learning as a nephrologist e. Quality assessment and improvement, patient safety, risk management, preventative medicine, and physician impairment as it relates to the nephrologist 7. Full Clinical Curriculum - in this section, specific Clinical Program goals and objectives, as outlined above, are related to the methods by which they are achieved. The methods of achieving the Clinical Program goals include: ♦ Types and locations of clinical encounters ♦ Patient characteristics including case-mix, population size, sex, age, and race ♦ Relevant procedural training ♦ Relevant educational training, including resources and teaching methods ♦ Nature of supervision ♦ Means of feedback and evaluation of Fellow’s performance A. Renal structure and function - Fellows will acquire expertise in understanding normal renal biology including renal anatomy and histology, renal physiology, fluid and electrolyte regulation, acid-base balance, mineral metabolism, blood pressure regulation, renal drug metabolism and pharmacokinetics, drug effects on renal function, renal function in pregnancy, renal functional changes with aging, and basic immunologic principles. 1) Educational training a. Handouts - At the beginning of the Fellowship, Fellows are given several books for their personal use. The books include: Clinical Nephrology (Johnson and Feehally), NKF Primer on Kidney Diseases, Urinalysis (Sister Martine Graf), Handbook of Dialysis (Daugirdas and Ing), and Handbook of Renal Transplantation (Danovitch). Fellows are also given access to UpToDate. While many of these sources primarily deal with renal disorders, they provide fundamental information on normal renal biology as well. b. Didactic sessions - While normal renal biology is discussed during more informal sessions (attending rounds, renal clinics) it is recognized that a structured approach is necessary to guarantee coverage of the basics of normal renal biology. To accomplish this, a didactic conference is held each Friday from 8-9 AM for 2 years. This conference is based on Clinical Nephrology (Johnson and Feehally). The Fellows are responsible for reading the assigned material in advance - a yearly schedule is provided. During the session, a faculty member facilitates discussion of the assigned material. A one-hour session is devoted to each of the following normal renal biology topics: water handling, potassium balance, sodium and volume, acid-base balance, Ca/Mg/PO4 metabolism, renal immunology, blood pressure regulation, and renal function in pregnancy. Drug metabolism is discussed during several sessions dealing with antihypertensives, immunosuppressants, and other topics. Renal anatomy and histology are extensively discussed during several sessions on glomerular and interstitial diseases in which diseased kidneys are compared to normal kidneys. c. Conferences - A renal pathology conference is held each Friday from 1-2 PM. Diseased kidneys are compared to normal kidneys throughout this conference. A multiheaded microscope is used for simultaneous viewing by all Fellows.
  14. 14. 13 2) Nature of supervision - A faculty member facilitates discussion of the assigned material during the didactic sessions. A renal pathology attending supervises discussion of the cases during the pathology conference. 3) Means of Fellow evaluation - Faculty members give Fellows immediate feedback on their knowledge base during the didactic sessions. At the end of each year of didactic sessions, the Fellows take an in-house MKSAP test in Nephrology and Hypertension. Fellows are counseled on areas of weakness by the Program Director. Also, please see information on knowledge base assessment in the General Nephrology section – much of the information covered in basic renal structure and function overlaps with that required for General Nephrology. B. General Nephrology 1) Goal Fellows will become competent in caring for patients with general nephrology problems. 2) Objectives (see General Nephrology Table) 3) Types of clinical encounters and supervision 1. Inpatient general nephrology encounters – Fellows spend 8 months/year on the inpatient service, 4 months at the UH and 4 months at the VAMC. The Fellows have direct patient care responsibilities for all Nephrology Service inpatients at the UH and VA, including transplant and dialysis patients. The Fellow is the first person from the Nephrology Service to evaluate a new inpatient, including a history, physical examination, and urinalysis (the latter faculty-supervised). The Fellow follows all nephrology inpatients with daily history and examinations and, after discussion with faculty, charts recommendations or writes orders. The Attending conducts didactic sessions each day on material relevant to the in-house cases. The Fellow is responsible for arranging outpatient renal follow-up and for providing a dictated discharge summary for use in renal clinic. The Attending is on-call with the Fellow 24 hours a day. 2. Outpatient dialysis encounters a. UH General Nephrology Clinic - Each Monday morning from 8:30 AM - noon, all Fellows, regardless of rotation, attend a general nephrology clinic at the University covering all aspects of nephrology except transplantation and dialysis. Patients are assigned to Fellows and followed on a continuity basis throughout their fellowship (2 years for clinical fellows and three years for research fellows). The clinic is staffed by Drs. Kohan and Gregory who are there solely to supervise and train the Fellows. Each Fellow is given 1/2 hour for follow-up visits and 1 hour for new patients. b. VA General Nephrology Clinic – Each Tuesday afternoon from 12:30-4:30 PM, the Fellow based at the VA and internal medicine residents assigned to the Nephrology services at either UH or the VAMC attend a general nephrology clinic at the VA covering all aspects of nephrology except transplantation and dialysis. These patients are followed on a non-continuity basis. All patients are presented to the VA Nephrology Attending who is in the clinic solely to supervise and teach. c. UH Renal Stones Clinic – Every other month, on Monday from 1-4:30 PM, the Fellow on the OP rotation attends a clinic that sees only patients with renal stones. Dr. Westenfelder staffs this clinic; patients are his and are seen by the Fellows on a non-continuity basis. 4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient General Nephrology census is 15-20 patients at UH and 6-8 patients at the VA (these numbers include dialysis patients). Approximately 30% of inpatients are in the intensive care units at both hospitals. Ninety percent of VA patients are male (mean age – 58 years) and 10% are female (mean age – 49 years); the SLVAMC has the widest geographic referral area of any VA in the nation and sees a broad spectrum of general nephrology problems. Approximately 50% of UH patients are male; ages for both sexes range from 20-90 years. Because Salt Lake City is situated over 400 miles from any other city with a major medical center, it receives a wide variety of referrals with an extremely broad range of renal disorders covering all aspects of
  15. 15. 14 general nephrology. In addition, genetic diseases are prevalent in this region providing a tremendous learning opportunity.. 2. Outpatients a. UH General Nephrology and Nephrolithiasis Clinics - Over the course of two years, each Fellow will follow a total of approximately 150 general nephrology patients on a continuity basis. These patients come from Idaho, Utah, Nevada, Wyoming, Colorado, and Montana. All aspects of general nephrology are represented with equal numbers of male:female patients and ages ranging from 20-90 years. The majority of patients are Caucasian, however there are significant numbers of Hispanic, Native American, and South Pacific (Tonga and Samoa) patients. African American patients are seen although they represent the smallest minority. The Nephrolithiasis and General Nephrology clinics see about 6-7 patients per clinic. b. VA General Nephrology Clinic – An average of 15 patients are seen in each clinic on a non- continuity basis. Demographics are similar to those for SLVAMC inpatients. A broad range of renal disorders are seen with particular emphasis on diabetes, hypertension, renal vascular disease, urinary tract obstruction, drug toxicity, primary glomerulopathies, and collagen vascular diseases. 5) Procedural training (see General Nephrology Table) 1. Percutaneous biopsy of native kidneys – Performed by the Fellow on inpatients on their inpatient service at UH, outpatients they follow on a continuity basis, and VA outpatients when the Fellow is based at the VA. Fellows perform about 20 native renal biopsies yearly. 2. Urinalysis – Performed by the Fellow on most new inpatients and outpatients, and on follow-up evaluation as necessary 3. Renal ultrasound – Fellows observe these during all renal biopsies. 4. Lithotripsy – Performed by the Urologists. Fellows are given didactic instruction in its use, indications, complications and outcomes. 5. Therapeutic plasmapheresis – Performed by the Blood Bank staff. Fellows are given didactic instruction in its indications, contraindications and outcomes. 6) Teaching methods (see General Nephrology Table) 1. Educational training a. Handouts - At the beginning of the Fellowship, Fellows are given several books and access to UpToDate. The books include: Clinical Nephrology (Johnson and Feehally), NKF Primer on Kidney Diseases, and Urinalysis (Sister Laurine Graff). Recent articles may be provided at the beginning of the Fellowship on interpretation of urine electrolytes and osmolality, management of the nephrotic syndrome, diagnostic strategies in disorders of fluid, electrolyte and acid-base homeostasis, clinical disorders of water metabolism, nondialytic management of acute renal failure, hypokalemic and hyperkalemic states, clinical findings and therapy of glomerulonephritis, hyponatremia and hypernatremia, pathogenesis and treatment of kidney stones, prevention of progression in chronic renal disease, pathophysiology of chronic renal failure, diagnosis of acute glomerulonephritis, management of urinary tract infections in adults, and medical management of diabetic nephropathy, and other areas. 2. Didactic sessions a. Weekly didactic conference – General nephrology issues are covered in detail in the didactic conference held each Wednesday from 8-9 AM for 2 years. This conference is based on Clinical Nephrology (Johnson and Feehally) and other sources. The Fellows are responsible for reading the assigned material in advance - a yearly schedule is provided. During the session, a faculty member facilitates discussion of the assigned material. A total of 85-90 sessions are held covering dialysis, renal transplantation, renal physiology, fluid and electrolyte disorders, glomerulopathies, interstitial nephritis, renal diseases of pregnancy, congenital urinary tract malformations, acute and chronic renal failure, inherited renal diseases, primary and secondary hypertension, nephrolithiasis, radiologic imaging of the kidney, surgical and radiologic issues relevant to vascular access, ESRD economics, epidemiology, statistics, study design, informed consent, psychosocial aspects of ESRD, special issues of the elderly and others. In addition,
  16. 16. 15 fellows receive a series of 4 lectures on biostatistics. Finally, 4 sessions each year are devoted to NephSap review. Fellows and the assigned faculty review the questions in NephSAP (Nephrology Self-Assessment Program) distributed by the American Society of Nephrology. In advance of this meeting, the Fellows meet with a designated faculty who is expert in the particular topic to review the text (typically around 50 pages of NephSAP text on which the questions are based). b. Primer Course: At the beginning of the Fellowship, a 2 day course is given to provide trainees with a basic level of instruction regarding several issues in Nephrology. While it is geared primarily towards a basic level of instruction regarding topics in Nephrology that the fellow is unlikely to have covered during residency and will need to understand at the outset of their fellowship (mechanics of dialysis and transplant protocols), some general nephrology issues are discussed. 3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference – held every other Wednesday from 4-5 PM. The conference is divided into cycles of 4 weeks each: 1) Journal club (week 1 of the cycle) - This consists of a journal club in which fellows and faculty briefly present an article of interest from the current literature. Fellows review assigned journals, identify and read important articles, and discuss these with faculty. All major nephrology journals are covered as well as some general research and clinical journals. 2) Case presentations (weeks 2 and 4 of the cycle) - Fellows and residents on the Nephrology Service prepare a 25 minute presentation including 5-10 minutes of case presentation followed by 15-20 minutes for review of relevant literature. Discussants pick the topic at least one week in advance and review their selection with their Attending. The discussant hands out one good review or original article, however their discussion should be based, at least in part, on review of original literature. The goal is to cover in-depth one, focused area pertinent to the case. In doing so, Fellows are closely critiqued and advised on interpretation of original articles, including study design, methods and data interpretation. Each Fellow presents once a month and keeps a log of cases they presented. 3) Landmark articles (week 3 of the cycle) - Fellows and faculty review landmark articles in a given area in nephrology. These are the key articles that define the current state of practice. At least one week in advance of this, Dr. Beddhu discusses the articles with the fellows. This review is held every other month. Fellows keep a log of articles presented. 4) Morbidity and Mortality conference (week 3 of the cycle) - Fellows and faculty present M&M cases that were encountered over the past 2 months. Correctable problems are identified and action plans initiated as appropriate. Fellows send potential M&M cases to the Training Program Director, Dr. Kohan, in advance of the meeting so that appropriate cases can be identified, including those that require more immediate attention. This conference is held every other month. Fellows keep a log of cases they presented. b. 5 PM Nephrology Conference – held each Wednesday from 5-6 PM. About 70% of the conferences are based on local or visiting faculty research, while the remaining 30% are an in- depth review of clinical topics by the faculty. c. Renal Pathology Conference - held each Friday from 1-2 PM during the two years. All biopsies performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows. Renal biopsies performed at the VA are reviewed by the Fellow, Attending and VA Renal Pathologist independent of this conference. 4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see General Nephrology Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific evaluation utilized is indicated in the General Nephrology Table. These include: a. Checklist 1) Fellows are evaluated at the end of each 2-week rotation with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and
  17. 17. 16 behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first year of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second year of fellowship, scores must average "7" or above; if not, the same steps are taken as discussed above. 2) Fellows are evaluated by the Program Director every 6 months. The Director uses a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to general nephrology. Fellows review this with the Program Director. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. If any significant issues exist (scores under "5" in year 1 or under "7" in year 2), an action plan is developed and the fellow re-evaluated by the Program Director in 6 months using the same evaluation measurements as above. b. 360 evaluation – this evaluation is completed by administrative assistants, secretaries, renal social workers, renal dieticians, nurses, pharmacists, technicians, nurse practitioners, and physician assistants in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the general nephrology health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas. c. Patient surveys – Over the course of the year, 10-20 different patients are asked to complete a form rating Fellow’s general nephrology clinic patient interaction. These are reviewed annually with the Program Director. Areas in need of improvement (defined as greater than 10% of patients responding negatively) are identified and reassessed, by patient survey, within 6 months. d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (250 question multiple choice style). Their performance is reviewed with the Program Director. General nephrology areas in need of improvement (defined as missing more than 2 questions in that area) are identified and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Program Director. e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than two hours. This session is not exclusively devoted to general nephrology, but contains at least 4 cases pertinent to major general nephrology issues. Faculty score the Fellow’s responses on a scale from 1-9. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement (defined as incorrectly answering any questions about major concepts in that area) are identified and an action plan formulated with the Program Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Program Director. f. Resident portfolio – This is partly intended to evaluate Fellow’s practice-based learning and improvement. Several approaches are utilized: 1) Faculty or fellow-initiated CQI project. The Fellow catalogues over time questions and issues that arose during patient care activities and identifies, with a faculty mentor, and issue to address. Once identified, an action plan is developed, the rationale expound (including identifying data sources used), actions taken, and the effect of such
  18. 18. 17 interventions assessed. This is reviewed every 6 months with the Program Director and the faculty mentor. 2) Practice Improvement Module (PIM) from ABIM. In place of a fellow or faculty-initiated CQI project, fellows may participate in the PIM in Hypertension, Specialty Referrals, or other areas. Dr. Martin Gregory mentors this experience which involves identifying an area in need of improvement within the given PIM topic, modifying the practice accordingly, and assessing the impact of such changes. 3) Morbidity and mortality conference. Identification of practice and/or system-based problems contributing to morbidity and mortality is an important aspect of meeting these core competencies. Fellows attendance at these conferences, and identification of the issues discussed and actions taken, is documented and included in the portfolio. 4) Case-based presentations. Each fellow does approximately 8 case-based presentations yearly. These presentations assist in improving the fellow's practice, detailing how they researched a topic relevant to a case they encountered and how such research impacted their care, or plan for subsequent care. The topics covered are listed in the portfolio and the presentation itself is added to the reference database in the web-based "Fellows Lounge" on the Nephrology Division website. This latter activity helps improve the practice of all fellows and faculty. 5) Journal club. Each fellow does approximately 8 journal club presentations yearly. The article that they presented is listed in the portfolio. This helps document the fellow's commitment to improving their analysis of the literature relevant to care of their patients. 6) Log of adverse events and actions taken. Fellows keep a computer log of this, independent of their M&M presentations. 7) Summative evaluations. All summative fellow evaluations are included in the portfolio to enable the fellow to review their progress and facilitate making any necessary changes. While this information can largely be obtained by each fellow using their unique logon access to the web-based evaluation system (MyEvaluations.com), having a written list facilitates discussion with, and review by, the Program Director. 8) Procedures. All procedures completed are listed here - see details in following section. 2. Procedures – Fellows are required to keep a log of all native kidney biopsies, indicating date, attending, patient identifier, indication and complications. Fellows are required to perform at least 10 native biopsies per year. These biopsies are always done in the presence of an attending, regardless of Fellow competency and experience. 3. Conferences – Fellows attendance at conferences is documented as described above. Participation in journal clubs, M&M, case-based presentations, and Landmark articles review, as they relate to general nephrology, is discussed with the Program Director during the 6-month evaluation. 4. Final (summative) evaluation - This evaluation includes a review of the Fellow’s performance during the final period of education, and verifies that the Fellow demonstrated sufficient professional ability to practice competently and independently 8) Assessment and evaluation of attendings by Fellows - discussed in section below devoted to this topic.
  19. 19. 18 General Nephrology Table Competency Competency objectives General Nephrology objectives relevant to competency Teaching Methods Evaluation Acceptable category Methods Performance Patient care Exhibit caring and Exhibit caring and respectful behaviors towards general Attending teaching Patient surveys ≤10% unacceptable respectful behaviors nephrology patients Conferences 360 evaluation ≥ “5” Orientation Checklist ≥ “5”, Yr 2 avg. ≥ 7 Core lectures Gather essential and Gather essential information about fellow’s general nephrology Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 accurate information patient Conferences 360 evaluation ≥ “5” about their patients Core lectures Make informed decisions Make informed decisions about diagnostic and therapeutic Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 about diagnostic and interventions in general nephrology patients Conferences Chart-stimulated Miss no major therapeutic interventions Core lectures recall concepts Develop and carry out Develop and carry out general nephrology patient management Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 patient management plans Conferences 360 evaluation ≥ “5” plans Core lectures Chart-stimulated Miss no major recall concepts Counsel and educate Counsel and educate general nephrology patients and families Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 patients and families with regard to their disease, socioeconomics, support systems, Conferences 360 evaluation ≥ “5” diet, lifestyle, medications Core lectures Use information Use information technology to assist caring for general Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 technology nephrology patients, including UpToDate, NIH information and Orientation databases, NephSAP, electronic medical records, PubMed, and Conferences other sources Perform: Examine the general nephrology patient, particularly with Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 Physical exam regard to the renal examination and organ systems affected by Conferences renal dysfunction Core lectures Perform: Understand the principles of informed consent, indications, Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 Procedures contraindications, alternative procedures, and the risks and Conferences benefits, and demonstrate the correct procedural techniques Core lectures for: 1. Percutaneous native renal biopsy Understand interpretation and demonstrate the correct technique for: 1. Urinalysis Provide preventative Provide preventative health care services relevant to general Conferences Checklist ≥ “5”, Yr 2 avg. ≥ 7 health care services nephrology patients Attending teaching Chart-stimulated recall Work within a team of Work within the general nephrology health care team, including Conferences Checklist ≥ “5”, Yr 2 avg. ≥ 7 health care professionals attendings, nurses, dieticians, social workers, physician Attending teaching 360 evaluation extenders, pharmacists and administrative assistants Orientation
  20. 20. 19 Medical Demonstrate Demonstrate investigatory and analytic thinking about clinical general Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 knowledge investigatory and nephrology situations Core lectures Chart-stimulated Miss no major analytic thinking Conferences recall concepts about clinical Journal club Written exam situations Clinical meetings Orientation Know and apply Fellows will acquire the fund of knowledge necessary for prevention, Attending teaching Written exam ≤2 incorrect each the basic and evaluation, and management of general nephrologic disorders in: Core lectures theme clinically a. Acute renal failure Conferences Chart-stimulated Miss no major supportive b. Chronic renal failure Journal club recall concepts sciences c. Fluid, electrolyte, and acid-base disorders Clinical meetings d. Disorders of mineral metabolism including nephrolithiasis and renal Orientation osteodystrophy (including use of lithotripsy) e. Urinary tract infections and pyelonephritis f. Hypertensive disorders g. Renal disorders related to pregnancy h. Primary and secondary glomerulopathies, including understanding of immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis i. Diabetic nephropathy j. Tubulointerstitial nephritis including papillary necrosis k. Genetic and developmental renal diseases including renal cystic diseases, hereditary glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma l. Vascular diseases including atheroembolic disease m. Disorders of drug metabolism and renal drug toxicity, including in geriatric patients n. Renal disorders associated with geriatric patients o. Renal cystic diseases without a recognized genetic basis Understand nutritional management of general nephrologic disorders Understand indications and interpretation of renal imaging, including ultrasound, CT, IVP, MRI, angiography, nuclear medicine studies Understand indications, complications and outcomes in therapeutic plasmapheresis
  21. 21. 20 Practice-based Analyze own Fellow will hold up a mirror to themselves to document, assess, Attending teaching Resident portfolio Completed PIM learning and practice and and improve their practice. This will involve: Case-based presentations (Fellow 8 case-based talks improvement perform a. Monitoring their practice on fellow’s own pts. catalogues over 8 journal clubs practice- b. Reflecting on or analyzing their practice to identify learning or Journal club time questions 4 M&M based improvement needs Participation in CQI activities and issues that ≥ “5”, Yr 2 avg. ≥ 7 improvement c. Engaging in a learning or plan improvement Exit rounds on patient arose during on checklists using a d. Applying the new learning or improvement discharge patient care Log of ≥2 significant systematic e. Monitoring the impact of the learning or improvement M&M on fellow’s own activities along events, how methodology patients with copies of the addressed, and Conferences data sources results Log of significant events and used, and Fellow/faculty plan to address actions taken, to initiated project Assigned faculty mentor address the (PIM is an PIM specific question alternative) or issue). Use evidence Use evidence from scientific studies related to general Attending teaching Chart-stimulated Miss no major from scientific nephrology patients’ health problems Case-based presentations recall concepts studies on fellow’s own pts. Written exam ≤2 incorrect each related to Journal club theme patients’ health problems Apply Apply knowledge of study designs and statistical methods to Statistics and epidemiology Chart-stimulated Miss no major knowledge of appraising clinical studies and other information course recall concepts study designs Conferences Written exam ≤2 incorrect each and statistical Journal club theme methods to Assigned faculty mentor appraising clinical studies and other information Use Use information technology as itemized in Patient Care above Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 information Orientation Resident portfolio See “Analyze own technology Conferences practice…” above Facilitate the Facilitate the learning of others, including faculty, residents, Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 learning of fellows, physician extenders, nurses and dialysis technicians Attending teaching 360 evaluation ≥ “5” others Conferences Interpersonal & Maintain a Maintain a therapeutic and ethical relationship with general Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 communication therapeutic nephrology patients Attending teaching 360 evaluation ≥ “5” skills and ethical Conferences Patient surveys ≤10% unacceptable relationship Core lectures with patients Demonstrate Demonstrate effective listening and writing skills Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 effective Attending teaching 360 evaluation ≥ “5” listening and Record review No deficiencies writing skills (attending co-signs)
  22. 22. 21 Professionalism Demonstrate Demonstrate respect, compassion, and integrity Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 respect, Attending teaching 360 evaluation ≥ “5” compassion, Patient surveys ≤10% unacceptable and integrity Demonstrate Demonstrate an ethically sound practice Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 an ethically Attending teaching 360 evaluation ≥ “5” sound Conferences practice Demonstrate Demonstrate sensitivity to patients’ culture, age, gender, and Role models Checklist ≥ “5”, Yr 2 avg. ≥ 7 sensitivity to disabilities Attending teaching 360 evaluation ≥ “5” patients’ Conferences Patient surveys ≤10% unacceptable culture, age, gender, and disabilities Systems-based Understand Understand interaction between fellow’s practice and the Conferences 360 evaluation ≥ “5” practice interaction of hospital and clinic staff, administration, surgical service, Attending teaching their practices radiology, and medical consult services with the larger system Understand Understand how types of general nephrology practice and Conferences Written exam ≤2 incorrect each types of providers deliver care Attending teaching theme medical practice and delivery systems Practice cost- Practice cost-effective general nephrology patient care Conferences Checklist ≥ “5”, Yr 2 avg. ≥ 7 effective Core lectures 360 evaluation ≥ “5” health care Attending teaching Advocate for Advocate for general nephrology patient quality care by Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 quality patient demonstrating proactive efforts towards dialysis CQI Participation in CQI 360 evaluation ≥ “5” care Conferences
  23. 23. 22 C. Transplant 1) Goal Fellows will become competent in caring for renal transplant patients and patients with renal complications of non-renal transplants. 2) Objectives (see Transplant Table) 3) Types of clinical encounters and supervision 1. Inpatient transplant encounters – Each Fellow spends 4 months/year on the UH rotation. It is during the UH rotation that the Fellow has inpatient transplant encounters. All UH patients admitted for surgical renal transplantation are admitted to the Transplant Surgery Service. These patients are followed by the Fellow on the UH rotation during the perioperative period. The Fellow discusses perioperative care with the Transplant Surgery Team each day. Subsequent admissions of renal transplant recipients are made to the Nephrology service (unless the problem is likely to require surgery); the Fellow is the primary provider for these patients, seeing them and writing notes on a daily basis. The Fellow makes sit-down interdisciplinary rounds with the renal transplant team on Mondays and Thursdays from 1-1:30 PM in which the patient’s current status and care plan are discussed. Post-transplant patients are very infrequently admitted to the VA. The Attending sees the patients together with the Fellow after the Fellow has done the initial evaluation. The Attending is on-call with the Fellow 24 hours a day. A Transplant Nephrologist is on-call 24 hours each day for back-up of difficult transplant issues. 2. Outpatient transplant encounters a. UH Post-Transplant Clinic - Each Tuesday morning, the Fellow on the outpatient nephrology (OP) rotation attends this clinic. In all, Fellows attend 4 months/year of weekly UH Post- Transplant Clinic on a non-continuity basis. All patients are initially evaluated by the Fellow or residents. Renal transplant coordinators are present to facilitate patient care. All patients are staffed with the Transplant attending. b. UH Pre-Transplant Clinic – Fellows attend this clinic every Wednesday morning while on the OP rotation. In all, each Fellow attends this clinic for 4 months/year. The Fellow initially evaluates pre-transplant candidates. Renal transplant coordinators are present to facilitate this process. All patients are staffed with the Transplant attending. 4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient renal transplant census is 2-4 patients at UH and very infrequently at the VAMC. Approximately 80 patients received renal transplants at UH in 2005 of which about 25 were living-related donors. Patient demographics are similar to those for general nephrology patients. VA patients are transplanted at UH but admitted to the VA subsequently. About 3-5 VA patients are transplanted each year. 2. Outpatients – Over 600 patients are followed in the UH Post-Transplant Clinic. An average of 15-20 patients are seen in the weekly UH Post-Transplant Clinic. The UH Pre-Transplant Clinic evaluates up to four patients each week. Patient demographics are similar to those for general nephrology patients. 5) Procedural training (see Transplant Table) 1. Percutaneous biopsy of transplanted kidneys – performed by the Fellow on inpatients on their service or outpatients they have seen in Post-Transplant Clinic. All renal transplant biopsies on inpatients are performed by the Fellow in the presence of the Attending. Each fellow performs about 15-20 renal transplant biopsies yearly. 6) Teaching methods (see Transplant Table) 1. Educational training
  24. 24. 23 a. Handouts - At the beginning of the Fellowship, Fellows are given the Handbook of Renal Transplantation (Danovitch) and access to UpToDate. Additionally, they are given the Handbook of Renal Transplant Protocols for the University of Utah. 2. Didactic sessions a. Weekly didactic conference – Renal transplant issues are covered in detail in the didactic conference held each Friday from 8-9 AM. Sessions are devoted to recipient evaluation, mechanisms of allograft rejection, immunosuppressive drugs, prophylaxis and treatment of graft rejection, non-rejection causes of graft dysfunction, major causes of post-transplant morbidity and mortality, and renal disease associated with liver, heart and bone marrow transplantation. b. Primer Course - At the beginning of the Fellowship, a 2 day course is given to provide a basic level of instruction regarding several issues in Nephrology. Those covered relevant to transplant include renal transplantation and UH Protocols, chronic immunosuppression, and approach to an elevated creatinine or fever in a transplant recipient. 3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference - See General Nephrology Section for details. General nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles, M&M, and journal club. b. 5 PM Nephrology Conference – See General Nephrology section for details. Several conferences are devoted to transplant yearly. c. Renal Pathology Conference – The conference is held each Friday from 1-2 PM during the two years. All biopsies of transplanted kidneys performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi- headed microscope and is attended by all Fellows 4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see Transplant Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific evaluation utilized is indicated in the Transplant Table. These include: a. Checklist 1) Fellows are evaluated at the end of each 2-week rotation with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first year of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second year of fellowship, scores must average "7" or above; if not, the same steps are taken as discussed above. 2) Fellows are evaluated by Transplant Director (Dr. Shihab) every 6 months. The Transplant Director uses a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to transplant. Fellows review this with the Program and Transplant Directors. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. If any significant issues exist (scores under "5" in year 1 or under "7" in year 2), an action plan is developed and the fellow re-evaluated by the Program and Transplant Directors in 6 months using the same evaluation measurements as above. b. 360 evaluation – this evaluation is completed by transplant nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the transplant health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores
  25. 25. 24 under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas. c. Patient surveys – Over the course of the year, about 10 different patients are asked to complete a form rating transplant patient interaction. These are reviewed annually with the Transplant Director. Areas in need of improvement are identified and reassessed, by patient survey, within 6 months. These evaluations are not fellow-specific, since fellows do not follow transplant patients on a continuity basis. However, fellows are involved in discussion of the patient surveys and identification of areas for improvement. d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (multiple choice style). Their performance is reviewed with the Program Director. Transplant areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Transplant Director. e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than 2 hours. This session is not exclusively devoted to transplant, but contains at least 2 cases pertinent to transplant. Faculty score the Fellow’s responses on a scale from 1-9. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement are identified (defined as incorrectly answering any questions about major concepts in that area) and an action plan formulated with the Transplant Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Transplant Director. f. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Transplant Director. 2. Procedures – Fellows must keep a log of all transplant kidney biopsies indicating date, attending, patient identifier, indication and complications. Fellows must do at least 5 transplant kidney biopsies each year. However, at no time may a Fellow do a biopsy without attending supervision. 3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and NephSAP review, as they relate to transplant, is discussed with the Program Director during the 6-month evaluation. 4. Final (summative) evaluation - This evaluation includes a review of the Fellow’s performance during the final period of education, and verifies that the Fellow demonstrated sufficient professional ability to practice competently and independently 8) Assessment and evaluation of attendings by Fellows - discussed in section below devoted to this topic.
  26. 26. 25 Transplant Table Competency Competency Transplant objectives relevant to competency Teaching Methods Evaluation Acceptable category objectives Methods Performance Patient care Exhibit caring and Exhibit caring and respectful behaviors towards transplant Attending teaching Patient surveys ≤10% unacceptable respectful behaviors patients Conferences 360 evaluation ≥ “5” Orientation Checklist ≥ “5”, Yr 2 avg. ≥ 7 Core lectures Gather essential Gather essential information about fellow’s transplant Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 and accurate patient Conferences 360 evaluation ≥ “5” information about Core lectures their patients Make informed Make informed decisions about diagnostic and therapeutic Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 decisions about interventions in transplant patients Conferences Chart-stimulated Miss no major diagnostic and Core lectures recall concepts therapeutic interventions Develop and carry Develop and carry out transplant patient management Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 out patient plans Conferences 360 evaluation ≥ “5” management plans Core lectures Chart-stimulated Miss no major recall concepts Counsel and Counsel and educate transplant patients and families with Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 educate patients regard to renal transplant types, socioeconomics, support Conferences 360 evaluation ≥ “5” and families systems, diet, lifestyle, medications Core lectures Interdisciplinary rounds Use information Use information technology to assist caring for transplant Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 technology patients, including UpToDate, NIH information and Orientation databases, NephSAP, electronic medical records, Conferences PubMed, and other sources Perform: Examine the transplant patient, particularly with regard to Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 Physical exam transplant-related problems, including examination of the Conferences transplant site Core lectures Perform: Understand the principles of informed consent, indications, Attending teaching Checklist ≥ “5”, Yr 2 avg. ≥ 7 Procedures contraindications, alternative procedures, and the risks and Conferences benefits, and demonstrate the correct procedural Core lectures techniques for: 1. Renal transplant biopsy Provide Provide preventative health care services relevant to Interdisciplinary rounds Checklist ≥ “5”, Yr 2 avg. ≥ 7 preventative health transplant patients Conferences Chart-stimulated Miss no major care services Attending teaching recall concepts Work within a team Work within the transplant health care team, including Interdisciplinary rounds Checklist ≥ “5”, Yr 2 avg. ≥ 7 of health care attendings, nurses, nurse coordinators, social workers, Conferences 360 evaluation ≥ “5” professionals physician extenders, pharmacists, and administrative Attending teaching assistants Orientation

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