Goals & Objectives

  • To provide exposure to a broad range of acute and chronic kidney problems in adults.

  • To develop familiarity with principles of dialysis, including the clinical indications, complications and the basic orders for acute and chronic hemo- and peritoneal dialysis. To become familiar with indications for vascular access creation, as well as assessment of a good access, and potential problems that may arise after creation and use. To also be exposed to slow low extended dialysis, and plasmapheresis.

  • To understand indications for consulting nephrology, deciding to do a renal biopsy and become adept, and diagnosing causes of kidney dysfunction.

  • To understand the pathophysiology of disorders of electrolyte and water metabolism, acid base pathophysiology and their management.

  • To develop a broad understanding of glomerular and tubulointerstitial disorders including acute tubular necrosis and their management.

  • The learner will be exposed to patients with hypertension and should enhance there understanding of its pathophysiology, etiology and management during the rotation.

Team Structure

  • Attending 
  • Renal Fellow
  • Medical Resident
  • Medical Student

Principal Teaching Methods

Case discussions and review

Case-based discussions and review conferences weekly including nephrology clinical conference, glomerular conference, fluid and electrolyte conference, professor rounds, and renal grand rounds.

Rounds

Direct supervision of patient care by attending physician on daily patient care rounds five days per week and in outpatient clinic.

Didactics

Didactic teaching conferences and lectures by attendings and by clinical fellows.

  • Weekly Renal Grand Rounds
  • Weekly nephrology Professor Rounds
  • Monthly nephrology Journal Club
  • Monthly renal biopsy conference

Educational Content

Mix of Diseases

Includes patients with acute renal failure in the intensive care unit setting, chronic dialysis patients with acute medical problems, recipients of kidney and kidney-pancreas transplants, bone marrow transplants with kidney disease, and a variety of acute and chronic diseases of the kidney referred for tertiary care and management. Consultative services are provided to patients with a variety of disorders of fluid and electrolyte metabolism on multiple different hospital services.

Patient Characteristics

Patients seen encompass a broad social economic spectrum including Medicaid, Medicare, prepaid managed care and privately insured patients. The ethnic mix reflects that of the city of Seattle. Patients with end-stage renal disease and renal transplantation are covered by Medicare.

Types of Clinical Encounters

  • Inpatient consultation
  • Intensive care unit consultation and management
  • Outpatient renal clinic
  • Emergent outpatient consultations

Procedures

Acute hemodialysis, chronic hemodialysis, acute peritoneal dialysis, chronic peritoneal dialysis (CAPD), ultrafiltration, slow low extended hemodialysis, plasmapharesis, vascular access placement and renal biopsy. Dialysis catheters are not placed by the nephrology team but the indications for placing them will be discussed.

Services

A full range of consultative and clinical services covering all aspects of nephrologic care are provided. This includes outpatient renal and transplant clinic, emergency room, intensive care unit, hypertension clinic, kidney-liver service, and access to all procedures listed above. (Residents and Students are not expected to attend regular outpatient clinics but are encouraged to see individual patients with the attending and fellow).

Call and Weekend Responsibilities

None

Principal Educational Materials Used

Recommended Readings

Computer access to internet and medical literature searches

Pathologic materials

Three hundred renal biopsies reviewed annually

Evaluating Resident and Program Performance

At the end of the rotation, the resident/student is evaluated in writing and their performance reviewed with them verbally by every attending and fellow he or she has interacted with for a significant amount of time.  The evaluator rates the resident/student on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident/student is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met.  The resident/student also evaluates the teaching competence of each attending and fellow with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibility for Care of Patients on this Service

Direct supervision of patient care by attending physician on daily patient care rounds five days per week and in outpatient clinic.

Final responsibility for patient care rests with the faculty attending on the renal consult service. Faculty attendings are available by digital pager 7days/week/24hrs/day and make rounds 7 days/week at the bedside. Renal fellows report directly to the faculty attending and the nephrology resident/student report to renal fellow and attending.

Note Writing

Fellows, residents and attendings are responsible for the notes.  Any contribution and participation of a medical student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements.  Exceptions to this requirement are review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable. The student may document services in the medical record; however, the attending may only refer to the student’s documentation of an E/M service that is related to the ROS and/or PFSH. The attending may not refer to a student’s documentation of physical examination findings or medical decision making when writing notes. If the student documents E/M services, the attending must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision making activities of the service. 

Attending

Decisions regarding the overall plan of management for renal patients are primarily the responsibility of the attending physician. The attending will also provide didactic and interactive formal teaching rounds on a daily basis. Separate attendings will cover the renal consult service.

Fellow

The fellow on the renal consult service is responsible for the renal care of all patients referred for consultation or undergoing renal dialysis. In conjunction with the attending, the fellow will plan the evaluation and management of patients including orders for renal procedures such as dialysis, plasma-pheresis and renal biopsy. The fellow will attend work rounds every morning with his/her team. While providing direction in renal management, the fellow allows the medical resident and student to provide direction and regular medical care. The fellow supervises the resident/student in renal procedures. When appropriate, the fellow provides references and articles relevant to particular patient problems. Fellows are also responsible for a group of outpatients with chronic renal failure and for responding to renal-related emergency calls from outpatients, area dialysis facilities and the emergency room.

Resident/Student

The resident/student on the renal consult service shares responsibility for patient evaluation with the fellow.  While the fellow and attending will provide the primary direction of the patient’s renal care, the resident/student directs the often-complicated medical management of these patients.