Education

NEPHROLOGY FELLOWSHIP GENERAL CURRICULUM

I.  General Description/ Educational Purpose of the Program:

The Postdoctoral Fellowship offered by the Division of Nephrology of the Department of Medicine provides an opportunity to pursue advanced training in clinical nephrology and to undertake training in basic science research or clinical research.  The program is designed for trainees who wish to receive outstanding educational training in order to pursue a career in academic medicine (basic science, clinical research, or clinical education) or private practice. 

The mission of the John Hopkins University School of Medicine Nephrology Fellowship program is to produce physicians that 1) are clinically competent in the field of nephrology, 2) are capable of working in a variety of settings, 3) possess habits of life-long learning to build upon their knowledge of skills and professionalism.  

This program provides fellows with the opportunity to become leaders in the organization and management of patient care, emphasizes scholarship and self -instruction, development of critical analysis of clinical problems, and the ability to make appropriate decisions.

The first year of the fellowship consists of intensive training in clinical nephrology in order to develop the fundamental skills and knowledge required to become an outstanding clinical nephrologist.  First year fellows rotate assignments on the Intensive Care Unit rotation, Nephrology Transplant rotation, Inpatient Consultation rotation and the Outpatient Dialysis Inpatient rotation (Bond Street) at The Johns Hopkins Hospital. 

The Intensive Care Unit rotation and Nephrology Transplantation rotation each consist of a nephrology fellow and nephrology teaching faculty member.   There may be a visiting nephrology fellow from the Johns Hopkins Bayview Hospital. There may be a visiting Intensive Care Unit fellow for the Johns Hopkins University School of Medicine.  The Inpatient Consultation team consists of the nephrology fellow, nephrology teaching faculty member and usually one or more Internal Medicine residents, and one or more medical students from Johns Hopkins or outside institutions.  The fellow on the Outpatient Dialysis Inpatient rotation rounds on hospitalized patients from Johns Hopkins Gambro dialysis unit.  

Fellows will become proficient in skills such as supervision of dialysis (hemodialysis, peritoneal dialysis and continuous renal replacement therapy), placement of temporary catheters for vascular access, performing native and renal transplant biopsies, and performance and interpretation of urinalysis. 

Fellows have Nephrology Outpatient Continuity Clinic one half-day per week.  Our continuity clinic is a referral center for patients who have renal transplants, glomerular diseases, recurrent kidney stones, refractory and secondary forms of hypertension, genetic kidney diseases, and other aspects of general nephrology.  Patients are seen in The Johns Hopkins Hospital Outpatient Center.  Two teaching faculty members provide supervision each week on a rotating schedule.

Fellows follow outpatient hemodialysis and peritoneal dialysis patients longitudinally during the Outpatient Dialysis Ambulatory Experience at the Johns Hopkins Gambro Dialysis Unit with the supervision of a Nephrology Attending.

The second (and optional third) year of training is designed to further prepare the fellow for a career in academic nephrology or private practice by developing more extensive experience in outpatient and inpatient nephrology to develop independence as a clinical nephrologist, and by  engaging in nephrology research and scholarly activity.  Currently, second year fellows engage in basic science research or clinical research.  Each fellow chooses the type of research and a mentor from a wide variety of research areas.  The fellows research is presented at divisional meetings (Renal Rounds, Renal Disease Interest Group Meeting, Basic Science journal Club/ Basic Science Research Conference) and, if possible, national meetings.  Research may result in peer reviewed publications.  Second year nephrology fellows may elect to follow additional hemodialysis, peritoneal dialysis, and /or renal transplant patients with supervising teaching faculty members throughout the year to gain additional longitudinal experience with outpatients. Second year fellows continue in the Nephrology Outpatient Continuity Clinic. In addition, second year fellows may participate in teaching second year medical students in renal pathophysiology in order to further develop teaching skills required of an academic physician.  The second year fellows have important roles in determining the content and organization of the Tutorials in Nephrology, Clinical Science Journal Club, and the Combined Vascular Access/Renal Interventional Radiology Conference. 

One second year fellow serves as the fellow representative for educational curriculum issues.  This fellow helps the program director review educational goals, as well as effectiveness of implementation of these goals.  The fellow representative is present for dedicated faculty meetings regarding curriculum issues.  A second year fellow helps with developing the call schedule for first and second year fellows.

The Johns Hopkins University School of Medicine Division of Nephrology is committed to diversity in our fellowship program. The Department of Medicine has a diversity council and Women’s Task Force which has created initiatives to improve diversity (http://diverstiycouncil.med.som.jhmi.edu/).

A series of multi-disciplinary seminars and conferences provide a framework of formal instruction to complement the practical training of a postdoctoral fellowship in Nephrology.  Members of the Faculty and the postdoctoral fellows attend and may present at weekly conferences.

1.  Tutorials in Nephrology:

This is a multi-disciplinary series taught by clinical and basic science faculty members from The Johns Hopkins University Departments of Medicine, Pathology, Urology, Radiology, Surgery, Immunology, by visiting Faculty from other institutions, and by Nephrology Fellows (40 in year 1 and 40 in year 2) each week.  These tutorials include topics in pathology, fluid, electrolyte and acid-base disorders, hypertensive disorders, mineral metabolism (including renal osteodystrophy), end-stage renal disease and dialysis (HD, PD, CRRT), urinary tract infections, renal disorders of pregnancy, vascular disease (including atherosclerotic diseases), systemic renal disease (diabetes), genetic and hereditary renal diseases, urinary tract abnormalities, glomerular and tubulointerstitial disease, acute and chronic renal failure.  The purpose of this course is to provide a systematic review of clinical nephrology for the benefit of the nephrology fellows and members of the faculty.  Fellows participate in this conference by presenting topics twice per year.  Fellows interact with their peers by asking questions or by voicing opinions on topics of discussion.  Second year fellows help the program director choose topics to be covered.  Faculty members will evaluate fellow presentations.

2.  Renal Rounds:

Johns Hopkins faculty members or invited speakers discuss various aspects of nephrology through case presentations or lectures each week.  It serves in part as a specific Clinical Pathologic Correlation conference where an interesting clinical case is presented, renal pathology reviewed, and didactic discussion is then presented.  Second year fellows are asked to present their scholarly activity in this conference.  Invited speakers are leaders in their respective fields of expertise in Nephrology.

3.   Basic Science Journal Club/ Basic Science Research Conference: 

This monthly conference may act as a journal club or serve to review various basic science topics.  The Basic Science Journal Club/ Basic Science Research Conference is organized by a faculty member who presents a basic science topic for review.  Cellular and molecular biology as it pertains to renal disease is emphasized.  Fellows may be asked to participate in preparing for Journal Club.  Basic science research seminars may be presented by teaching faculty members and invited speakers. 

4.  Clinical Science Journal Club:

The clinical science journal club takes place twice per month and reviews important clinical scientific articles in Nephrology.  Fellows may present assigned articles and give background information, critique methods, and discuss results and conclusions. Journal club review focuses on review of methods with formal instruction and clinical assessment of medical literature, clinical epidemiology, biostatistics, and clinical decision theory.

5.  July Core Lecture Series: 

Daily core lectures covering basic topics in clinical nephrology are presented in July primarily for the benefits of first year fellows, but serve as a review for second year fellows. 

 6.  Renal Biopsy Conference:

Renal pathologists of The Johns Hopkins University School of Medicine review native and transplant renal biopsy cases from the previous week.  Cases from outside institutions are also reviewed.  This serves as a specific biopsy conference each week

8.  Renal Transplantation Conference: 

Topics covering various aspects of renal transplantation are reviewed by our faculty members and invited speakers each week.  The Nephrology Transplantation team and Transplant Surgery team jointly attend this multidisciplinary conference.  Nephrology fellows on the Nephrology Transplantation rotation attend this conference.

 9. Combined Vascular Access/Renal Interventional Radiology Conference:

Once per month Nephrology and Interventional Radiology has a joint conference to discuss difficult vascular access cases and various topics (such as non-surgical placement of peritoneal dialysis catheters) as a multidisciplinary conference.  Nephrology fellows attend this conference.

10. Renal Disease Interest Group:

This joint conference discusses clinical science research projects once per month.   Participating in this conference are Nephrology faculty and fellows as well as the faculty from the Welch Center for Epidemiology.  Nephrology fellows who elect to pursue clinical science research training may present at this conference.

11.  Kidney -Pancreas Transplant Meeting:

Specific renal transplant donor and recipient issues are discussed weekly after initial evaluation performed to confirm final transplantation status.  Psychosocial, ethical, cultural as well as medical issues are jointly discussed with all members of the Transplant team including coordinators, social workers, a psychologist, Transplant Surgeons and Nephrology Transplant team as a multidisciplinary conference each week. The Nephrology fellow on the Nephrology Transplant rotation attends this conference.

12.  Ambulatory Care Management Conference:

This monthly conference focuses on management of ambulatory care patients.  Patients may be seen in the Nephrology Fellow’s Continuity Clinic or by the outpatient clinic of a teaching faculty member.

13. Autopsy Conference:

Fellows attend the Autopsy Conferences organized by the Department of Pathology when patients cared for by fellows have autopsies performed.   

III. Specific Formal Instruction:

Please see specific rotations for more details regarding educational purpose, teaching methods, mix of diseases, patient characteristics, types of clinical encounters, procedures and services, reading lists and other educational resources,  methods of evaluation, and supervision and lines of responsibility.  The curriculum is reviewed at the start of each rotation.  Medical problems, health promotion, cultural, socioeconomic, ethical, occupational, environmental, and behavioral issues in rotations are integrated for learning goals and objectives for each rotation and learning experience.  Other educational resources will be provided such as funding for educational materials and attendance at national conferences.

Instruction will be given on social and economic impact of medical decision on patient and society, quality assessment and improvement and risk management. The Nephrology Program will give the Fellow the opportunity to achieve cognitive knowledge, procedural skills, interpersonal skills, professional attitudes and behaviors, humanistic qualities, and practical experience to develop into an outstanding nephrologist.

The following topics will be covered by formal instruction in the 2 years of Nephrology training:

Immunology

1. Basic principles
2. Immunologic mechanisms of renal disease; and
3. Fundamental aspects of diagnostic laboratory immunology relevant to renal diseases

Transplantation

1. Biology of transplantation rejection
2. Indications for and contraindications to renal transplantation
3. Principles of transplant recipient evaluation and selection
4. Principles of evaluation of transplant donors, both live and cadaveric, including histocompatibility testing
5. Principles of organ harvesting, preservation, and sharing
6. The pathogenesis and management of urinary tract infections
7. The pathogenesis and management of acute renal failure
8. Indications for and interpretations of radiologic tests of the kidney and urinary tract; and
9. Disorders of fluids and electrolytes and acid-base balance specific to transplantation

Indications for and interpretations of radiologic tests of the kidney and urinary tract

End-stage renal disease/dialysis

1. The kinetic principles of hemodialysis and peritoneal dialysis
2. The indications for each mode of dialysis
3. The short-term and long-term complications of each mode of dialysis and management
4. The principles of dialysis access (acute and long-term vascular and peritoneal), including indications, placement techniques, complications, diagnosis (radiology), and treatment of complications ( e.g. angioplasty of vascular access)
5. Urea kinetics and protein catabolic rate
6. Dialysis modes and their relation to metabolism
7. Nutritional management of dialysis patients
8. Dialysis water treatment, delivery systems, and reuse of artificial kidneys
9. The artificial membranes used in hemodialysis and biocompatibility; and
10. The psychosocial and ethical issues of dialysis
11. Aspect of long term-care (e.g. renal osteodystrophy-bone biopsy) for longitudinal follow up.

Geriatric aspects of Nephrology

Core Competencies:

The Program Director will send fellows information regarding educational materials which pertain to core competencies which may be sent by the Graduate Medical Education Committee or other sources. Fellows are required to complete HIPAA on line courses (General Privacy Issues, Conflict of Interest and Commitment) relating to Professionalism. The division has obtained a CD to provide information for Disclosure of Medical Errors. Courses are offered through The Johns Hopkins University School of Medicine for Evidence Based Medicine.

IV. Methods of Evaluation of Fellow’s Performance:

Monthly evaluations are conducted using the following guidelines of the American Board of Internal Medicine Form for Evaluation of Clinical Competence, American Board of Medical Specialties Generic Form for Global Ratings of Resident Performance and Mini-Clinical Evaluation Exercise (CEX) during each monthly rotation.  Humanistic qualities and the need to be the primary care advocate for patient’s needs are emphasized.  A 360 degree evaluation is performed by acute unit dialysis nurses regarding inpatient dialysis, peritoneal dialysis nurses for peritoneal dialysis patients seen during the Outpatient Dialysis Ambulatory experience, and nurse practitioners for hemodialysis patients seen during the Outpatient Dialysis Ambulatory experience every three months.

The fellow’s performances in the Nephrology Continuity Clinic and Chronic dialysis Ambulatory Experience are reviewed by supervising attending physicians every 6 months. 

Second year Nephrology Research Evaluation is reviewed with the fellows by the supervising mentor. 

The Program Director may receive informal comments regarding fellows which may merit documentation.

Fellows may be able to view their written evaluations at anytime.  Fellows will be advanced to positions on the basis of satisfactory progressive scholarship and professional growth.  In the event of an adverse annual evaluation, fellows are offered the opportunity to address judgments of academic deficiencies or misconduct before the Director of Post Doctoral Fellows in Internal Medicine (presently David Levine, M.D.), who may convene an independently constituted clinical competence committee if required.  

A. American Board of Internal Medicine Form for evaluation of Clinical Competence-Guidelines for Evaluation

The board defines the certifiable nephrologist at the completion of required training as being competent to provide comprehensive and specialized medical care based on a high standard of demonstrated component skills. These skills should clearly exceed those demonstrated by the certified nephrologist. Specifically, the Board asks program directors and their faculties to evaluate the following components of clinical competence:

1. Patient Care

These refined abilities include a) obtaining appropriately directed medical histories that are precise, logical, thorough and reliable; b) conducting expert, focused physical examinations that elicit subtle findings and are directed toward the patient's problems; and c) demonstrating understanding and proficiency while minimizing risk and discomfort to patients in the performance of diagnostic and technical procedures.

Evaluation of key procedures include percutaneous renal biopsy of both autologous and transplanted kidneys, placement of temporary vascular access for hemodialysis or continuous renal replacement therapy, acute and chronic hemodialysis, peritoneal dialysis, continuous renal replacement therapy, and urinalysis.  The evaluation will take into account the length of the fellow’s training.  See procedures section of specific criteria in evaluation.

2. Medical Knowledge

This is defined as the specialized, current basic and clinical science knowledge necessary to function as an expert clinical nephrologist. (This includes a broad base of knowledge of the pathogenesis, natural history and management of congenital and acquired diseases of the kidney and urinary tract; renal physiology; disorders of fluid, electrolyte and acid base regulation; normal and disordered mineral metabolism; acute and chronic renal failure; the management of patients receiving immunosuppressive therapy; and the management and diagnosis of severe hypertension. The clinical nephrologist also must be proficient in the principles and applications of various forms of renal replacement therapy including the management and systems operations of hemodialysis, peritoneal dialysis and renal transplantation.) The resourceful development of knowledge and comprehensive understanding of complex relationships in patient care

3.  Practice-Based Learning and Improvement

These are demonstrated skills that include a) the ability to self-evaluate and improve upon one’s own performance, b) incorporation of feedback into improvement, and c) effective use technology to manage information for both patient care and self-improvement.

4. Interpersonal and Communication Skills

The Nephrology Program emphasizes of the humanistic qualities of this component of clinical competence.   This includes the ability establish highly effective, humanistic and therapeutic relationships with patients and families.  This includes demonstration of listening to patients, as well as narrative and non verbal skills.  This also includes education and counseling of patients, families, and colleagues as well. 

5. Professionalism

This includes demonstrating respect, compassion, integrity, and honesty.  It includes teaching and role modeling responsible behavior.  This also involves commitment to self -assessment, where the fellow willingly acknowledges errors; consistently considers needs for patients, families and colleagues, and the need to be the patient’s primary care advocate.

6.  Systems-Based Learning

This includes demonstration of effective access/utilization of outside resources; effective use of systematic approaches to reduce errors and improve patient care; and enthusiastic assistance in developing systems’ improvement.

7. Moral and Ethical Behavior

The high standard of ethical and moral behavior is evaluated as satisfactory or unsatisfactory. This implies the consistent demonstration of a high standard of moral and ethical behavior expected within the clinical setting and of the medical profession. The ABIM considers it unethical for a physician to refuse to treat a patient solely on the basis of that patient's disease, when that disease is within the physician's area of competence..

8. Overall Clinical Competence as a Specialist in Nephrology

This represents the supervising attending physician’s overall assessment of the degree to which the fellows possesses the knowledge, skills, and attitudes essential for certification by the American Board of Internal Medicine also taking into context the amount of training.

In the evaluation of these competencies there is an implicit commitment to scholarship.  This encompasses the commitment to maintain and update clinical skills throughout one's professional career, to acquire new knowledge through computer access and by reading the current medical literature, to participate in the design and conduct of clinical studies or related research, to attend scientific and clinical meetings for nephrologists and to evaluate critically the new medical scientific information relevant to the subspecialty.

B. American Board of Medical Specialties Generic Form for Global Ratings of Resident Performance

This Rating Sheet was designed to be adapted for use during fellowship training.  The categories or wording of each component are the summary ratings for the six domains of the core competencies and are evaluated as Satisfactory or Not Satisfactory with specific components which may be evaluated as improvement needed. 

1.  Patient Care

• Medical Interviewing (History Taking)
• Physical Examination
• Diagnostic Studies (selection, implementation)
• Synthesis of clinical data, differential diagnosis
• Develop management plan
• Prescribe, perform essential procedures
• Counsel patients, providing information needed to understand illness, prevent disease
• Demonstrate clinical judgment
• Provide care sensitive to culture, social circumstances
• Use information technology to optimize care
• Respect the patient’s privacy and autonomy

2.  Medical Knowledge

• Possess appropriate fund of medical knowledge
• Know, critically evaluate, and use current medical information
• Commitment to scholarship
• Respect the patient’s privacy and autonomy

3.  Professionalism

• Demonstrate high standards of ethical/moral behavior
• Demonstrate honesty/integrity
• Demonstrate compassion/empathy
• Demonstrate reliability/responsibility
• Be respectful of others:  patients, families and colleagues
• Respect dignity of patients including gender, age and culture
• Demonstrate work habits which support effective role performance as physician
• Communicate/collaborate effectively with patients, families and colleagues
• Demonstrate dependability/commitment
• No documented current abuse of alcohol or use of illegal drugs
• No cognitive, physical, sensory or motor impairment precluding function in current medical role
• Demonstrate self awareness/knowledge of limits
• Have no restriction, condition, limitation or revocation of license to practice medicine

4.  Practice Based Learning and Improvement

• Demonstrate continuous practice improvement
• analyze one’s practice experience
• Recognize gaps in knowledge and expertise
• Use evaluation of performance to improve practice
• Engage in life-long learning to improve knowledge, skill
• Seek ways to improve quality of patient care
• Use information technology to optimize learning
• Facilitate learning by teaching patients, families, students

5.  Interpersonal and Communication Skills

• Communicate effectively with patients, families
• Communicate effectively with physicians and other health professionals or agencies
• Work effectively as member or leader of health care team
• Be available as consultant to other professionals
• Maintain comprehensive and legible medical records (written and electronic)

6.  Systems-Based Practice

• Work effectively in various health care delivery settings and systems
• Incorporate cost-awareness and risk-benefit analysis
• Possess business skills important for effective practice management
• Advocate for quality care in interest of one’s patients
• Promote health and prevent disease in populations

Overall Rating of Performance (evaluated as Satisfactory or Not Satisfactory) – with Comments.

C. Mini-Clinical Evaluation Exercise.

The mini-clinical evaluation exercise (CEX) focuses on the core skills that residents demonstrate in patient encounters.  The mini CEX is a 15-20 minute observation of a resident/patient interaction.  Attendings are encouraged to perform one mini-CEX per resident per rotation.  The following competencies are evaluated as Not Observed, Unsatisfactory, Satisfactory, Superior.

1.  Medical Interviewing Skills:  Facilitates patient’s telling of story:  effectively uses questions/directions to obtain accurate, adequate information needed.

2.  Physical Examination:  Follows efficient, logical sequence, balances screening diagnostic steps for problem; informs patient; sensitive to patient’s comfort, modesty.

3.  Humanistic Qualities/Professionalism:  Shows respect, compassion, empathy, establishes trust, attends to patient’s needs of comfort, modesty, confidentiality, information.

4.  Clinical Judgment:  Selectively orders/performs appropriate diagnostic studies, considers risks, benefits.

5.  Counseling Skills:  Explains rationale for test/treatment obtains patient’s consent, educates/counsels regarding management.

6.  Organization/Efficiency:  Prioritizes; is timely, succinct.  

7.  Overall Clinical Competence:  Demonstrates judgment, synthesis; caring; effectiveness; efficiency.

D.  360 Degree Evaluation:

Fellows are evaluated by nursing staff quarterly on a 0-4 scale with 0 representing not applicable; 1= 25 % of the time; 2 = 25-50% of the time; 3 = 50 -75% of the time; 4 = >75% of the time for the following :

1.  Privacy:  Fellow makes appropriate introductions and explains personnel roles.

2.  Communication with Patient:  The fellow uses appropriate language at the proper developmental/educational level for the patient and/or caregivers/family members.

3.  Responsiveness to Staff:   The fellow is responsive to the requests of nursing/ancillary staff

4.  Patient Rights:  The fellow respects and informs patients/families of their rights as individuals (e.g., provides appropriate explanations, obtains adequate informed consent, etc.)

5.  Team Input:  The fellow requests/accepts input regarding patient care from all members of the health care team.

6.  Tests and Treatments:  The fellow effectively orders tests and treatments in conjunction with the nursing staff and other members of the health care team.

7.  Verbal Orders:  The fellow’s verbal orders are clear/easy to understand.

8.  Learns names:  The fellow takes time to learn the names of other employees.

9.  Respect to Co-Workers:  The fellow shows respect to co-workers and provides information when needed.

10. Medical Records:  Medical records are thorough, readable and done on time.

11.  Overall Teaching Skills:   The fellow shows initative and ability to teach nursing/ancillary staff.

V. Evaluation of Teaching

Fellows evaluate Supervising faculty members by filling out a standardized evaluation form every six months for Supervising Attendings involved in monthly rotations, Nephrology Continuity Clinic and the Outpatient Dialysis Ambulatory Care Experience.

1.  RELATIONSHIP WITH TRAINEES, SUPPORTIVE (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Was supportive
• Was approachable
• Was patient
• Was empathetic

2.  FEEDBACK (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Provided effective feedback in a clear, timely, and specific manner
• No feedback to individuals from team
• Feedback presented in inappropriate, humiliating manner
• Gives specific and timely feedback on remediable problems
• Gives positive feedback when and where appropriate

3.  TEACHING SKILLS, AUTONOMY (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Provided an appropriate balance between independence and supervision

4.  TEACHING SKILLS, BEDSIDE TEACHING (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Skillfully demonstrated medical interview and physical diagnosis techniques at the bedside

5.  TEACHING SKILLS, COMMUNICATION OF KNOWLEDGE (evaluated as Not Applicable,  Unsatisfactory, Satisfactory, or Superior) 

• Effectively communicated medical knowledge in presentations
• Effectively communicated medical knowledge in articulation of clinical reasoning
• Too much information, no summary points or poor flow of case discussion
• Explains clearly, presents material in an organized manner, summarizes, emphasizes what is important and communicates what is expected to be learned

6. TEACHING SKILLS, EXPECTATIONS (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Set clear expectations

7.  TEACHING SKILLS, ENTHUSIASM (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Was enthusiastic about teaching
• Teaching appeared an additional chore; rounds were passive and uninteresting
• Dynamic and energetic, enjoys teaching; has an interesting style of presentation that stimulates interest in the subject

8.  TEACHING SKILLS, ORGANIZATION (evaluated as Not Applicable,  Unsatisfactory, Satisfactory, or Superior)

• Was organized for teaching

9.  TEACHING SKILLS, PROBLEM SOLVING (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Stimulated problem solving, asked effective questions

10.  ROLE MODELING, CLINCAL JUDGMENT (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Served as a role model for clinical judgment.

11.  ROLE MODELING, COLLEGIAL RELATIONSHIP (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Served as a role model for relationships with other health care professionals.
• Team functioned poorly, poor communication, low morale.
• Creates atmosphere which strengthens team work; goals of team clearly identified, encourages openness.

• Served as a role model for use of medical evidence, e.g., from the medical literature.

13. ROLE MODELING, PATIENT CARE COORDINATION (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior) 

• Served as a role model for coordination of patient care; cost-effective use of health care systems. 
• Disregards input from health care team. Fails to use alternative sites of care.
• Uses resources of entire health care team.  Demonstrates appropriate, effective communication.

14. ROLE MODELING, PATIENT RELATIONSHIPS  (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior) 

• Served as a role model for relationships wit patients/families.
• Lacked humanism and sensitivity with patients/families; did not value patient perspective
• Demonstrated effective and compassionate care in communications with patients and families.

15. OVERALL TEACHING SKILLS  (Narrative)

• What suggestions would you give this teaching faculty member to improve his/her teaching?

16.  LECTURE SKILLS (Narrative)

• What suggestions would you give this teaching faculty member to improve his/her noon conference lectures?

16. TEACHING SKILLS, OVERALL. (evaluated as Not Applicable, Unsatisfactory, Satisfactory, or Superior)

• Overall teaching effectiveness.

17.  CONFIDENTIAL COMMENTS (Narrative)

VI. Procedures

Fellows use an electronic online database to log procedures for vascular access placement and native and transplant renal biopsies.  The supervising teaching faculty member evaluates the fellow’s performance of the procedure.

Evaluation of key procedures include percutaneous renal biopsy of both autologous and transplanted kidneys, placement of temporary vascular access for hemodialysis or continuous renal replacement therapy, acute and chronic hemodialysis, peritoneal dialysis, continuous renal replacement therapy, and urinalysis.  The evaluation will take into account the length of the fellow’s training.

Satisfactory performance of percutaneous biopsy of autologous and transplant kidneys entails knowledge of indications for the procedure, obtaining informed consent, performance of the procedure itself including minimizing patient discomfort, and interpretation of results of the biopsy.

Satisfactory placement of vascular access entails knowledge of informed consent, proper Seldinger technique, knowledge of vascular anatomy, minimizing patient discomfort, as well as functional catheter placement.

Satisfactory performance of acute and chromic dialysis entails knowledge of proper indications for hemodialysis, knowledge of first dialysis precautions, writing of dialysis orders which includes choosing  dialysis filters, estimating dry weight and modification during special circumstances ( immediate allograft dysfunction), choosing dialysate composition, understanding and treatment of complications, and modifying dialysis prescription for inadequate kinetics in chronic hemodialysis patients.

Satisfactory performance of peritoneal dialysis entails knowledge of proper indications of peritoneal dialysis, writing orders for peritoneal dialysis which includes dialysis prescription (volume of dialysate, frequency of exchanges, and use of different hypertonic solutions), understanding and treatment of complications, and modifying dialysis prescription for inadequate kinetics in chronic peritoneal dialysis patients.

Satisfactory performance of continuous renal replacement therapy entails knowledge of proper indications of continuous renal replacement therapy, writing orders for continuous renal replacement therapy (flow rate of dialysate, choosing ultrafiltration rate, choosing dialysate composition including the use of bicarbonate based solutions), understanding and treatment of complications, and modifying dialysis prescription for inadequate clearance in patients undergoing continuous renal replacement therapy.

Satisfactory performance of urinalysis includes correct performance of urinalysis and interpretation of findings, and knowledge of limitations of interpretation as applied to patient care.

VII. Supervision and Lines of Responsibility for Nephrology Fellows

The program director coordinates all aspects of the nephrology fellows’ education and training, including their supervision by faculty members.  Fellows are provided with responsibilities consistent with their level of training.  Every patient examined, and every procedure or test performed is either done under the direct supervision of a faculty member or is reviewed with a faculty member.  Faculty members are directly responsible for ensuring that resident procedures are performed to the high standards set by the Program and that appropriate documentation is completed (including documentation for resident credentialing).  Appropriate faculty supervision is provided during all educational experiences.  The specific mechanisms for proper supervision of residents are as follows:

A. Clinical Training 

Nephrology fellows round and present clinical cases in teaching rounds, Nephrology Continuity experience, and Outpatient Dialysis Ambulatory experience and receive one-on-one instruction and feedback in history taking, physical examination and in-patient and outpatient management of nephrology patients. These case presentations may include review of clinical data, urinalysis, review of pathologic specimens, and imaging data.  Nephrology teaching faculty members interview, examine and discuss assessment and plans with the nephrology fellows for all inpatient consultations, nephrology continuity clinic outpatients, and outpatient dialysis ambulatory patients. All inpatient consultations and follow up care, Nephrology Outpatient Clinic visits, and Outpatient Dialysis patients are discussed and supervised by Nephrology teaching faculty members. All outpatient supervision, whether in the Nephrology Outpatient clinic or for Outpatient Dialysis Ambulatory experience is directly supervised with the attending present. During the Nephrology Intensive Care Unit and Nephrology Consultation rotations, the Nephrology fellow directs a team of residents, and medical students.  The nephrology fellow is responsible for organization of rounds, assisting the attending physician with the education of the Internal Medicine residents and medical students, and supervising the Internal Medicine residents and medical students.

B. Procedural Supervision

Procedures such as renal biopsy, urinalysis, placement of the temporary vascular access catheters, and hemodialysis and peritoneal dialysis procedures are directly supervised.  The placement of vascular access catheters is supervised for the placement of 10 catheters. Fellows’ advancement to independent performance of procedures is based upon successful completion of procedures as well as review with attending physicians who must certify residents based upon clinical and procedural competency. 

Direct supervision of hemodialysis and peritoneal dialysis treatments are not performed if the attending is not present on site, i.e. at a time when it is after hours, however, the Nephrology fellow discusses any placement of a vascular access catheter and hemodialysis, peritoneal dialysis, or continuous renal replacement therapy with the nephrology teaching faculty member prior to the initiation of these procedures.

Fellows receive formal feedback to procedural competence as part of each post rotational evaluation. An on-line log of procedures or equivalent which nephrology fellows are credentialed to perform is maintained.

 C. Research

 Throughout the course of any research project, Nephrology fellows meet regularly with their faculty research mentor to report their progress and discuss the design and content of their projects.  Every Nephrology fellow research project is supervised by a faculty mentor who is available to discuss any issues that may arise.  Residents also discuss their progress with other residents and other interested attending faculty at various research conference and clinical conferences.

The teaching faculty member on-call schedule is structured such that the three separate supervising faculty members are on-call at all times (except weekends) for the rotation which they are supervising (Intensive Care Unit rotation, Consultation rotation and Nephrology Transplant rotation).  All nephrology faculty members are available for the fellows for the Outpatient Dialysis (Bond Street) Inpatient rotation. Nephrology fellows are expected to present all new patient encounters with the appropriate attending on nights and weekends.  On weekends, the on-call attending conducts formal rounds with the on-call fellows to assure appropriate supervision. The program director serves as the back up attending faculty member for all supervision if a particular faculty member can not be reached. The division director serves as the backup faculty member for supervision if the program director is on vacation. All procedures are performed under supervision (see narrative on supervision).