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2008-2009

  1. 1. Nephrology Training Program UCLA Division of Nephrology ACGME Program (1480511110) 2008-2009 CURRICULUM Page I. Overall Goals and Objectives 3 II. Inpatient General Nephrology Rotation (PGY4) 4 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations III. Transplant Nephrology Rotation (PGY4) 11 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations IV. Outpatient Dialysis Rotation (PGY4) 18 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations V. Continuity Clinics (PGY4) 25 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations VI. Inpatient General Nephrology Rotation (PGY5) 32 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations
  2. 2. VII. Transplant Nephrology Rotation (PGY5) 40 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations VIII. Continuity Clinics (PGY5) 47 A. Goals & Objectives B. Core Competencies C. Methods of Teaching and Implementation D. Reading Material E. Evaluations IX. Syllabus 54 X. Principal Teaching Method 60 2
  3. 3. I. Goals and Objectives The Nephrology Training Program of UCLA is dedicated to provide advanced training and experience for residents to acquire expertise expected of consultants in nephrology. The duration of training is 2 years with an optional third year of dedicated research The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. 3
  4. 4. II. Inpatient General Nephrology (PGY4) A. Goals & Objectives Residents are expected to see new consults and follow up on previous consults in this inpatient rotation. During this rotation they always have a precepting attending who overlooks the management and care of the patient but provides adequate independence to the residents to formulate their own plan. PGY4 fellows have senior fellows (PGY5) as back up if needed. The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. B. Core Competencies 1. Patient Care Residents are trained and educated to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents 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 from various resources including consulting physician/team, computer database, other subspecialties and nursing and ancillary staff • 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 in accordance to the accepted guidelines • counsel and educate patients and their families about renal failure, electrolyte abnormalities, hypertension and dialysis modalities • 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 including temporary dialysis access placement, renal biopsy and urine analysis 4
  5. 5. • provide health care services aimed at preventing health problems or maintaining health including prevention of renal and cardiovascular disease progression • work with health care professionals, including those from other disciplines, to provide patient-focused care 2. Medical Knowledge By the end of this rotation the residents are expected to be well versed with • Diagnosis, work up and management of acute kidney injury and its various causes • Acid base physiology with sound understanding of pathophysiology and management • Evaluation and selection of patients for acute hemodialysis including continuous renal replacement therapy • Various complications of dialysis including access issues • Drug dosage in patients on dialysis • Various procedures including emergent vascular access placement for hemodialysis and renal biopsy • Work up and management of various electrolyte abnormalities in hospitalized patients • Management of hypertensive urgencies and emergencies • Residents are expected to take care of patients with different level of complexities eg floor, step down and intensive critical care units • Residents are also expected to teach other healthcare professionals regarding various renal, acid-base, electrolyte abnormalities and hypertension • Addressing renal issues in non-renal transplant patients both pre and post operative 3. Practice-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents 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 Residents 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. Residents are expected to: • create and sustain a therapeutic and ethically sound relationship with patients 5
  6. 6. • 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 Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development • 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 Residents 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. Residents 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 C. Methods of Teaching and Implementation 1. Clinical Experience A. Total of 16 weeks will be devoted to inpatient nephrology training. During this time, the fellow is expected to manage: • ~500-600 new and 250 follow-up in-patients per rotation. B. Patient- mix includes diversity in • Age and sex: 21 years and older to geriatric age group of both sexes. On occasion 18-21 years old will also be seen. • Social economic status • Racial, ethnic & cultural background C. Formal instruction and clinical experience in the prevention, evaluation and management of the entire spectrum of nephrological disorders (see Syllabus) 6
  7. 7. 2. Technical and Other Skills A. Indications, contraindications, complications and interpretation of results in: • Urinalysis • Percutaneous biopsy of native • Peritoneal dialysis • Placement of temporary vascular access for hemodialysis and other extracorporeal therapies • Acute and chronic hemodialysis • Renal imaging • Continuous renal replacement therapy B. Familiarity with the principle, utility, complications and cost effectiveness of: • Radiology of vascular access • Balloon angioplasty of vascular access • Therapeutic plasmapheresis • Bone biopsy • Placement of peritoneal catheters 3. Research Experience A. Throughout the 24 months of fellowship training faculty members (all are involved in active research) inculcates a research culture into the thinking and clinical practice of the trainees. In addition, specific instruction on topics including the design and interpretation of research studies; the essentials of informed consent and the critical assessment of new therapies and the biomedical literature are taught and discussed during the: • Journal Club on both clinical and basic science research papers • Basic Science Conference by local and visiting research professors • Research Conference given by trainees, local and visiting research professors • Attendance at national and ocal nephrology meetings with heavy emphasis on clinical and basic research • Basic science and research topics are covered in the Pathophysiology course B. Hands on experience in the conduct of medical research: All fellows with no previous experience in direct research are encouraged to complete a minimum of a 1-month research in the first year and 7-8 months of research in the second year of training. Fellows who have worked and published research papers have the choice of using the research rotation for an, in-depth rotation, focusing on a topic in consultative nephrology, dialysis or transplantation. C. Research requirements for nephrology fellows with no formal research training: One-month of research experience is required for Nephrology in the first year. In the second year, at least six months of research experience is required. A Nephrology fellow will first have the opportunity to get familiarized with the ongoing research activities of the faculty members of the Program and thereafter select a research project. Under the mentorship of the selected faculty member, the fellow will acquire knowledge in the design and interpretation of research studies, research ethics and responsible use of informed consent, research methodology and interpretation of data, and training in writing and presenting the outcome of the studies. 7
  8. 8. D. Research requirements for nephrology fellow with prior research training: Nephrology fellows are selected, in part, because of their strength and track-record in clinical and basic research. This is usually reflected by their letters of recommendation and publications reflecting intensive training in research methods and skills. For fellows that are interested, the STAR program offers them the opportunity to obtain advanced degrees in clinical or basic research. These fellows are required to spend 80% of their time in research in the second year. Fellows in the STAR program can either continue after their second year to get a Masters in clinical science or a PhD in health outcome research or in basic science. Instruction in basic sciences as they relate to Nephrology is given at a Pathophysiology Course, a Basic Science Course, Research Conference, Journal Club meetings, a ESRD conference and, Renal Grand Rounds. Each fellow attends local/regional and national and international scientific conferences or training sessions each year. Nationally and internationally recognized Nephrologists visit the program each year, approximately half of these visiting professors work in basic sciences related to Nephrology. 4. Conference and Scholarly Activities Renal Conferences • Renal Grand Rounds • Nephrology Noon Conference (includes Basic Science & Research) • Consult Service Teaching Seminar/Journal club • Pathophysiology Course • Transplant Conference Multidisciplinary Conference • Renal-Pathology Conference • Medical Grand Rounds • Noon-Conference • Morning Report Visiting Professorships • National and international professors visit each year. They represent authorities in a wide spectrum of basic research and clinical expertise in the field of nephrology and related disciplines. Special Courses • Introduction to Renal Pathology • Advances in Renal Transplantation Attendance at Scholarly Conferences • Annual Scientific Symposium on the National Kidney Foundation of Southern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Internet Facilities • Up-to-Date: A quarterly up-dated nephrology reference. • HDCN: A web-site providing all important references and advanced on nephrology and related subjects including complete lectures from all national and international conferences. • NEPHROL: An international web-site where practicing nephrologists exchange views and experience Special Courses Special courses lasting days to weeks are spaced through the two year training include: 8
  9. 9. • Introduction to Renal Pathology • Advances in Renal Transplantation • Comprehensive Course on Elements of Dialytic Therapy • STAR program. Selected fellows are accepted as candidates for a masters or PhD program Other Scholarly Conferences Each year the fellow is given the opportunity to attend: • Annual Scientific Symposium of the National Kidney Foundation of Sourthern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Journal, Video and Audio Material Every resident can receive journal subscriptions and video-tapes on lectures if available. 5. Teaching and Communication Experience Fellows are given daily opportunity to learn from and model after the attending nephrologists in teaching, communication and leadership skills. These skills are specifically developed in the following activities: • Weekly lectures to residents, interns and medical students taking nephrology elective. • Opportunities to teach at the weekly "Nephrology Core Curriculum for Residents." • Presentations and participation as active discussants at the weekly UCLA Nephrology Grand Rounds. • Presentation of research papers and participation as active discussants at Journal Clubs. 6. Training in Self-Instruction and Informatics Fellows are provided with educational and informatics facilities and trained to utilize them on a daily basis to effectively search and gather information for critical analysis of clinical problems and the resource and ability to make appropriate decisions. This is expected to be a life-long culture the fellows will carry with them upon graduation. Specifically, the following sources and facilities are available: • Up-To-Date: Our program subscribes to this well known electronic clinical reference in nephrology and hypertension. Included also are continuously undated information on an adult primary care and internal medicine; cardovascular medicine; endocrinolgoy and diabetes; gastroenterology and hepatology; infectious diseases; pulmonary disease; critical care and rheumatology • HDCN: Abbreviation for Hypertension, Dialysis and Clinical Nephrology, an electronic journal and an official education program of the American Society of Nephrology and the Renal Physician Association. Our program encourages trainees to subscribe and pays for the subscription • NEPHROL: Trainees are encouraged to participate in the discussion of this cyber-forum. Over 1,400 national and international nephrologists exchange their views on the management of patients with nephrological and hypertensive disorders. • MD Consult: Our program subscribes to MD Consult, a premier online medical information it also provides all standard nephrological and other medical text books on-line. • OVID: We also subscribe to Ovid, a powerful , high-end information retrieval solution for researchers and professional sin academic and medical settings. • Teton Data Systems: We subscribe to this site which provides medical and drug information designed exclusively for physicians. Provides facility for cross-searching more that 31 medical texts including Medline, Stedman's Medical Dictionary and other standard medical texts. 9
  10. 10. • PubMed: PubMed is the National Library of Medicine's search service that provides access to over 11 million citations in MEDLINE, PreMEDLINE, and other related databases, with links to participating online journals. Trainees are actively encouraged to access to this resource. • GratefulMed: Internet Grateful Med (IGM) searches MEDLINE® using the retrieval engine of NLM's PubMed system. Trainees are actively encouraged to access this resource. D. Reading Material PGY4 are strongly encouraged to stay current with literature by reading the following journals (JASN, AJKD, Kidney International, American Journal of Nephrology, Clinical & Experimental Nephrology, Current Opinion in Nephrology and Hypertension, New England Journal of Medicine, JAMA, Lancet, Nature, Science). GENERAL NEPHROLOGY 1. Brenner and Rector The Kidney, Saunders 2. Massry and Glassock Textbook of Nephrology, Williams & Williams. 3. Nissenson, Fine and Gentile Clinical Dialysis, Appleton & Lange. ACID-BASE AND ELECTROLYTE DISORDERS 1. Ira Kurtz, Acid – Base Handbook, Trafford Publishing, 2004. 2. Burton David Rose Clinical physiology of acid-base and electrolyte disorders, McGraw-Hill. 3. Robert W. Schrier Renal and electrolyte disorders, Little & Brown Co. 4. Brenner, Rector, Coe Renal physiology in health and disease, Saunders. CLINICAL NEPHROLOGY, HYPERTENSION 1. Brenner, Coe, Rector Clinical Nephrology, Saunders. 2. Burton David Rose Pathophysiology of renal disease, McGraw-Hill. 3. Robert W. Schrier Renal and electrolyte disorders, Little & Brown Co. RENAL PATHOLOGY 1. Columbia Pathology Review Course slides 2. AJKD website - www.ajkd.org 3. Up-to-Date program E. Evaluations 1. The program director meets all residents informally on a weekly basis and formally on a quarterly basis and at the end of each year. 2. After each rotation, a resident is evaluated by the attending nephrologist using the standard American Board of Internal Medicine (ABIM) format: "Evaluation of Subspecialty Trainees". PGY4s have 2 written tests per year to evaluate their knowledge of the syllabus and an in-service test. Evaluation include assessment of: • Clinical judgment • Medical knowledge • Clinical skills: medical interviewing, physical examination, procedural skills • Humanistic qualities • Professionalism 10
  11. 11. • Medical care • Continuing Scholarship • Overall clinical competence as a nephrologist 3. Procedure records of each resident are maintained using the standard forms provided in the ABIM Guidelines on Evaluation of Clinical Competence and Other Information: "Trainee's Log of Supervised Procedures." 4. The program director or his designate meets with each resident quarterly for performance review and counseling. Evaluation includes residents' technical proficiency, teaching skills, communication, humanistic qualities, professional attitudes and behavior and commitment to scholarship. A written summary is filed for each such encounter. 5. The program director or his/her designate completes written American Board of Internal Medicine (ABIM) tracking form on clinical competence of each resident annually and at the conclusion of the fellow's training. In case of adverse evaluations, special programs are instituted for remedial education and training. In case of persistent documented deficiency unresponsive to corrective actions, the resident is discontinued from the program. III. Transplant Nephrology Rotation (PGY4) A. Goals & Objectives Renal Transplantation Each fellow must complete 1- month of rotation on the renal transplant service. Additional elective transplant rotation can be arranged. Clinical experience consists of active involvement, under supervision, in the management of pre- and immediate post-transplant and long-term care of donors and recipients and include: a) Evaluation and selection of transplant candidates b) Preoperative evaluation and preparation of transplant recipients c) Immediate postoperative management of transplant recipients, including administration of immunosuppressants d) Clinical diagnosis of all forms of rejections including laboratory, histopathologic and imaging techniques e) Medical management of rejection, including use of immunosuppresssant drugs and other agents f) Recognition and medical management of surgical and nonsurgical complications of transplantaions g) Long-term follow-up of transplant recipients in the ambulatory setting. Each fellow does a month rotation of inpatient transplant nephrology. During this rotation they always have a precepting attending who overlooks the management and care of the patient but provides adequate independence to the residents to formulate their own plan. The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. 11
  12. 12. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. B. Core Competencies 1. Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents 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 By the end of the rotation, the residents are expected to be well versed with the following • Evaluation and selection of renal transplant candidates • Preoperative evaluation and preparation of renal transplant recipients • Immediate postoperative management of transplant recipients including administration of immunosuppresants • Clinical diagnosis of all forms of rejection including laboratory, histopathological and imaging techniques • Medical management of rejection, including use of immunosuppresants • Recognition and medical management of surgical and nonsurgical complications of renal transplantation • Long term follow-up of renal transplant recipients in ambulatory setting • demonstrate an investigatory and analytic thinking approach to clinical situations 12
  13. 13. • know and apply the basic and clinically supportive sciences towards evaluation of patients for cadaveric and living donor transplant, follow patients immediate pre, peri and post transplant, evaluate renal failure for rejection, recurrence of original disease, calcineurin inhibitor toxicity, surgical complications • Residents are expected to take care of patients with different level of complexities eg floor, step down and intensive critical care units • Residents are also expected to teach other healthcare professionals regarding various renal transplant issues 3. Practice-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents 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 Residents 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. Residents 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 Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development • 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 13
  14. 14. 6. Systems-Based Practice Residents 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. Residents 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 C. Method of Teaching & Implementation 1. Clinical Experience A. 4 weeks will be devoted to clinical training. It is estimated that you will manage: • During your transplant rotation you will manage at least 30 new patients and 45 follow-up patients. • Longitudinal follow-up of transplant patients are also seen throughout the year, in the in-patient and outpatient nephrology rotations. B. Patient- mix includes diversity in • Age and sex: adolescent to geriatric age group of both sexes • Social economic status • Racial-cultural background C. Formal instruction and clinical experience in the prevention, evaluation and management of the entire spectrum of nephrological disorders (see Syllabus) 2. Technical and Other Skills B. Indications, contraindications, complications and interpretation of results in: • Urinalysis • Percutaneous biopsy of native and transplant kidneys • Peritoneal dialysis • Placement of temporary vascular access for hemodialysis and other extracorporeal therapies • Acute and chronic hemodialysis • Renal imaging • Continuous renal replacement therapy B. Familiarity with the principle, utility, complications and cost effectiveness of: • Radiology of vascular access • Balloon angioplasty of vascular access • Therapeutic plasmapheresis 14
  15. 15. • Bone biopsy • Placement of peritoneal catheters C. Research Experience A. Throughout the 24 months of fellowship training faculty members (all are involved in active research) inculcates a research culture into the thinking and clinical practice of the trainees. In addition, specific instruction on topics including the design and interpretation of research studies; the essentials of informed consent and the critical assessment of new therapies and the biomedical literature are taught and discussed during the: • Journal Club on both clinical and basic science research papers • Basic Science Conferences by local and visiting research professors • Research Conference given by trainees, local and visiting research professors • Attendance at nephrology meetings with heavy emphasis on clinical and basic research • Basic science and research topics are covered in the Pathophysiology course B. Hands on experience in the conduct of medical research: All fellows with no previous experience in direct research are required to complete a minimum of a 1-month research in the first year and 7-8 months of research in the second year of training. Fellows who have worked and published research papers have the choice of using the research rotation for an, in-depth rotation, focusing on a topic in consultative nephrology, dialysis or transplantation. C. Research requirements for nephrology fellows with no formal research training: One-month of research experience is required for Nephrology in the first year. In the second year, at least six months of research experience is required. A Nephrology fellow will first have the opportunity to get familiarized with the ongoing research activities of the faculty members of the Program and thereafter select a research project. Under the mentorship of the selected faculty member, the fellow will acquire knowledge in the design and interpretation of research studies, research ethics and responsible use of informed consent, research methodology and interpretation of data, and training in writing and presenting the outcome of the studies. D. Research requirements for nephrology fellow with prior research training: Nephrology fellows are selected, in part, because of their strength and track-record in clinical and basic research. This is usually reflected by their letters of recommendation and publications reflecting intensive training in research methods and skills. For fellows that are interested, the STAR program offers them the opportunity to obtain advanced degrees in clinical or basic research. These fellows are required to spend 80% of their time in research in the second year. Fellows in the STAR program can either continue after their second year to get a Masters in clinical science or a PhD in health outcome research or in basic science. Instruction in basic sciences as they relate to Nephrology is given at a Pathophysiology Course, a Basic Science Course, Research Conference, Journal Club meetings, a ESRD conference and, Renal Grand Rounds. Each fellow attends local/regional and national and international scientific conferences or training sessions each year. Nationally and internationally recognized Nephrologists visit the program each year, approximately half of these visiting professors work in basic sciences related to Nephrology. D. Conference and Scholarly Activities Renal Conferences • Renal Grand Rounds 15
  16. 16. • ESRD Conference • Pathophysiology Course • Transplant Conference/Journal Club • Basic Science and research conferences Multidisciplinary Conference • Renal-Pathology Conference • Medical Grand Rounds • Noon-Conference • Morning Report Visiting Professorships • The Program is visited by national and international professors each year. They represent authorities in a wide spectrum of basic research and clinical expertise in the field of nephrology and related disciplines. Special Courses • Introduction to Renal Pathology • Advances in Renal Transplantation Attendance at Scholarly Conferences • Annual Scientific Symposium on the National Kidney Foundation of Southern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Internet Facilities • Up-to-Date: A quarterly up-dated nephrology reference. • HDCN: A web-site providing all important references and advanced on nephrology and related subjects including complete lectures from all national and international conferences. • NEPHROL: An international web-site where practicing nephrologists exchange views and experience Special Courses Special courses lasting days to weeks are spaced through the two year training include: • Introduction to Renal Pathology • Advances in Renal Transplantation • Comprehensive Course on Elements of Dialytic Therapy • STAR program. Selected fellows are accepted as candidates for a masters or PhD program Other Scholarly Conferences Each year the fellow is given the opportunity to attend: • Annual Scientific Symposium of the National Kidney Foundation of Sourthern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Journal, Video and Audio Material Every resident is given journal subscriptions and video-tapes on lectures if available. E. Teaching and Communication Experience Fellows are give daily opportunity to learn from and model after the attending nephrologists in teaching, communication and leadership skills. These skills are specifically developed in the following activities: 16
  17. 17. • Lectures to residents, interns and medical students taking nephrology elective. • Opportunities to teach at rounds and transplant conferences • Presentation/participation as active discussants at the Nephrology Grand Rounds. • Presentation/participation of research papers as active discussants at the transplant Journal Club F. Training in Self-Instruction and Informatics Fellows are provided with educational and informatics facilities and trained to utilize them on a daily basis to effectively search and gather information for critical analysis of clinical problems and the resource and ability to make appropriate decisions. This is expected to be a life-long culture the fellows will carry with them upon graduation. Specifically, the following sources and facilities are available: • Up-To-Date: Our program subscribes to this well known electronic clinical reference in nephrology and hypertension. Included also are continuously undated information on an adult primary care and internal medicine; cardovascular medicine; endocrinolgoy and diabetes; gastroenterology and hepatology; infectious diseases; pulmonary disease; critical care and rheumatology • HDCN: Abbreviation for Hypertension, Dialysis and Clinical Nephrology, an electronic journal and an official education program of the American Society of Nephrology and the Renal Physician Association. Our program encourages trainees to subscribe and pays for the subscription • NEPHROL: Trainees are encouraged to participate in the discussion of this cyber-forum. Over 1,400 national and international nephrologists exchange their views on the management of patients with nephrological and hypertensive disorders. • MD Consult: Our program subscribes to MD Consult, a premier online medical information it also provides all standard nephrological and other medical text books on-line. • OVID: We also subscribe to Ovid, a powerful , high-end information retrieval solution for researchers and professional sin academic and medical settings. • Teton Data Systems: We subscribe to this site which provides medical and drug information designed exclusively for physicians. Provides facility for cross-searching more that 31 medical texts including Medline, Stedman's Medical Dictionary and other standard medical texts. • PubMed: PubMed is the National Library of Medicine's search service that provides access to over 11 million citations in MEDLINE, PreMEDLINE, and other related databases, with links to participating online journals. Trainees are actively encouraged to access to this resource. • GratefulMed: Internet Grateful Med (IGM) searches MEDLINE® using the retrieval engine of NLM's PubMed system. Trainees are actively encouraged to access this resource. D. Reading material • Danovitch G. M. Handbook of Kidney Transplantation, Little & Brown Co. E. Evaluations 1. The program director meets all residents informally on a weekly basis and formally on a quarterly basis and at the end of each year. 2. After each rotation, a resident is evaluated by the attending nephrologist using the standard American Board of Internal Medicine (ABIM) format: "Evaluation of Subspecialty Trainees". Fellows have 2 written tests per year to evaluate their knowledge of the syllabus. Evaluation include assessmnet of: • Clinical judgment • Medical knowledge 17
  18. 18. • Clinical skills: medical interviewing, physical examination, procedural skills • Humanistic qualities • Professionalism • Medical care • Continuing Scholarship • Overall clinical competence as a nephrologist 3. Procedure records of each resident are maintained using the standard forms provided in the ABIM Guidelines on Evaluation of Clinical Competence and Other Information: "Trainee's Log of Supervised Procedures." 4. The program director or his designate meets with each resident quarterly for performance review and counseling. Evaluation includes residents' technical proficiency, teaching skills, communication, humanistic qualities, professional attitudes and behavior and commitment to scholarship.A written summary is filed for each such encounter. 5. The program director or his designate completes written American Board of Internal Medicine (ABIM) tracking form on clinical competence of each resident annually and at the conclusion of the fellow's training. In case of adverse evaluations, special programs are instituted for remedial education and training. 6. In case of persistent documented deficiency unresponsive to corrective actions, the resident is discontinued from the program. IV. Outpatient Dialysis (PGY4) A. Goals and Objectives Dialysis and extracorporeal therapy Each resident must complete 16 weeks on the dialysis rotation. Additional elective rotations can be arranged. Clinical experience must entail supervised involvement in decision making for patients undergoing these therapies. This experience must include: 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 and modification during dialysis and other extracorporeal therapies d) Evaluation and management of medical complications in patients during and between dialyses and other extracorporeal therapies, including dialysis access, and an understanding of their pathogenesis and prevention. e) Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription and 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 automated 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. 18
  19. 19. 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, pleural effusions, and other less common complications and their management. l) An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient. Residents are expected to see and evaluate patients new to dialysis and follow chronic patients in the dialysis unit. During this rotation they always have a precepting attending who overlooks the management and care of the patient but provides adequate independence to the residents to formulate their own plan. The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. B. Core Competencies 1. Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents 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 from various resources including primary care physician, nurses, dietician, social worker and other subspecialists and health care professionals. • 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 developed after discussing with the attending nephrologist, nurse, dietician and social worker • counsel and educate patients and their families regarding various dislysis modalities, vascular access issues, importance of preventive medicine and the option of transplant. • use information technology to support patient care decisions and patient education 19
  20. 20. • perform competently all medical and invasive procedures considered essential for the area of practice including emergent dialysis (both hemo and peritoneal), vascular access placement and renal biopsy • provide health care services aimed at preventing health problems or maintaining health • work with health care professionals, including nurses, dietician, social worker and those from other disciplines, to provide patient-focused care 2. Medical Knowledge By the end of the rotation, the residents are expected to be well versed with the following • Evaluation and selection of patients with end stage renal disease for various modalities of renal replacement therapy including hemodialysis and peritoneal dialysis • Writing prescription for different dialysis modalities and assessing adequacy of dialysis • Drug dosage and modification during dialysis • Evaluation and management of various complications of dialysis including access issues • Long term follow up of patients undergoing chronic dialysis • Understanding the principals and technical aspects of dialysis • Understanding of special nutritional requirements of patients on dialysis 3. Practice-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents 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 Residents 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. Residents 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 20
  21. 21. 5. Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development • 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 Residents 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. Residents 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 C. Methods of Teaching and Implementation 1. Clinical Experience A. 16 weeks will be devoted to clinical training. It is estimated that you will manage: • Continued care of 8-10 out-patients per week and 1-2 new out-patients each month during the dialysis rotation. In addition the fellow will follow 50-60 ESRD patients in the chronic dialysis unit. • Longitudinal follow-up dialysis patients are also seen throughout the year in in-patient and outpatient nephrology rotations. B. Patient- mix includes diversity in • Age and sex: adolescent to geriatric age group of both sexes • Social economic status • Racial-cultural background C. Formal instruction and clinical experience in the prevention, evaluation and management of the entire spectrum of nephrological disorders (see Syllabus) 21
  22. 22. 2. Technical and Other Skills 1. Indications, contraindications, complications and interpretation of results in: • Urinalysis • Percutaneous biopsy of native and transplant kidneys • Peritoneal dialysis • Placement of temporary vascular access for hemodialysis and other extracorporeal therapies • Acute and chronic hemodialysis • Renal imaging • Continuous renal replacement therapy B. Familiarity with the principle, utility, complications and cost effectiveness of: • Radiology of vascular access • Balloon angioplasty of vascular access • Therapeutic plasmapheresis • Bone biopsy • Placement of peritoneal catheters 3. Research Experience A. Throughout the 24 months of fellowship training faculty members (involved in active research) inculcate a research culture into the thinking and clinical practice of the trainees. In addition, specific instruction on topics including the design and interpretation of research studies; the essentials of informed consent and the critical assessment of new therapies and the biomedical literature are taught and discussed during the: • Journal Club on both clinical and basic science research papers • Basic Science Conferences by local and visiting research professors • Research Conferences given by trainees, local and visiting research professors • Attendance at nephrology meetings with heavy emphasis on clinical and basic research • Basic science and research topics are covered in the Pathophysiology course B. Hands on experience in the conduct of medical research: All fellows with no previous experience in direct research are required to complete a minimum of a 1-month research in the first year and 8 months of research in the second year of training. Fellows who have worked and published research papers have the choice of using the research rotation for an, in-depth rotation, focusing on a topic in consultative nephrology, dialysis or transplantation. C. Research requirements for nephrology fellows with no formal research training: One-month of research experience is required for Nephrology in the first year. In the second year, at least six months of research experience is required. A Nephrology fellow will first have the opportunity to get familiarized with the ongoing research activities of the faculty members of the Program and thereafter select a research project. Under the mentorship of the selected faculty member, the fellow will acquire knowledge in the design and interpretation of research studies, research ethics and responsible use of informed consent, research methodology and interpretation of data, and training in writing and presenting the outcome of the studies. D. Research requirements for nephrology fellow with prior research training: Nephrology fellows are selected, in part, because of their strength and track-record in clinical and basic research. This is usually reflected by their letters of recommendation and publications reflecting intensive training in research methods and skills. 22
  23. 23. For fellows that are interested, the STAR program offers them the opportunity to obtain advanced degrees in clinical or basic research. These fellows are required to spend 80% of their time in research in the second year. Fellows in the STAR program can either continue after their second year to get a Masters in clinical science or a PhD in health outcome research or in basic science. Instruction in basic sciences as they relate to Nephrology is given at a Pathophysiology Course with basic Science lectures , Research Conferences, Journal Club meetings, ESRD conferences, and, Renal Grand Rounds. Each fellow attends local/regional and national and international scientific conferences or training sessions each year. Nationally and internationally recognized Nephrologists visit the program each year, approximately half of these visiting professors work in basic sciences related to Nephrology. 4. Conference and Scholarly Activities Renal Conferences • Renal Grand Rounds • ESRD Conference • Consult Service Teaching Seminar/Journal club • Pathophysiology Course • Transplant Conference • Basic science and research conferences Multidisciplinary Conference • Renal-Pathology Conference • Medical Grand Rounds • Noon-Conference • Morning Report Visiting Professorships • The Program is visited by national and international professors each year. They represent authorities in a wide spectrum of basic research and clinical expertise in the field of nephrology and related disciplines. Special Courses • Introduction to Renal Pathology • Advances in Renal Transplantation Attendance at Scholarly Conferences • Annual Scientific Symposium on the National Kidney Foundation of Southern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Internet Facilities • Up-to-Date: A quarterly up-dated nephrology reference. • HDCN: A web-site providing all important references and advanced on nephrology and related subjects including complete lectures from all national and international conferences. • NEPHROL: An international web-site where practicing nephrologists exchange views and experience Special Courses Special courses lasting days to weeks are spaced through the two year training include: • Introduction to Renal Pathology • Advances in Renal Transplantation 23
  24. 24. • Comprehensive Course on Elements of Dialytic Therapy • STAR program. Selected fellows are accepted as candidates for a masters or PhD program Other Scholarly Conferences Each year the fellow is given the opportunity to attend: • Annual Scientific Symposium of the National Kidney Foundation of Sourthern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Journal, Video and Audio Material Every resident is given journal subscriptions and video-tapes on lectures if available. 5. Teaching and Communication Experience Fellows are give daily opportunity to learn from and model after the attending nephrologists in teaching, communication and leadership skills. These skills are specifically developed in the following activities: • Lectures to residents, interns and medical students taking nephrology elective. • Opportunities to teach at rounds and transplant conferences • Presentation/participation as active discussants at Nephrology Grand Rounds. • Presentation/participation as active discussants at Journal Clubs 6. Training in Self-Instruction and Informatics Fellows are provided with educational and informatics facilities and trained to utilize them on a daily basis to effectively search and gather information for critical analysis of clinical problems and the resource and ability to make appropriate decisions. This is expected to be a life-long culture the fellows will carry with them upon graduation. Specifically, the following sources and facilities are available: • Up-To-Date: Our program subscribes to this well known electronic clinical reference in nephrology and hypertension. Included also are continuously undated information on an adult primary care and internal medicine; cardovascular medicine; endocrinolgoy and diabetes; gastroenterology and hepatology; infectious diseases; pulmonary disease; critical care and rheumatology • HDCN: Abbreviation for Hypertension, Dialysis and Clinical Nephrology, an electronic journal and an official education program of the American Society of Nephrology and the Renal Physician Association. Our program encourages trainees to subscribe and pays for the subscription • NEPHROL: Trainees are encouraged to participate in the discussion of this cyber-forum. Over 1,400 national and international nephrologists exchange their views on the management of patients with nephrological and hypertensive disorders. • MD Consult: Our program subscribes to MD Consult, a premier online medical information it also provides all standard nephrological and other medical text books on-line. • OVID: We also subscribe to Ovid, a powerful , high-end information retrieval solution for researchers and professional sin academic and medical settings. • Teton Data Systems: We subscribe to this site which provides medical and drug information designed exclusively for physicians. Provides facility for cross-searching more that 31 medical texts including Medline, Stedman's Medical Dictionary and other standard medical texts. • PubMed: PubMed is the National Library of Medicine's search service that provides access to over 11 million citations in MEDLINE, PreMEDLINE, and other related databases, with links to participating online journals. Trainees are actively encouraged to access to this resource. • GratefulMed: Internet Grateful Med (IGM) searches MEDLINE® using the retrieval engine of NLM's PubMed system. Trainees are actively encouraged to access this resource. 24
  25. 25. D. Reading Material • Daugirdas and Ing Handbook of Dialysis, Little & Brown Co. • Nissenson, Fine, Gentile Clinical Dialysis, 3rd Edition, Appleton Century Crofts Publishers • Nissenson, Fine, Editors Dialysis Therapy, Hanley and Belfus Publishers E. Evaluations 1. The program director meets all residents informally on a weekly basis and formally on a quarterly basis and at the end of each year. 2. After each rotation, a resident is evaluated by the attending nephrologist using the standard American Board of Internal Medicine (ABIM) format: "Evaluation of Subspecialty Trainees". Fellows have 2 written tests per year to evaluate their knowledge of the syllabus. Evaluation include assessmnet of: • Clinical judgment • Medical knowledge • Clinical skills: medical interviewing, physical examination, procedural skills • Humanistic qualities • Professionalism • Medical care • Continuing Scholarship • Overall clinical competence as a nephrologist 3. Procedure records of each resident are maintained using the standard forms provided in the ABIM Guidelines on Evaluation of Clinical Competence and Other Information: "Trainee's Log of Supervised Procedures." 4. The program director or his designate meets with each resident quarterly for performance review and counseling. Evaluation includes residents' technical proficiency, teaching skills, communication, humanistic qualities, professional attitudes and behavior and commitment to scholarship. A written summary is filed for each such encounter. 5. The program director or his designate completes written American Board of Internal Medicine (ABIM) tracking form on clinical competence of each resident annually and at the conclusion of the fellow's training. 6. In case of adverse evaluations, special programs are instituted for remedial education and training. In case of persistent documented deficiency unresponsive to corrective actions, the resident is discontinued from the program. V. Continuity Clinics (PGY 4) A. Goals & Objectives Residents are expected to see new patients and follow their old patients in these clinics two half days a week for their entire duration of fellowship training as required by ACGME. During this rotation they always have a precepting attending who overlooks the management and care of the patient but provides adequate independence to the residents to formulate their own plan. 25
  26. 26. The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. B. Core Competencies 1. Patient Care They must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents 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 from various sources including but not limited to referring physician, computer data base, other subspecialists and the patient themselves. • make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment The studies include but are not limited to biopsies, chemistry panels, various radiological and nuclear medicine studies • develop and carry out patient management plans along with other health professionals after discussing with the precepting attending • counsel and educate patients and their families regarding renal failure, various complications from renal failure, advise them regarding possible outcomes including end stage renal disease, various dialysis modalities and transplant • 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 including but not limited to renal biopsy, placement of emergent access if needed and urine analysis. • provide health care services aimed at preventing health problems or maintaining health including but not limited to prevention of renal disease progression, cardiovascular disease and other preventive practices appropriate for patients age. • work with health care professionals, including those from other disciplines including but not limited to vascular surgery, radiology, endocrinology and cardiology, to provide patient-focused care 2. Medical Knowledge 26
  27. 27. By the end of this rotation the residents are expected to be well versed with • Diagnosis, work up and management of acute renal failure • Management of chronic kidney disease • Management of anemia associated with renal failure • Management of secondary hyperparathyroidism in the setting of renal failure • Drug dosage in the setting of various degrees of renal insufficiency • Diagnosis, work up and management of various electrolyte abnormalities • Diagnosis, work up and management of secondary hypertension • Diagnosis, work up and management of renal stones 3. Practice-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents 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 Residents 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. Residents 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 Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices 27
  28. 28. • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities 6. Systems-Based Practice Residents 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. Residents 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 D. Methods of Teaching and Implementation 1. Clinical Experience A. Two half days per week throughout the training is devoted to continuity clinical training. It is estimated that you will manage: • 2 new, and 6 follow-up patients per week. Longitudinal follow-up are also seen throughout the year, in in-patient and out-patient nephrology rotations. B. Patient- mix includes diversity in • Age and sex: adolescent to geriatric age group of both sexes • Social economic status • Racial-cultural background C. Formal instruction and clinical experience in the prevention, evaluation and management of the entire spectrum of nephrological disorders (see Syllabus) 2. Technical and Other Skills 1. Indications, contraindications, complications and interpretation of results in: • Urinalysis • Percutaneous biopsy of native and transplant kidneys • Peritoneal dialysis • Placement of temporary vascular access for hemodialysis and other extracorporeal therapies • Acute and chronic hemodialysis • Renal imaging • Continuous renal replacement therapy B. Familiarity with the principle, utility, complications and cost effectiveness of: • Radiology of vascular access • Balloon angioplasty of vascular access 28
  29. 29. • Therapeutic plasmapheresis • Bone biopsy • Placement of peritoneal catheters 4. Research Experience A. Throughout the 24 months of fellowship training faculty members (all are involved in active research) inculcates a research culture into the thinking and clinical practice of the trainees. In addition, specific instruction on topics including the design and interpretation of research studies; the essentials of informed consent and the critical assessment of new therapies and the biomedical literature are taught and discussed during the: • Journal Club on both clinical and basic science research papers • Basic Science Conferences by local and visiting research professors • Research Conference given by trainees, local and visiting research professors • Attendance at nephrology meetings with heavy emphasis on clinical and basic research • Basic science and research topics are covered in the Pathophysiology course B. Hands on experience in the conduct of medical research: All fellows with no previous experience in direct research are required to complete a minimum of a 1-month research in the first year and 8 months of research in the second year of training. Fellows who have worked and published research papers have the choice of using the research rotation for an, in-depth rotation, focusing on a topic in consultative nephrology, dialysis or transplantation. C. Research requirements for nephrology fellows with no formal research training: One-month of research experience is required for Nephrology in the first year. In the second year, at least six months of research experience is required. A Nephrology fellow will first have the opportunity to get familiarized with the ongoing research activities of the faculty members of the Program and thereafter select a research project. Under the mentorship of the selected faculty member, the fellow will acquire knowledge in the design and interpretation of research studies, research ethics and responsible use of informed consent, research methodology and interpretation of data, and training in writing and presenting the outcome of the studies. D. Research requirements for nephrology fellow with prior research training: Nephrology fellows are selected, in part, because of their strength and track-record in clinical and basic research. This is usually reflected by their letters of recommendation and publications reflecting intensive training in research methods and skills. For fellows that are interested, the STAR program offers them the opportunity to obtain advanced degrees in clinical or basic research. These fellows are required to spend 80% of their time in research in the second year. Fellows in the STAR program can either continue after their second year to get a Masters in clinical science or a PhD in health outcome research or in basic science. Instruction in basic sciences as they relate to Nephrology is given at a Pathophysiology Course, a Basic Science Course, Research Conference, Journal Club meetings, a ESRD conference and, Renal Grand Rounds. Each fellow attends local/regional and national and international scientific conferences or training sessions each year. Nationally and internationally recognized Nephrologists visit the program each year, approximately half of these visiting professors work in basic sciences related to Nephrology. 4. Conference and Scholarly Activities Renal Conferences 29
  30. 30. • Renal Grand Rounds • ESRD Conferences • Consult Service Teaching Seminar/Journal club • Pathophysiology Course • Transplant Conference • Basic science and research conferences Multidisciplinary Conference • Renal-Pathology Conference • Medical Grand Rounds • Noon-Conference • Morning Report Visiting Professorships • The Program is visited by national and international professors each year. They represent authorities in a wide spectrum of basic research and clinical expertise in the field of nephrology and related disciplines. Special Courses • Introduction to Renal Pathology • Advances in Renal Transplantation Attendance at Scholarly Conferences • Annual Scientific Symposium on the National Kidney Foundation of Southern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Internet Facilities • Up-to-Date: A quarterly up-dated nephrology reference. • HDCN: A web-site providing all important references and advanced on nephrology and related subjects including complete lectures from all national and international conferences. • NEPHROL: An international web-site where practicing nephrologists exchange views and experience Special Courses Special courses lasting days to weeks are spaced through the two year training include: • Introduction to Renal Pathology • Advances in Renal Transplantation • Comprehensive Course on Elements of Dialytic Therapy • STAR program. Selected fellows are accepted as candidates for a masters or PhD program Other Scholarly Conferences Each year the fellow is given the opportunity to attend: • Annual Scientific Symposium of the National Kidney Foundation of Sourthern California • UCLA Society of Nephrology Conferences • Either the National Meeting of the American Society of Nephrology or the National Meeting of the National Kidney Foundation Journal, Video and Audio Material Every resident is given journal subscriptions and video-tapes on lectures if available. 30
  31. 31. 5. Teaching and Communication Experience Fellows are give daily opportunity to learn from and model after the attending nephrologists in teaching, communication and leadership skills. These skills are specifically developed in the following activities: • Weekly lectures to residents, interns and medical students taking nephrology elective. • Opportunities to teach at the weekly "Nephrology Core Curriculum for Residents." • Presentations and participation as active discussants at the weekly UCLA Nephrology Grand Rounds. • Presentation of research papers and participation as active discussants at the weekly Journal Club 6. Training in Self-Instruction and Informatics Fellows are provided with educational and informatics facilities and trained to utilize them on a daily basis to effectively search and gather information for critical analysis of clinical problems and the resource and ability to make appropriate decisions. This is expected to be a life-long culture the fellows will carry with them upon graduation. Specifically, the following sources and facilities are available: • Up-To-Date: Our program subscribes to this well known electronic clinical reference in nephrology and hypertension. Included also are continuously undated information on an adult primary care and internal medicine; cardovascular medicine; endocrinolgoy and diabetes; gastroenterology and hepatology; infectious diseases; pulmonary disease; critical care and rheumatology • HDCN: Abbreviation for Hypertension, Dialysis and Clinical Nephrology, an electronic journal and an official education program of the American Society of Nephrology and the Renal Physician Association. Our program encourages trainees to subscribe and pays for the subscription • NEPHROL: Trainees are encouraged to participate in the discussion of this cyber-forum. Over 1,400 national and international nephrologists exchange their views on the management of patients with nephrological and hypertensive disorders. • MD Consult: Our program subscribes to MD Consult, a premier online medical information it also provides all standard nephrological and other medical text books on-line. • OVID: We also subscribe to Ovid, a powerful , high-end information retrieval solution for researchers and professional sin academic and medical settings. • Teton Data Systems: We subscribe to this site which provides medical and drug information designed exclusively for physicians. Provides facility for cross-searching more that 31 medical texts including Medline, Stedman's Medical Dictionary and other standard medical texts. • PubMed: PubMed is the National Library of Medicine's search service that provides access to over 11 million citations in MEDLINE, PreMEDLINE, and other related databases, with links to participating online journals. Trainees are actively encouraged to access to this resource. • GratefulMed: Internet Grateful Med (IGM) searches MEDLINE® using the retrieval engine of NLM's PubMed system. Trainees are actively encouraged to access this resource. D. Reading material • Danovitch G. M. Handbook of Kidney Transplantation, Little & Brown Co. E. Evaluations 1. The program director meets all residents informally on a weekly basis and formally on a quarterly basis and at the end of each year. 2. After each rotation, a resident is evaluated by the attending nephrologist using the standard American 31
  32. 32. Board of Internal Medicine (ABIM) format: "Evaluation of Subspecialty Trainees". Fellows have 2 written tests per year to evaluate their knowledge of the syllabus. Evaluation include assessment of: • Clinical judgment • Medical knowledge • Clinical skills: medical interviewing, physical examination, procedural skills • Humanistic qualities • Professionalism • Medical care • Continuing Scholarship • Overall clinical competence as a nephrologist 3. Procedure records of each resident are maintained using the standard forms provided in the ABIM Guidelines on Evaluation of Clinical Competence and Other Information: "Trainee's Log of Supervised Procedures." 4. The program director or his designate meets with each resident quarterly for performance review and counseling. Evaluation includes residents' technical proficiency, teaching skills, communication, humanistic qualities, professional attitudes and behavior and commitment to scholarship. A written summary is filed for each such encounter. 5. The program director or his designate completes written American Board of Internal Medicine (ABIM) tracking form on clinical competence of each resident annually and at the conclusion of the fellow's training.In case of adverse evaluations, special programs are instituted for remedial education and training. 6. In case of persistent documented deficiency unresponsive to corrective actions, the resident is discontinued from the program. VI. Inpatient General Nephrology (PGY5) A. Goals & Objectives Residents are expected to see new consults and follow up on previous consults in this inpatient rotation. During this rotation they always have a precepting attending who overlooks the management and care of the patient but provides adequate independence to the residents to formulate their own plan. The goals and objectives of the training program include: • To educate and train residents in cognitive knowledge, procedural skills, interpersonal skills, professional attitudes, humanistic qualities and clinical experience expected of a consultant nephrologist. • To provide a research-oriented environment for developing critical analysis of new information, problem- solving skills and rational decision-making. To ensure each resident has some hands-on experience in basic research methodology. • To emphasize scholarship and continued self-instruction and to provide opportunity for acquiring leadership and management skills. • To provide faculty mentors for adequate and appropriate supervision and as role-models throughout the training period. • To acquire knowledge and experience in: occupational safety and health, critical assessment and decision sciences, evaluation of medical literature, clinical epidemiology, clinical study design, relative and absolute risks of disease, medical statistics and medical decision-making, psychosocial, economic and ethical issues 32
  33. 33. in nephrology, cultural, social, family, behavioral and economic issues, educational and counseling skills, and research and critical assessment of new therapies and of the medical literature. There is a progressive increase in responsibility for the second year fellows in the Nephrology Training Program. • Orient and supervise the first year fellows in learning procedures and conduct didactic lectures • Responsible for Training and teaching medical students and housestaff clinically and by giving lectures in a didactic setting • Responsible for organizing the CKD (Chronic Kidney Disease) Wednesday Conference including contacting physicians inside and outside of division to speak on relevant topics as well as giving lectures themselves. • Responsible for scheduling the annual rotations on the different services for all the UCLA fellows as well as the rotations for fellows who rotate on the Transplant & Dialysis Services at UCLA from outside institutions. Additionally, create the Nephrology call schedule on a monthly basis. • Review the nephrology fellowship applications and assist in interviewing the applicants. B. Core Competencies 1. Patient Care Residents are trained and educated to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents 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 from various resources including consulting physician/team, computer database, other subspecialties and nursing and ancillary staff • 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 in accordance to the accepted guidelines • counsel and educate patients and their families about renal failure, electrolyte abnormalities, hypertension and dialysis modalities • 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 including temporary dialysis access placement, renal biopsy and urine analysis • provide health care services aimed at preventing health problems or maintaining health including prevention of renal and cardiovascular disease progression • work with health care professionals, including those from other disciplines, to provide patient-focused care 7. Medical Knowledge By the end of this rotation the residents are expected to be well versed with • Diagnosis, work up and management of acute kidney injury and its various causes • Acid base physiology with sound understanding of pathophysiology and management 33
  34. 34. • Evaluation and selection of patients for acute hemodialysis including continuous renal replacement therapy • Various complications of dialysis including access issues • Drug dosage in patients on dialysis • Various procedures including emergent vascular access placement for hemodialysis and renal biopsy • Work up and management of various electrolyte abnormalities in hospitalized patients • Management of hypertensive urgencies and emergencies • Residents are expected to take care of patients with different level of complexities eg floor, step down and intensive critical care units • Residents are also expected to teach other healthcare professionals regarding various renal, acid-base, electrolyte abnormalities and hypertension • Addressing renal issues in non-renal transplant patients both pre and post operative 8. Practice-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents 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 9. Interpersonal and Communication Skills Residents 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. Residents 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 10. Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development 34

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