Nephrology

I. Intro

Nephrology elective is available for PGY 1 - PGY 3's at Montefiore and Weiler Hospitals as a 2 or 4 week elective.

While on elective there are daily attending teaching rounds for consults seen throughout the day, a weekly outpatient renal clinic and structured didactics for the residents / fellows. Resident continuity clinic is 1 full day per week.

Weiler Campus

On your first day please arrive at 9:00 am (8:45 am if Tuesday) and go to the second floor dialysis unit. From there page the consult fellow for further instructions.

*Renal clinic is Tuesday's 9:00 am at CFCC

Moses Campus

On your first day please arrive at 9:00 am and page the renal consult fellow.

*Renal clinic is Wednesday's 1:00 pm at MAP, Building 3400 Bainbridge Ave

Weekly Didactic and Clinic Schedule

Monday - consults and attending rounds

Tuesday - Renal clinic in AM (Weiler Rotators)

Wednesday - Renal Clinic in PM (Moses Rotators)

Thursday - 4:00 pm Core Curriculum conference, details per fellow; 5:00 pm Renal Grand Rounds (alternate between Cham in Moses campus or Ulmann 623 at Einstein Campus)

Friday - 8:00 am Renal Journal Club at Moses; 12:00 pm Noon Conference in Ulmann Building room 623 (Weiler Rotators)

Continuity Clinic: Monday or Tuesday (Moses) or Tuesday or Wednesday (Weiler campus) per New Innovations schedules.


II. Level-Based Learning Objectives

PGY1:

- Patient Care: Recognize the daily patient workload and prioritize; recognize the significance of a patient’s renal conditions; differentiate the acuity level of illness, to establish patient focused care.

- Medical Knowledge: Use discussions during daily rounds; use literature and reference sources to increase knowledge base, to learn guidelines apply for patient management; acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of cardiac disease states.

- Professionalism: Learn to establish trust with critically ill renal patients and family; to participate in teamwork. Exhibit honesty, reliability, and responsibility in patient care; demonstrate respect for patients and staff; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes; listen to patients and staff and communicate; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use literature to improve your practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of cardiac patients to improve outcomes in the future.

- System Based Practice: Be an advocate for renal patients; accept and try to apply necessary devised guidelines; to develop understanding about the health care systems/structure and how it relates to patients requiring cardiac procedures.

PGY2:

- Patient Care: Prioritize the daily tasks; recognize the relative significance

of a given renal patient’s list of renal related conditions; begin to recognize the acuity levels of illness; understand the indications, contraindications and risks of cardiac procedures; work with all providers to provide patient focused care.

- Medical Knowledge: Use literature and reference sources to increase knowledge base in nephrology; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of renal disease states; apply knowledge in the treatment of patients.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes and consultation reports; listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed. .

- System Based Practice: Advocate for renal patients; apply necessary devised guidelines; develop understanding about the health care systems/structure and how it relates to patients requiring cardiac procedures.

PGY3:

- Patient Care: Prioritize the daily work load of renal patients and supervise the junior house staff appropriately; recognize the relative significance of a given patients list of renal related conditions; recognize the acuity levels of illness; recite the indications, contraindications and risks of common and uncommon procedures; discuss risks/benefits native of patient’s with specialists.

- Medical Knowledge: Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology an the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff and junior house staff who you are supervising; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences.

- Interpersonal and Communication Skills: Write understandable and timely notes and consultation reports; actively listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team, and be an example for your junior house officers.

- Practice Based Learning and Improvement: recognize limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of cardiac patients under your care and alter practice patterns to improve outcomes in the future; aid junior house staff in evaluating their practice patterns.

- System Based Practice: Advocate for patients; develop a sophisticated understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients.


III. AREAS COVERED DURING NEPHROLOGY ROTATION

1. Principles, Physiology and Basic Sciences: Develop an understanding of:

a) Glomerular and tubular function

b) Sodium, water and electrolyte handling in various nephron segments

c) Acid-base physiology

d) Osmoregulation

2. Practice skills unique to Nephrology:

e) History and physical examination: with attention to BP, cardiac exam, abdominal exam with attention to kidney palpation and renal artery bruits, assessment of functional AV fistulas and grafts

f) Specific tests and procedures: use and interpretation: urinanalysis/Uosm, sonography, CT/MRI, nuclear scans, renal biopsy

g) Preventive care: microalbuminuria in dm, monitoring renal lab tests

h) Patient education: diet, adherence to uremia, pre-dialysis counseling

i) Attitudes/values: understand the psychosocial issues surrounding chronic illness, dialysis and withdrawal of dialysis

3. Approach to presenting complaints/problems in Nephrology:

a) Dysuria

b) Hematuria

c) Edema/anasarca

d) Changes in urine volume

e) Proteinuria/nephrotic syndrome

f) Glomerulonephritis

g) Use of nephrotoxic agents

h) Dosage modification in renal failure

i) Hypertension

4. Specific Diagnoses in Nephrology:

a) Infections of the kidney

b) Acute renal failure, including dialysis

c) Chronic renal failure, including dialysis and transplantation

d) Hereditary kidney diseases (PKD)

e) Electrolyte abnormalities:

i) Hypo/Hypernatremia (SIADH, DI)

ii) Hypo/Hypercalcemia

iii) Hypo/Hyperphosphatemia

iv) Hypo/Hypermagnesemia

v) Hypo/Hyperkalemia

f) Acid-base abnormalities:

i) Acidoses (metabolic/respiratory)

ii) Alkaloses (metabolic/respiratory)

g) Renal complications of systemic diseases

h) Nephrolithiasis

i) Hypertension

j) Renal tumors

k) Preeclampsia

l) Glomerular diseases (nephrosis/nephritis)

m) Vasculitis

5. Emergencies/Therapeutic Interventions:

a) Acute hyperkalemia

b) Anuria

c) Acute renal obstruction/ de-obstruction

d) Hypertensive crisis

e) Uremia/Acute indications for dialysis

f) Conservation of renal function

i) ACEI, ARB, BP control, protein restriction

g) Erythropoietin therapy

6) Technical Skills:

a) Familiarity with renal biopsy

b) Urinalysis

c) Fundoscopic exam

d) Familiarity with renal sonography


IV. REFERENCES

See reading list in literature section


V. METHODS OF TEACHING COMPETENCY ASSESSMENT

The house officers are evaluated continuously during their Nephrology rotation. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professionalism, medical care and continuing scholarships.