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WRITTEN CURRICULUM

FELLOWSHIP GOALS AND OBJECTIVES

DIVISION OF PEDIATRIC NEPHROLOGY AND HYPERTENSIONDEPARTMENT OF PEDIATRICS

UNIVERSITY OF TEXAS –HOUSTON MEDICAL SCHOOL

Fellowship Goals and Objectives

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INTRODUCTION

The mission of the Division of Pediatric Nephrology and Hypertension is to educate and train physicians as clinically skilled Pediatric Nephrologists or Medicine/Pediatric Nephrologists in cooperation with the Division of Renal Diseases and Hypertension; and to generate new knowledge in the biomedical and Health Sciences. The cornerstone of this program is teaching at a level of excellence which fosters excitement and enthusiasm for a lifetime commitment to scholarship.

The purpose of the training program is to provide the subspecialty resident with the capability and experience to diagnose and manage kidney diseases and to understand the physiology of fluid and electrolyte and acid-base regulation. The fellowship program is under the supervision of the Department of Pediatrics Fellowship Committee.

GENERAL ASPECTS OF TRAINING

The training program at the University of Texas – Houston Medical School is accredited by the ACGME (Accreditation Council for Graduate Medical Education). The Division offers a formal three year straight pediatric or four year medicine/pediatric fellowship providing training in both clinical nephrology and clinical/basic investigation, to physicians who have already completed Pediatric Residency training or Internal Medicine/Pediatric Residency training. The educational objective of the fellowship is to teach residents a formal Nephrology Core Curriculum which develops expertise in the evaluation and management of patients with kidney disease. Experience is attained by clinical rotations in three different hospitals, exposure to a population of chronic dialysis outpatients, rotations in pediatric urology and renal pathology; and inpatient service experience including renal transplants, acute renal replacement therapy and consultation service; and continuity clinics in general nephrology and renal transplantation.

The training program is designed to develop the resident’s competence in clinical diagnosis, pathophysiology, and medical treatment of disorders of the kidneys; urologic abnormalities; hypertension; and disorders of body fluid physiology in newborns, infants, children, adolescents, and young adults. This experience includes the therapy of acute renal failure and end stage renal disease, including hemodialysis, continuous renal replacement therapy, slow low-efficiency dialysis, peritoneal dialysis, and renal transplantation. Training and experience is provided in selection, performance, and evaluation of procedures, including the assessment of urinalysis and renal biopsy.

There is also training in the evaluation of psychosocial aspects of life-threatening and chronic diseases as they affect the patient and the family and in counseling both acutely and chronically ill patients and their families.

The resident is also provided with instruction and experience in the operational aspects of a pediatric nephrology service, including the dialysis facility. Knowledge of the staffing needs, unit management, preparation of grant proposals, quality improvement programs,


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appropriate communications with the referring physicians, and planning for program development will be acquired during training.

The subspecialty resident’s education is supplemented by numerous didactic sessions presented by full time division faculty, adult nephrology faculty, subspecialty residents, and visiting faculty.

The training program is of sufficient size to ensure adequate exposure of the subspecialty residents to patients with acute renal failure and a chronic dialysis patient population, including patients that utilize home dialysis treatment modalities to ensure adequate training in chronic dialysis. We have at least 5 pediatric kidney transplants per year ensuring nephrology residents will have adequate experience with renal transplantation.

The training program must afford the residents the opportunity to care for patients with renal and other disorders in the intensive care unit setting.

Adequate numbers of patients with a wide variety and complexity of renal disorders must be available to the training program. It is important that the residents have continuing responsibility for the care of outpatients throughout their training.

B. Clinical Experience

The residents will have formal instruction, clinical experience, or opportunities to acquire expertise in the prevention, evaluation, and management of the following:

1. Perinatal and neonatal conditions including genetic disorders and congenital anomaliesof the genitourinary tract2. Hypertension3. Acute renal failure4. Chronic renal failure5. New end-stage renal disease6. Urinary tract infections7. Renal transplantation8. Neoplasms of the kidney9. Fluid and electrolyte and acid base disorders10. Acute and chronic glomerular diseases11. Renal tubular disorders12. Nephrolithiasis13. Voiding dysfunction and urologic disorders14. Renal dysplasia and cystic diseases of the kidney15. Inherited renal disorders

Special Experiences

In addition, residents will have experience in the following:1. Evaluation and selection of transplant candidates


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2. Preoperative evaluation and preparation of transplant recipients.3. Recognition and medical management of surgical and non-surgical complications oftransplantation.4. Dialysis therapy; each resident should have exposure to dialysis and extracorporealtherapies, that includes.a. Evaluation and selection of patients for continuous renal replacement therapies.b. Long-term follow-up with patients undergoing chronic dialysis.c. Understanding of the principles and practices of both hemodialysis and peritonealaccess.d. Understanding of the special nutritional requirements of hemodialysis of patients.

C. Technical ExperiencesResidents must be given sufficient experience with indications, contraindications, complications, and interpretation of results in the following areas to enable them to develop appropriate expertise:1. Urinalysis2. Percutaneous biopsy of both native and transplanted kidneys3. Peritoneal dialysis4. Acute and chronic dialysis and hemofiltration5. Renal ultrasound, nuclear renal scans, MRI and MRA, angiography, VCUG

D. Curriculum

1. The program offers instruction through courses, workshops, seminars, and laboratory experience to provide appropriate background for residents in diagnostic techniques and in the basic and fundamental disciplines related to the kidney. These should include immunopathology, cell biology, molecular biology, magnetic resonance imaging, computer tomography, ultrasound, and nuclear medicine.

2. Lifetime commitment to scholarship and self-directed learning to foster continued intellectual growth for application of new knowledge to patient care.

3. Excellent communication skills, both oral and written, in order to provide the highest standard of care to patients and their families, and to effectively work with primary care providers, consultants, other health care providers (dietitians, social workers), the community, and health care agencies.

4. High ethical and professional standards to provide the most compassionate and cost effective patient care.

5. A strong background in evidenced based medicine utilizing the disciplines of epidemiology, biostatistics, outcomes research, and critical appraisal of the literature.


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GENERAL GUIDELINES

1. Order Writing

A. All orders pertaining to dialysis must be written on preprinted dialysis order forms. Verbal orders are acceptable at the discretion of the nursing staff, and must be cosigned by the prescribing physician within a 24-hour period. No orders may be written on the dialysis order sheets by any other physician and will not be followed by the dialysis nurse. Since the subspecialty resident is responsible for meaningful patient care, attendings are discouraged from writing any orders. Rather, their role should be reviewing the orders with the subspecialty resident and providing educational feedback on the treatment plan.

B. On the renal inpatient service at Memorial Hermann Hospital and all consulting services, order writing by the subspecialty resident is discouraged unless it has been discussed with the primary service for that patient. In order to foster communication between services, a treatment plan for the patient should be relayed to the consulting service in a timely manner. At that juncture, the orders pertaining to further evaluation can be written either by the primary service or if requested by them, by the renal subspecialty resident. On the renal inpatient service, orders not pertaining to the dialysis prescription should be written by the medical house staff (students, interns, and residents) assigned to the service that month.

2. Lines of Responsibility A. As consultants, our primary role is to suggest a diagnostic evaluation and

treatment plan to the primary service. In this role, all decisions related to the care of the patient are the purview of the primary service. It is expected that subspecialty residents will teach both students and residents assigned to the various renal services as well as the residents who have called consults. Timely communication with the consulting physicians will expedite work-up. The pediatric nephrology service is only directly responsible for care and management of issues directly related to the question we are being asked to address. One must be sure that an order for the consultation has been written in the order or note section of the chart. All initial consults are to be dictated into the EMR such that we can refer to them in outpatient follow-up.


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3. Days Off

Subspecialty residents will as a minimum have one 24-hour period off each 7-day period factored every 14 days. Beepers are to be turned off during this period.

4. Call

Subspecialty residents are expected to see and evaluate any patient when consulted on-call. After the evaluation, they should phone the appropriate attending to discuss their findings and review their proposed treatment plan.

5. Work-Hours

On average, subspecialty residents will work less than 70 hours per week and will adhere to the Duty Hours policy instituted by UTHMS. When averaged over a year, excluding vacation, subspecialty residents are provided a minimum of 48 days free of patient care duties, including home-call responsibility. They will not be on service in the hospital for greater than 30 consecutive hours.

6. Conference Responsibilities

Subspecialty residents are expected to prepare and present in a variety of conference settings including renal grand rounds, pediatric grand rounds, resident conferences, morning report, journal club and research conferences. Topics for grand rounds should be considered cutting-edge and prepared in power-point fashion. Topics for teaching residents and student should reflect a general overview based on evidenced based facts. As part of an on-going improvement process, and new for academic year 2004-5, subspecialty residents will provide the methods and results of their literature searches for these conferences. Those searches will be critiqued by key faculty and become part of the subspecialty resident’s portfolio.

7. Personal Conduct/Ethical Behavior

Subspecialty residents must have the welfare of their patients as their primary professional concern. Subspecialty residents must demonstrate humanistic qualities that foster empathetic, constructive, and effective patient/physician relationships. Such qualities include integrity, respect, compassion, professional responsibility, courtesy, sensitivity to patient needs for comfort and encouragement, and a professional attitude and behavior towards colleagues. Professionalism will be assessed through direct observation by attending physicians, as well as by evaluation forms completed by nursing personnel and patients.


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8. Evaluation/Promotion

For medicine-pediatric fellows, application to the American Board of Pediatrics, sub-board of Pediatric Nephrology will be made within the first 6 months of fellowship for the 2 year abbreviated fellowship in pediatrics with 2 in internal medicine nephrology. Any other applications for fast tracking or other combined fellowship programs will be made before fellowship begins.

The Attending Nephrologist evaluates the subspecialty resident’s performance at the end of each month or block rotation. These evaluations will be recorded in the GMEIS system. The evaluation will be at a minimum of every 3 months. These evaluations are in turn monitored by the subspecialty resident Review Committee (pediatric nephrology faculty) that meets quarterly. Finally, the Program Director meets with each subspecialty resident a minimum of twice per year. Satisfactory performance is necessary for promotion and certification to sit for the American Board of Pediatric, sub-board of Pediatric Nephrology. If a subspecialty resident’s performance is poor, the Program Director outlines the deficiencies and devises a course of action for improvement. Performance is then monitored on a weekly basis. If substantial improvement is not made after a reasonable time period, the subspecialty resident may not be promoted, or may be dismissed. Such subspecialty residents have the right to a grievance hearing as outlined in the UT System Medical Foundation GME Handbook distributed at the beginning of the year.

9. Policy for Moonlighting

i. Subspecialty residents are not required or encouraged to engage in moonlighting.

ii. At no time will the subspecialty resident represent the University of Texas Health Science Center while moonlighting.

iii. The subspecialty resident will not be allowed to moonlight in nephrology (the area in which they are currently being trained), or risk jeopardizing his/her status in the subspecialty residency program with the University of Texas.

iv. Moonlighting should be limited to no more then 3-4 nights per month, and only when it will not interfere with performance of one’s clinical and academic duties. The resident may not moonlight and be simultaneously on call for the pediatric nephrology service.

v. All subspecialty residents engaged in moonlighting must be licensed for unsupervised medical practice in Texas. It is the responsibility of the institution hiring the subspecialty resident to moonlight to determine whether such licensure is in place, whether adequate liability coverage is provided (the University of Texas Health Science Center will not provide liability coverage for moonlighting activities), and whether the subspecialty resident has


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the appropriate training and skills to carry out assigned duties. The sponsoring institution must ensure that Dr. Portman as program director acknowledges in writing that he is aware that the subspecialty resident is moonlighting, and that this information is made part of the subspecialty resident’s file.

vi. According to the ACGME institutional policy, each subspecialty resident who engages in moonlighting activities must provide written notification of their intent and participation to Ronald J Portman, M.D., Program Director for Pediatric Nephrology Fellowship Program of the Division of Pediatric Nephrology and Hypertension, and receive approval, in advance from Dr. Portman.

CORE COMPETENCIES

As directed by the ACGME, we have begun to implement a system to provide subspecialty residents a means to achieve competency in 6 core areas. The clinical and teaching venues where these core areas are taught and the evaluation tools that will be utilized are outlined below as well as in the specific content section of each rotation.

1. PATIENT CARE (PC)

Subspecialty 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. Subspecialty 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

(a) Educational sites/methods I) Inpatient ward/consult servicesII) Outpatient clinicsIII) Outpatient dialysis


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IV) Patient care conference (PCC) at dialysis(b) Evaluation tools that may be used

I) Direct faculty observations (DFO) using evaluation formsII) Associate evaluation form (AEF) (360 evaluation including

nurses, dieticians, administrative staff, social workers, residents and students)

III) Oral examination (OE)IV) Written examination (WE)V) Computer simulated cases (CSC)VI) Patient evaluation form (PEF)

2. MEDICAL KNOWLEDGE (MK)

Subspecialty residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Subspecialty residents are expected to:

demonstrate an investigatory and analytic thinking approach to clinical situations know and apply the basic and clinically supportive sciences which are appropriate to their discipline

i. Educational sites/methods 1. Inpatient wards and consult services2. Outpatient clinics3. Outpatient dialysis4. Renal Grand Rounds5. Renal Journal Club6. Research conference7. Biopsy conference8. Renal-Urology-Nephrology (RUN) Conference9. Transplant conference10. Patient care conferences11. Resident conferences12. Morning report

ii. Evaluation tools that may be used 1. Direct faculty observation (DFO)2. Oral examination (OE)3. Written examination (WE)4. Computer simulated cases (CSC)5. Literature search review (LSR)6. Presentation critique form (PCF)

3. PRACTICE-BASED LEARNING AND IMPROVEMENT (PBL)


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Subspecialty residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Subspecialty 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

a) Educational sites/methods I) Inpatient wards and consultsII) Outpatient clinics and dialysisIII) PCCIV) ESRD conferenceV) Renal Journal ClubVI) Biopsy conference

b) Evaluation tools that may be used I) Direct faculty observation (DFO)II) Literature search review (LSR)III) Presentation critique form (PCF)IV) Associate evaluation form (AEF)V) Oral examination (OE)VI) Written examination (WE)

4. INTERPERSONAL AND COMMUNICATION SKILLS (ICS)

Subspecialty 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. Subspecialty 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

a) Educational sites/methods I) Inpatient wards and consultsII) Outpatient clinics and dialysisIII) PCC


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IV) ESRD conferenceb) Evaluation tools that may be used

I) Direct faculty observation (DFO)II) Associate evaluation form (AEF)III) Patient evaluation form (PEF)

5. PROFESSIONALISM (P)

Subspecialty residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Subspecialty residents are expected to:

demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development 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 a) Educational sites/methods

I) Inpatient wards and consultsII) Outpatient clinics and dialysisIII) PCCIV) ESRD conferenceV) Standardized patient

b) Evaluation tools that may be used I) Direct faculty observation (DFO)II) Associate evaluation form (AEF)III) Patient evaluation form (PEF)

6. SYSTEMS-BASED PRACTICE (SBP)

Subspecialty 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. Subspecialty 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


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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 performancea) Educational sites/methods

I) Inpatient wards and consultsII) Outpatient clinics and dialysisIII) PCCIV) ESRD conferenceV) Renal Grand Rounds

b) Evaluation tools that may be used I) Direct faculty observation (DFO)II) Oral examination (EO)III) Written examination (WE)IV) Associate evaluation form (AEF)

Those residents choosing the clinical scientist research tract will also be educated in these areas while obtaining either the Masters of Clinical Research or Master’s of Public Health degrees.

EVALUATION TOOLS FOR CORE COMPETENCIES

The following is a guide to the evaluation tools to assess adequacy in the core competencies.

1. Direct Faculty Observation Form : Traditional form graded on a 1 through 5 scale on several key areas. Observation takes place during the month long consult and inpatient ward assignments. These forms will be completed on GMEIS system.

2. Oral Examination : Currently oral examination includes the traditional Socratic teaching methods on rounds, in clinics and at conferences. We are developing 3-5 written simulated cases that will be discussed with a faculty member including the differential diagnosis and proposed treatement plans. Faculty will be scripted to appropriate questions to ask to appraise the subspecialty residents medical knowledge, synthesis skills, knowledge of current literature and ability to think ‘on their feet’.

3. Written Examination : Annually subspecialty residents will take a board-style multiple-choice examination to assess their medical knowledge. This is an in-training examination provided by the American Board of Pediatrics and taken in a standardized testing center. Feedback from the ABP will be used for assessing both the resident’s knowledge and the program’s effectiveness.

4. Associate Evaluation Form : Will be filled out by the nursing staff on the inpatient ward, inpatient and outpatient dialysis units, and the outpatient clinics. It will also


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include residents, students, social workers, administrative staff and dieticians. It is an attempt to give feedback on others’ perception of the subspecialty resident’s interpersonal skills, professionalism, and medical knowledge.

5. Patient Evaluation Form : To be filled out by clinic and dialysis patients assigned to the subspecialty resident. Its purpose is to provide feedback on interpersonal skills, compassion, and professionalism as perceived by the patients.

6. Computer Simulated Cases : The subspecialty residents are given a CD that contains simulated cases including interpretation of renal biopsy slides and slides of urinalyses. The purpose is to ensure the ability to interpret correctly these diagnostic studies, assess medical knowledge, and verify familiarity with the medical literature. The fellow will document when they have completed each section with a requirement to complete the program each year. New discs will be provided each year as they become available.

7. Literature Search Review : Each subspecialty resident will provide a copy of the methods used to search the medical literature when preparing for Renal Grand Rounds, Renal Biopsy Conference, Case Presentation Conference and Research Conference. The results of the search will be discussed with the subspecialty resident by a member of the division with expertise in evidence based medicine and literature searching. The purpose is to continually improve the skill of the subspecialty resident in the use of the medical literature and evidence based medicine.

8. Presentation Critique Form : all faculty and fellows at any conference given by the subspecialty resident will fill out the form. Its purpose is to provide feedback on presentation skills, teaching skills, medical knowledge, and familiarity with the medical literature.

9. Portfolio: The aforementioned evaluation tools, along with procedure logs placed in the subspecialty resident’s permanent file constitutes the portfolio. It is expected that the synthesis of these varied data will better define the individual strengths of the subspecialty resident and suggest areas for further improvement.

Abbreviations for Specific Content

Core competencies to obtain1. Patient Care = PC2. Medical Knowledge = MK3. Practice-Based Learning and Improvement = PBL4. Interpersonal and Communication Skills = ICS5. Professionalism = P6. Systems-Based Practice = SBP

Evaluation Tools1. Direct Faculty Observation = DFO2. Oral Examination = OE3. Written Examination = WE4. Associate Evaluation Form = AEF5. Patient Evaluation Form = PEF


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6. Computer Simulated Cases = CSC7. Literature Search Review = LSR8. Presentation Critique Form = PCF

SPECIFIC CONTENT

INPATIENT AND CONSULT SERVICE

Patients are admitted to the Pediatric Nephrology and Hypertension service only at Memorial Hermann Children’s Hospital. Consults are performed at that hospital as well as the University of Texas MD Anderson Cancer Center and the Harris County LBJ Memorial Hospital.

I. Educational Purpose: The purpose of this rotation is to develop expertise in the evaluation and management of nephrologic disorders in a large primary and tertiary care center. This rotation also stresses effective communication skills and cost containment.

II. Principle Teaching Method: The principle teaching method on this rotation is daily teaching rounds with the Attending nephrologist, and core competency evaluation tools. Rounds are made every day where bedside teaching takes place.

III. Educational Objectives: A. Memorial-Hermann Children’s Hospital is a private general hospital adjacent to the medical school in the Texas Medical Center with 185 pediatric beds. It is a primary and tertiary care center, as well as a trauma hospital, and exposes trainees to a wide variety of patients and a broad mix of diseases. Consults are derived from all pediatric services at the hospital, including general Pediatrics, Surgery and its subspecialty services, and OB/GYN. All major medical services, an emergency room, trauma center, and pediatric, cardiovascular and neonatal intensive care units are present, and it offers state of the art clinical laboratories and imaging facilities: renal pathology with election microscopy and immunofluorescence, a diagnostic radio nuclide laboratory, biochemistry and serologic laboratories, pediatric dieticians, child life program, inpatient teachers affiliated with the Houston Independent School District, case managers, member of the Harris County Child Protective Services, social services, CT/spiral CT scans, MRI/MRA, PET scanning, gamma knife, and an active Interventional Radiology department.

Subspecialty residents are assigned on a monthly basis for nine months spread over the years of their fellowship with the bulk of service time in the first year of training. They are supervised by a full time faculty attending. The ‘fellow’ is the supervisor of a team consisting of pediatric interns, residents and senior medical students on elective. The monthly Attending nephrologist meets with the team daily to evaluate and discuss new patients and to see all follow up patients. Subspecialty residents take call from home for any night or weekend


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consults/emergencies, always under supervision of an Attending nephrologist. Patients who require follow-up after discharge are referred to the continuity clinic of the consulting subspecialty resident.

At the University of Texas M.D. Anderson Cancer Center (MDACC), located within the Texas Medical Center, is a 418-bed (25 pediatric) facility that provides care to patients with cancer. It provides care to Texans regardless of the ability to pay, and as an internationally recognized center of excellence, it has many patients from out of state and foreign countries. Therefore, the mix of diseases ranges from simple toxin mediated renal disease to rare, or previously unrecognized, paraneoplastic renal syndromes. MDACC has a busy emergency room, multiple outpatient clinics, medical, pediatric and surgical intensive care units, and active medical and surgical services from which consultations are derived. The hospital offers a full array of clinical laboratory biochemistry and serologic laboratories, Interventional Radiology, nutritional support services, and social services. Renal biopsy specimens obtained at MDACC are processed and evaluated by the Pathology Department at UT. Acute dialysis and renal replacement therapy is performed there on children 5 years of age or older. If younger, the patient is transferred to MHCH for such care.

Lyndon B. Johnson (LBJ) General Hospital is a 306-bed (83 pediatric beds) acute care facility operated by the Harris Country Hospital District and staffed solely by the faculty of the University of Texas – Houston Medical School. It serves as one of two county hospitals providing care to indigent people in Harris County, and is located approximately 12 miles from the Texas Medical Center. It has a busy emergency room and intensive care unit, and active medical, surgical, pediatric and obstetrical services from which consultations are derived. LBJ General Hospital offers full clinical laboratories and imaging facilities: CT scan diagnostic radionuclide laboratory, biochemistry and serologic laboratories, MRI/MRA, Interventional Radiology, nutritional support services, and social services. Renal biopsy specimens obtained at LBJ General Hospital are processed and evaluated by the Pathology Department at Hermann Hospital. The busy general pediatric service and neonatal intensive care units provide patients for consultation. There is no PICU there and no pediatric renal replacement therapy is performed there. Residents of Harris County are cared for without regard to financial resources.

B. Patients are of varied ethnicity and include self-pay, managed care and private insurance. By its founding charter, Memorial-Hermann Hospital has a strong commitment to indigent care in the greater Houston area.

C. Specific educational objectives on this rotation includes:1) Evaluation and management of Acute Renal Failure (ARF)2) Management of Intermittent Hemodialysis for ARF, poisonings and intoxications.3) Management of continuous renal replacement therapies (CVVHD/Fand

SLED)


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4) Evaluation and treatment of proteinuria and hematuria5) Evaluation and management of glomerular diseases including immune

complex diseases (e.g. SLE) and vasculitis6) Evaluation and treatment of diabetic nephropathy7) Evaluation and management of primary and secondary hypertension8) Evaluation and management of renal diseases in pregnancy9) Evaluation and management of acid base disturbances10) Evaluation and management of fluid and electrolyte disorders11) Evaluation and management of vascular diseases of the kidney12) Understand the social and ethical issues of patient encounters and learn

from the faculty how to address these for the patient’s best interests.13) Evaluation and management of Tumor Lysis Syndrome14) Evaluation and management of Acute Renal Failure (ARF) in Bone

Marrow Transplantation15) Evaluation and management of paraneoplastic renal syndromes16) Evaluation and management of ARF associated with biological agents17) Evaluation and management of toxin mediated renal disease

D. Core competencies obtained: PC, MK, PBL, ICS, P, SBP

IV. Procedures: On this rotation trainees will learn the indications, contraindications, and performance of:

1. Urinalysis2. Percutaneous renal biopsy3. Peritoneal dialysis4. Hemodialysis5. Continuous dialysis6. Intravenous access for temporary dialysis may be electively learned with the

intensive care team (internal jugular, subclavian and femoral veins)(No dialysis is performed at LBJ Hospital)

Subspecialty residents are required to maintain a record of all procedures performed, which is verified by the Attending nephrologist.

V. Ancillary Education: Trainees are provided with a supplemental reading list and syllabus. Trainees are expected to attend The Division’s weekly educational conferences at the Medical School, as well as attend weekly Pediatric Grand Rounds.

VI. Methods of Evaluation: 1. At the start of the rotation, the subspecialty resident is provided a list of

educational objectives, expected to be met by the end of the rotation. 2. Evaluation tools: DFO, WE, OE, CSC3. At the end of the rotation, the evaluation tools are submitted to the program

committee, which meets quarterly to evaluate trainees. On at least a semi-annual basis, the program director meets with each trainee and discusses his or her performance. Trainees also complete forms at the end of the rotation identifying the strengths and weaknesses of the Attending nephrologist as well as the sponsoring institution. These forms are reviewed by the program


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director. Starting with the 2004-2005 academic year, all of these evaluations (fellow, faculty and program) are done through the GMEIS (Graduate Medical Education Information System).

The responsibilities for the fellows change with increasing experience in both the inpatient and outpatient arena. The independence allowed the subspecialty resident must be tempered by rules governing attending physician involvement with patient care and billing.

First 5 months of service: (usually during first year of fellowship)The subspecialty resident is the supervisor of the team. He/she coordinates all aspects of patient care including data collection, patient assessment; ensuring orders are timely and proper even though the subspecialty resident is discouraged from writing orders (other than dialysis orders); and coordination and interpretation of appropriate tests. The subspecialty resident will read appropriate textbooks (purchased for the fellow), syllabus and review articles about the patient’s problems and will be asked to synthesize a reasonable plan for diagnosis, evaluation and treatment. The subspecialty resident will also learn how to interact with other teams as a consultant and utilize the multi-disciplinary teams required for optimal patient care. When technical procedures are required, the subspecialty resident writes the orders for and participates in the procedure with the attending. As skills are learned more responsibility is given.

Next 2 months of service: (usually during the second year for pediatric and second or third year for med-peds)

The subspecialty resident continues to be the supervisor of the team. He/she coordinates all aspects of patient care including data collection, patient assessment; ensuring orders are timely and proper even though the subspecialty resident is discouraged from writing orders (other than dialysis orders); and coordination and interpretation of appropriate tests. The subspecialty resident will now read the latest articles about the patient’s problems and will be asked to synthesize a reasonable plan for diagnosis, evaluation and treatment. The subspecialty resident will now be responsible for being the primary communicator with other teams as a consultant and utilize the multi-disciplinary teams required for optimal patient care. The resident now is expected to develop a well thought out plan for the patient’s care and will carry out that plan after consultation with the attending physician. The fellow will be allowed to perform procedures with less supervision from the attending. For example, the biopsies will be performed completely by the resident but with the Attending present. After an initial acute dialysis, the fellow will be allowed to perform and supervise renal replacement therapy without the Attending’s initial presence. The fellow will also begin to take more responsibility for teaching during bedside rounds.


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Final 2 months of service (generally during last year of residency)The subspecialty resident continues to be the supervisor of the team but now acts as the acting attending. The resident rounds with the team on his/her own. He/she will round with the attending separately from the team and will present complete assessment and plans for the patient. Depending on ability, they will be given the latitude to independently carry out those plans. He/she must defend those decisions and know when to consult with the attending before acting. The subspecialty resident will read appropriate literature about the patient’s problems and will be asked to synthesize and carry out a reasonable plan for diagnosis, evaluation and treatment. The subspecialty resident will interact with other teams as the consultant and utilize the multi-disciplinary teams required for optimal patient care. The fellow will be expected perform procedures with little supervision from the attending given the constraints of the Attending’s billing responsibilities. For example, the biopsies will be performed completely by the resident but with the Attending present. The fellow will be allowed to perform and supervise renal replacement therapy without the Attending’s initial presence. The fellow will also have the responsibility for teaching during bedside rounds. The Attending will periodically attend these rounds to assess teaching effectiveness.

These job descriptions at different levels of trainings include weekend call and independence in patient care in continuity clinics.


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PEDIATRIC UROLOGY ROTATION

I. Educational Purpose: The purpose of this rotation is to develop expertise in the evaluation and management of urologic disorders in childhood.

II. Principle Teaching Method: The principle teaching method on this rotation is daily teaching rounds with the Attending urologist where bedside teaching is stressed, outpatient pediatric urology clinics and urodynamic laboratory and observation in the operating room with evaluation by core competency evaluation tools.

III. Educational Objectives:

B. Specific educational objectives on this rotation includes:

1) Evaluation and management of urinary tract infection2) Evaluation and management of gross hematuria3) Evaluation and management of vesico-ureteral reflux4) Evaluation and management of enuresis5) Evaluation and management of incontinence6) Evaluation and management of abnormal bladder morphology with

specific assessment of function by urodynamics7) Evaluation and management of obstructive uropathy8) Urologic evaluation and management of nephrolithiasis9) Urologic evaluation of congenital renal anomalies10) Evaluation and management of prenatal hydronephrosis11) Pre-transplant assessment of the bladder12) Evaluation and management of hypospadeus and ectopic ureters13) Evaluation and management of renal tumors14) Evaluation and management of cryptorchidism15) Evaluation and management of renal dysplasia and cystic kidney

disease from the urologic perspective16) Evaluation and management of ambiguous genitalia17) The resident will be exposed to observing the surgical management of

these pediatric urologic problemsC. Core competencies obtained: PC, MK, PBL, ICS, P, SBP

IV. Procedures : On this rotation, trainees will learn the indications and contraindications of:

Indications for uroradiologic testing including cystoscopyurodynamic studiesrenal ultrasound with dopplerslasix renogramIVPCT/spiral CT


2004 20

MRI/ MRAWhitaker testingPercutaneous nephrostomies

V. Ancillary Education: The residents are to be provided by the attending urologist with a supplemental reading list. The resident will continue to attend their pediatric nephrology continuity clinics and take weekend call. There are no urology call responsibilities. The division also purchases a pediatric urology text for the residents that is recommended by the pediatric urology faculty.


educational objectives, expected to be met by the end of the rotation. 2. Evaluation tools: DFO, WE, LSR3. At the end of the rotation, the evaluation tools are submitted to the program

committee, which meets quarterly to evaluate trainees. On at least a semi-annual basis, the program director or associate director meets with each trainee and discusses his or her performance. Trainees also complete forms at the end of the rotation identifying the strengths and weaknesses of the Attending nephrologist as well as the sponsoring institution. These forms are reviewed by the program director. All of these data are entered into GMEIS.


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PEDIATRIC PATHOLOGY ROTATION

I. Educational Purpose: The purpose of this rotation is to develop expertise in the evaluation of pathology of renal disorders of childhood.

II. Principle Teaching Method: The principle teaching method on this rotation is daily preparation and examination of renal pathology specimens with the Attending Renal Pathologist. The resident will also examine the teaching file of pathology specimens to ensure that the full gamut of pediatric renal pathology is explored. III. Educational Objectives:

D. Specific educational objectives on this rotation includes pathological evaluation of:

1) Glomerular diseases2) Tubulointerstitial diseases3) Cystic diseases4) Renal dysplasias5) Vasculitis6) Acute tubular necrosis7) Transplant glomerulopathy 8) Transplant rejection9) Congenital lesions such as congenital nephrotic syndrome10) Renal tumors

E. Core competencies obtained: MK, PC

V. Procedures : On this rotation, trainees will learn the assessment of biopsy and nephrectomy specimens including:

Light microscopy with all available stainsImmunofluorescent microscopyElectron microscopySpecial immunofluorescent staining techniques

V. Ancillary Education: The residents are to be provided by the renal pathologist with a supplemental reading list and access to the teaching files. The resident will continue to attend their pediatric nephrology clinics and take weekend call. There are no pathology call responsibilities.


educational objectives, expected to be met by the end of the rotation.


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5. Evaluation tools: DFO, WE6. At the end of the rotation, the evaluation tools are submitted to the program

committee, which meets quarterly to evaluate trainees. On at least a semi-annual basis, the program director or associate director meets with each trainee and discusses his or her performance. Trainees also complete forms at the end of the rotation identifying the strengths and weaknesses of the Attending nephrologist as well as the sponsoring institution. These forms are reviewed by the program director. All of these data are entered into GMEIS.

RENAL CONTINUITY CLINIC

Each subspecialty resident is assigned for two years to an outpatient renal continuity clinic directly supervised by an Attending nephrologist. It meets one-half day per week, and it is expected that the subspecialty resident will attend the clinic during all rotations. Typically, the subspecialty resident in each clinic sees 1-3 new patients and 3-6 return patients.

I. Educational Purpose: The educational purpose of this experience is to provide trainees an opportunity to evaluate and manage patients with a variety of renal diseases in a longitudinal manner. In this way, trainees gain insight into the progression of renal disease and the impact of therapy.

II. Principle Teaching Method: The principle teaching method on the rotation is discussion at the bedside with the Attending nephrologist, and the core competency evaluation tools.


For straight pediatric subspecialty residents, the continuity clinic is changed every 6 months so that the resident may learn the different styles of patient management from different attending nephrologists as well as the different patient populations cared for in that clinic. Patients can follow the fellow to different clinics to maintain continuity. The med-peds resident rotates every months for 4 years between adult nephrology and pediatric nephrology continuity clinics. Available clinics include:

A. The Renal Continuity Clinics takes place in the Memorial-Hermann Professional Building (HPB) at the Kid’s Place located in the Texas Medical Center directly across the street from Memorial Hermann Children’s Hospital, connected by an elevated walkway. This clinic may also take place at the LBJ Clinic or the MD Anderson Pediatric Nephrology Clinic. The full array of clinical laboratory and imaging facilities are provided at all of these hospitals as described. Pediatric residents and subspecialty residents evaluate all patients first and then present them to the Attending nephrologist who then also evaluates the patient. Together, the subspecialty resident and faculty determine diagnostic procedures and therapeutic plans. By example of the


2004 23

faculty, the subspecialty resident learns the skills necessary to provide outpatient consults in the managed care environment and effective communication with primary care providers. The mix of diseases typifies what outpatient nephrologists in the community traditionally see. In addition, many unusual or rare disorders are referred to the clinic because of its association with the Medical School. As the subspecialty residents gain experience, they take over more of the planning of the patients care. They also begin to supervise and teach pediatric resident in seeing clinic patients.

B. The patients are diverse and are referred from faculty in other divisions of the Medical School, private physicians in the community, and occasionally other pediatricians in the community. This renal clinic also provides hospital follow-up for patients seen by the subspecialty resident while on the Inpatient Consult Service at Hermann Hospital. Most patients have Medicaid, managed care, or private health insurance.

C. Specific educational objectives:1) Evaluation and management of proteinuria and hematuria2) Evaluation and management of secondary hypertension3) Evaluation and management of urolithiasis and nephrocalcinosis4) Evaluation and management of glomerular diseases5) Evaluation and management of diabetic nephropathy6) Evaluation and management of genetic renal diseases7) Evaluation and management of tubulointerstitial diseases8) Evaluation and management of acquired and congenital cystic disease9) Evaluation and management of acid base disorders10) Evaluation and management of renal disease associated with

neoplasms11) Evaluation and management of renal tumors12) Evaluation and management of fluid and electrolyte disorders13) Evaluation and management of urinary tract infections14) Prevention of progression of kidney failure15) Dietary therapy of chronic kidney disease16) Indications and contraindications of renal biopsy17) Management of metabolic bone disease18) Management of growth failure related to CKD19) Management of anemia of CKD20) Renal function testing21) Pharmacology of drugs in renal diseases22) Evaluations and management of vascular diseases of the kidney23) Assessment of ESRD and need for initiation of dialysis24) Management of social problems that are frequent roadblocks to patient

care including utilization of Child Protective Services where indicated25) Effective communication skills to provide consultation in the managed

care environment and timely feedback to primary care physicians.D. Core competency evaluation tools: PC, MK, PBL, ICS, P, SBP

IV. Procedures:


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1. Interpretation of renal function tests such as:a) ultrasoundb) IVPc) renal nuclide scansd) renal biopsy resultse) urinalysisf) renal function testing of GFR

V. Ancillary Education: The trainee is supplied with a supplemental reading list and is expected to attend the weekly Divisional educational conferences at the Medical School.

VI. Methods of Evaluation: 1.On a semi-annual basis, the trainee’s supervisory Attending nephrologist fills out a standardized evaluation form, which is submitted to the program committee. On at least a semiannual basis, the program director or associate director meets with each trainee and discusses his or her performance.2. Evaluation tools: DFO, AEF, PEF, WE, OE, CSC

TRANSPLANTATION CLINIC

Each subspecialty resident is assigned for 1 of their 6 month rotations as well as during their 12 month on service time to our outpatient renal transplant clinic that meets biweekly. An Attending Nephrologist/Transplant Surgeon directly supervises the subspecialty resident.

I. Educational Purpose: The educational purpose of this experience is to provide trainees an opportunity to evaluate and manage renal transplant patients in an ambulatory setting.

II. Principal Teaching Method: The principle teaching method on the rotation is discussion in the clinic with the Attending Nephrologist/Transplant Surgeon, and the core competency evaluation tools.


A. Renal Transplant Clinic takes place in Memorial-Hermann Hospital. Physicians in the local community or adjacent states refer most patients for transplantation. There is also a large contingent of international clients. Follow-up transplant patients are derived from the previously described renal Transplant Inpatient Service.

B. Specific educational objectives on this rotation includes:1) Evaluation and selection of the transplant recipient2) Evaluation of the transplant donor3) Medical management of acute and chronic rejection


2004 25

4) Clinical diagnosis of all forms of rejection including laboratory, histopathologic, and imaging techniques

5) Mechanism of action and side effects of immunosuppressant drugs, including steroids, cyclosporin, azothioprine, mycophenolate, tacrolimus, rapamycin, ALG and monoclonal antibodies.

6) Drug – drug interactions in transplant patients7) Evaluation and management of post transplant hypertension8) Evaluation and management of infections in transplant patients9) Secondary malignancies in transplant patients10) Transplantation immunology11) Socio-economic barriers to transplantation12) Management of immunosuppressants

C. Core competencies obtained: PC, MK, PBL, ICS, P, SBP

IV. Procedures:1. Interpretation of renal transplant tests such as:

a) ultrasoundb) cross-matching c) renal nuclide scansd) transplant renal biopsy resultse) urinalysisf) pharmacokinetic studiesg) tissue typingf) renal function testing of GFR

V. Ancillary Education: The subspecialty resident is supplied with a supplemental reading list and is expected to attend the weekly Divisional educational conferences at the Medical School and the Pediatric Transplant Conference.

VI. Methods of Evaluation: 1.On a semi-annual basis, the trainee’s supervisory Attending Nephrologist/Transplant Surgeon fills out a standardized evaluation form, which is submitted to the program committee. On at least a semiannual basis, the program director or associate director meets with each trainee and discusses his or her performance. All data are entered into GMEIS.2. Evaluation tools: DFO, WE, OE, CSC

HYPERTENSION CLINC

Each subspecialty resident attends the pediatric hypertension clinic as part of their outpatient responsibilities when on service. An Attending Nephrologist/Cardiologist directly supervises the subspecialty resident.

I. Educational Purpose: The educational purpose of this experience is to provide trainees an opportunity to evaluate and manage children and adolescents with hypertension.


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II. Principal Teaching Method: The principle teaching method on the rotation is discussion in the clinic with the Attending Nephrologist/Cardiologist, and the core competency evaluation tools. The resident also interacts with entire hypertension team including our research nurses, echo and vascular technicians, data managers.


A. Hypertension Clinic takes place at the Kid’s Place in the Hermann Professional Building. Physicians in the local community refer patients to the clinic as well as our own Department of Pediatrics. We also perform an active screening program as part of our community outreach program and these patients are also seen in our clinic. The fellows are also introduced to a clinical research program in hypertension funded by multiple different sources including the NIH, local grants and pharmaceutical companies.

B. Specific educational objectives on this rotation includes:1) Learn the normal values for BP in children based on the Fourth

NHLBI Working Group on normal BP in Children2) Diagnosis of hypertension 3) Evaluation of the etiology of hypertension4) Assessment of co-morbidites5) Assessment of hypertensive end organ damage6) Non-pharmacologic management of hypertension7) Pharmacologic therapy of hypertension8) Evaluation and management of neonatal hypertension


IV. Procedures:1. Interpretation of renal transplant tests such as:

a) ultrasoundb) ambulatory blood pressure monitoringc) carotid intima-media thickeningd) endothelium dependent and independent dilatatione) echocardiogram with pulse wave velocityf) radial pulse wave analysisg) measurement of BP by oscillometry and auscultation

V. Ancillary Education: The subspecialty resident is supplied with the book Pediatric Hypertension.

VI. Methods of Evaluation: 1.On a semi-annual basis, the trainee’s supervisory Attending Nephrologist/Transplant Surgeon fills out a standardized evaluation form, which is submitted to the program committee. On at least a semiannual basis, the program director or associate director meets with each trainee and discusses his or her performance.2. Evaluation tools: DFO, WE, OE, CSC


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OUTPATIENT DIALYSIS ROTATION

Each first-year subspecialty resident is assigned to the pediatric hemodialysis unit at Memorial Hermann Children’s Hospital, a 7 bed unit currently dialyzing 15 children by hemodialysis and other 10-15 children on peritoneal dialysis for a one month rotation.

I. Educational Purpose: The educational purpose of this rotation is for the trainees to gain experience in the outpatient management of dialysis patients, including patients on home-based therapies.

II. Principle Teaching Method: Discussion on a daily basis with the Attending nephrologist on the techniques of various forms of chronic dialysis and progress of patients, and the core competency evaluation tools.

III. Educational Objectives:A. The mix of diseases is typical of what is seen in chronic dialysis patients such

as congenital structural renal abnormalities, glomerular diseases and collagen vascular diseases. Full laboratory and serologic services are provided. All imaging and inpatient services are provided at Hermann Hospital as well as outpatient Interventional Radiology Services.

The subspecialty resident also directs, under the supervision of the Attending Nephrologist, the monthly Patient Care Conference (PCC), a multidisciplinary meeting composed of the nephrologist, dietitian, child life worker, social worker and head nurse of the unit to discuss each patient’s medical, educational, social and emotional needs (see V. Ancillary Education).

B. Specific Educational Objectivess:1) Principles and practices of hemodialysis2) Principles and practices of peritoneal dialysis3) Assessment of adequacy of dialysis4) Urea kinetic modeling5) Water purification systems6) Metabolic bone disease7) Anemia of renal failure8) Aluminum intoxication9) Growth failure 10) Calcium, phosphorous and vitamin D metabolism11) Iron therapy in dialysis patients12) Evaluation and management of vascular access malfunction13) Nutritional management of dialysis patients14) Management of medical conditions in dialysis patients


2004 28

15) Understand the social and ethical issues of caring for patients with ESRD and learn from the faculty how to address them in the best interests of the patient.

16) Use of automated cyclers in peritoneal dialysis.17) Use of peritoneal equilibration testing and the principles of peritoneal

biopsy.18) Understanding the complications of peritoneal dialysis including

peritonitis, exit site and tunnel infection and their management, hernias, and pleural effusions.


IV. Ancillary Education:1. Patient Care Conference: The trainee will direct the PCC on their dialysis patients. Here, a multidisciplinary team discusses medical, dietary and social issues of each patient.2. The trainee is supplied with the book “The Handbook of Dialysis,” as well as an extensive 3 volume syllabus with all of the latest articles in pediatric dialysis. The resident is expected to attend the weekly divisional educational conferences at the Medical School, and his/her continuity clinic.

V. Methods of Evaluation:1. At the start of the rotation, the subspecialty resident is provided a list of

educational objectives, expected to be met by the end of the rotation. 2. Evaluation tools: DFO, WE, OE, AEF, PEF, CSC3. At the end of the rotation, the Attending nephrologist fills out a

standardized evaluation form on the trainee, which is forwarded to the program committee. On at least a semi-annual basis, the program director or associate director meets with each trainee and discusses his or her performance.

TRAINING IN CHRONIC HEMODIALYSIS

I. Educational Purpose: Each resident must have an experience in caring for children whose medical condition requires chronic dialysis –peritoneal or hemodialysis. This rotation is mandatory for pediatric nephrology fellows during their second or third year; and optional for Medicine/Pediatric Fellows (as this is part of their adult training and the month rotation in pediatric dialysis plus problem management while on service suffices as an acceptable experience)

HemodialysisOptional Morning or Evening Shift for 6 months

PeritonealFollow peritoneal dialysis patients for minimum 6 months or starting first year of fellowship, follow patients chronically for several years. Following peritoneal dialysis patients would entail: Thursday afternoon clinic, this would be once a month to weekly depending on patient.


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II. Principle Teaching Method: Discussion with the attending physician on a weekly basis and daily as needed to discuss the management of chronic dialysis patients, patients progress and core competence evaluation tools.

Fellow Responsibilities: Rounding and discussion with Dialysis Director on patients once weekly for

hemodialysis and in clinic for PD Transitioning to receive all initial phone calls from dialysis unit on their patients Reviewing in timely manner, laboratory data with adjustments discussed with

Dialysis Director Coordinating all lapses in coverage with Dialysis Director

III. Educational Objectives:D. The mix of diseases is typical of what is seen in chronic dialysis patients such

as congenital structural renal abnormalities, glomerular diseases and collagen vascular diseases. Full laboratory and serologic services are provided. All imaging and inpatient services are provided at Memorial Hermann Hospital as well as outpatient Interventional Radiology Services.

The subspecialty resident also directs, under the supervision of the Attending Nephrologist, the monthly Patient Care Conference (PCC), a multidisciplinary meeting composed of the nephrologist, dietitian, child life worker, social worker and head nurse of the unit to discuss each patient’s medical, educational, social and emotional needs (see V. Ancillary Education).

E. Specific Educational Objectives:Specific focus of this chronic patient experience compared to the one month rotation:

1) Understanding management of chronic dialysis patient including growth, development and psychosocial issues

2) Further understanding of Anemia Management in the ESRD3) Further understanding of Hyperparathyroidism Management in ESRD4) Dialysis access maintenance and management

The rotation will also include these objectives common to the one month rotation:

5) Principles and practices of hemodialysis6) Principles and practices of peritoneal dialysis7) Assessment of adequacy of dialysis8) Urea kinetic modeling9) Water purification systems10) Metabolic bone disease11) Anemia of renal failure12) Aluminum intoxication13) Growth failure 14) Calcium, phosphorous and vitamin D metabolism15) Iron therapy in dialysis patients


2004 30

16) Evaluation and management of vascular access malfunction17) Nutritional management of dialysis patients18) Management of medical conditions in dialysis patients19) Understand the social and ethical issues of caring for patients with

ESRD and learn from the faculty how to address them in the best interests of the patient.

20) Use of automated cyclers in peritoneal dialysis.21) Use of peritoneal equilibration testing and the principles of peritoneal

biopsy.22) Understanding the complications of peritoneal dialysis including

peritonitis, exit site and tunnel infection and their management, hernias, and pleural effusions.

F. Core competencies obtained: PC, MK, PBL, ICS, P, SBP

IV. Ancillary Education:1. Patient Care Conference: The trainee will direct the PCC on their dialysis patients. Here, a multidisciplinary team discusses medical, dietary and social issues of each patient.2. The trainee is supplied with the book “The Handbook of Dialysis,” as well as an extensive 3 volume syllabus with all of the latest articles in pediatric dialysis. The resident is expected to attend the weekly divisional educational conferences at the Medical School, and his/her continuity clinic.

V. Methods of Evaluation:4. At the start of the rotation, the subspecialty resident is provided a list of

educational objectives, expected to be met by the end of the rotation. 5. Evaluation tools: DFO, WE, OE, AEF, PEF, CSC6. At the end of the rotation, the Attending nephrologist fills out a

standardized evaluation form on the trainee, which is forwarded to the program committee. On at least a semi-annual basis, the program director or associate director meets with each trainee and discusses his or her performance. Evaluation data are entered on GMEIS.

RESEARCH TRAINING

I. Education Purpose: The educational purpose is for trainee is to engage the fellow in specific areas of scholarly activity to allow acquisition of skills in the critical analysis of the work of others; to assimilate new knowledge, concepts and techniques related to the field of one’s practice; to formulate clear and testable questions from a body of information/data so as to be prepared to become effective subspecialists and to advance research in pediatrics; to translate ideas into written and oral forms as teachers; to serve as consultants for colleagues in other medical or scientific specialties and to develop as leaders in their fields.

II. Educational Objectives:


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1. All fellows will be expected to engage in projects in which they develop hypotheses or in projects of substantive scholarly exploration and analysis that require critical thinking. Areas in which scholarly activity may be pursued include, but are not limited to: basic, clinical or translational biomedicine; health services; quality improvement; bioethics; education and public policy. Fellows must gather and analyze data, derive and defend conclusions, place conclusions in the context of what is known or not known about a specific area of inquiry and present their work in oral and written form to their Scholarship Oversight Committee (SOC) and elsewhere.

2. Work product of scholarly activity may include: A peer-reviewed publication in which a fellow played a substantial role An in-depth manuscript describing a completed project A thesis or dissertation written in connection with the pursuit of an

advanced degree An extramural grant application that has either been accepted or favorably

reviewed A progress report fro projects of exceptional complexity, such as a multi-

year trial3. We offer two tracts for completion of research requirement: basic science and

clinical science tract.

Those selecting the basic science tract find a mentor in a laboratory anywhere in the medical center. They must have their project approved by the SOC as appropriate to satisfy the ABP/RCC research requirements. The mentor must be a faculty member with a strong history of research excellence, teaching and finances to support the fellow’s research. Those subspecialty residents are encouraged to attend the University Clinical Research Center’s (UCRC) “METHODS in RESEARCH” course offered annually.

Those choosing the clinical scientist tract must be adequately trained in study design, epidemiology, biometry, health services and statistics. Our program has decided that any fellow choosing the clinical science pathway will attain the degree of Master’s of Clinical Research from the Medical School or Master’s of Public Health from the UT School of Public Health. All residents understand that this is our requirement before they begin their fellowships.

4. Each subspecialty resident will have a Scholarship Oversight Committee that will review the scholarly activity. Our SOC consists of 3 members, one whom is outside of the Division. If the Program Director is the mentor for the resident, he will be a non-voting member of the SOC. The SOC will

determine whether a specific activity is appropriate to meet the ABP guidelines for scholarly activity

determine a course of preparation beyond the core fellowship curriculum to ensure successful completion of the project

evaluate the fellow’s progress as related to scholarly activity meet with the fellow early in the training period and regularly thereafter


2004 32

require the fellow to present/defend the project to his/her scholarly activity advise the program director on the fellow’s progress and assess whether

the fellow has satisfactorily met the guidelines associated with the requirement for the active participation in scholarly activities.

5. We have compiled a list of ongoing or future research projects of the renal faculty. The subspecialty residents may select a project/mentor from this list, design their own project if it is approved by the SOC or chose a project that is renally related from outside the division. The subspecialty resident, under the supervision of the full time faculty mentor then designs and performs a research project. Although protected time is provided, many projects can be continued while subspecialty residents are on service since most projects are clinically based research.

6. Subspecialty residents attend Renal Research Conference where subspecialty residents and faculty of the Division, or visiting professors, present updates on research currently on-going in their respective laboratories or clinical settings.

7. Subspecialty residents are expected to submit their research for presentations at national scientific meetings and submit manuscripts to peer reviewed journals.

III. Core Competencies Obtained: PC, MK, PBL

Evaluation Tools:LSR, PCF


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CONFERENCES

Several weekly conferences are provided within the Pediatric Nephrology Division and the Adult Division, in addition to those offered by the Department of Pediatrics. These sessions are given both by faculty and by subspecialty residents. The goal of these conferences is to provide an in-depth review of a particular clinical or research topic, and to strengthen the teaching and oral presentation skills of the subspecialty resident. The various conferences are described below.

1. Clinical Case RoundsA. Description: A weekly one hour didactic session where a subspecialty resident

and faculty present patients seen over the weekend and discusses management issues. Then a resident/faculty team present and discuss a patient from their specific clinic. The expectation is the presentation will review the case and the current literature about the case.

B. Purposes:1. To discuss clinical cases with all the residents and faculty to discuss the

latest diagnostic and therapeutic information about the clinical entity2. To strengthen the teaching and oral presentation skills of the subspecialty

resident.

C. Core Competencies Obtained: PC, MK, PBL, SBP, ICS

D. Evaluation Tools: WE, OE, CSC, LSR, PCF

2. Renal Grand Rounds with the Adult DivisionA. Description: A weekly one hour didactic session where a subspecialty

resident, faculty, or visiting professor presents topics outlined in the Core Curriculum of the ASN. The expectation is the presentation will review current literature rather than merely reciting what is found in textbooks or review papers. Renal Grand Rounds is an intellectual and academic exercise.

In addition, the lecturer should provide a list of 5-7 pertinent learning issues relevant to the topic, and a bibliography of 4-6 articles.

B. Purposes:1) To provide clinically relevant in-depth updates on topics important to

nephrologists2) To strengthen the teaching and oral presentation skills of the

subspecialty resident.

C. Core Competencies Obtained: PC, MK, PBL, SBP



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3. Pediatric Renal Patient Care ConferenceA. Description: A weekly one hour multidisciplinary conference to discuss

current inpatients and the dialysis patients. The conference is led by the subspecialty resident with the attending physician. Other attendees include social workers, child life specialists, dialysis nurses, ward nurses, dieticians, and dialysis administrators.

B. Purposes:1. To integrate the resident into the multidisciplinary care required by these complex patients including ethical issues, financial issues, utilization of health care system, home health care, insurance companies, child protective services, and quality improvement processes.2. To strengthen the teaching and oral presentation skills of the subspecialty resident.

C. Core Competencies Obtained: PC, MK, PBL, SBP, P, ICS

D. Evaluation Tools: DFO, WE, AEF, CSC, LSR, PCF

4. Journal Club:A. Description: A monthly one-hour session where three clinical articles by

either subspecialty residents and/or faculty each present a clinical paper from a recent publication pertinent to the practice of nephrology. Research methods and results, rather than mere content, are scrutinized.

B. Purposes:1. To promote evidence based medicine2. To teach critical appraisal of the literature, study design and interpretation3. To promote a life time commitment to scholarship

C. Core Competencies Obtained: PC, MK, PBL, ICS, SBP


5. Research ConferenceA. Description: A monthly one-hour session where faculty, subspecialty

residents, or visiting professors present their research in progress with relevant background. If no recent data is available for presentation, then the expectation is 2 articles relevant to the research area should be presented and critically appraised for the conference. The medicine-pediatric resident also present their research at the adult research conference.

B. Purposes:1. To present basic and/or clinical science topics relevant to nephrology


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2. To teach subspecialty residents the principles of research design, implementation, and interpretation of research projects.

C. Core Competencies Obtained:PC, MK, PBL, ICS, SBP

D. Evaluation Tools:WE, OE, CSC, LSR, PCF

6. Renal Biopsy ConferenceA. Description: Two monthly one-hour sessions where subspecialty residents

present interesting patients as unknowns who underwent renal biopsies for various indications. One of these conferences is shared with the adult division. All faculty, subspecialty residents, residents and medical students participate in the discussion of the differential diagnosis and the suspected biopsy result. The biopsy results are then presented and discussed by the Attending renal pathologist. Subspecialty residents should have reviewed the pertinent literature on the disease ascertained by the biopsy in order to provide the group with a concise review of etiology, prognosis and treatment. A relevant article or bibliography should also be provided.

B. Purposes:1. To teach clinical decision making, formulation of an appropriate

differential diagnosis and diagnostic work up2. To teach the indication, contra-indication, and interpretation of renal

biopsies



7. Renal Morbidity and Mortality (M&M) ConferenceA. Description: This hour conference is held quarterly. It is intended to review

complications, potential or realized adverse events, and deaths in patients cared for by the Pediatric Nephrology Division. Autopsy findings are presented when appropriate.

B. Purposes:1. To elucidate potential errors that occur in clinical practice to avoid such

occurrences in the future.2. To learn what disease processes cause death in our patient population.3. Change behaviors to decrease patient harm and decrease medical liability.



2004 36


8. Subspecialty Resident’s Conference:

A. Description: subspecialty residents meet with the Program Director and other faculty bimonthly to provides an avenue for subspecialty residents to provide feedback on the program in order to assess quality of educational issues. This forum functions as an educational committee for the subspecialty residents. The meeting will also be used to discuss other issues related to the practice of pediatric nephrology such as interviewing for faculty positions, involvement with the national and international nephrology community and organizations, medical directorships etc.

B. Core Competencies Obtained:PC, MK, PBL, ICS, P, SBP

C. Evaluation Tools: WE, OE, CSC

9. Renal Transplant ConferenceA. Description: A monthly one hour session where the faculty and fellows discuss the patients on the transplant list, the management of current transplants, and a review of recent transplant literature. Faculty from transplant surgery and the immunology laboratory also attend.

B. Purposes:1. To provide clinically relevant in-depth updates on renal transplants2. To discuss the management of pediatric transplantation


D. Evaluation Tools: WE, OE, CSC, LSR

10. Radiology-Urology-Nephrolgy ConferenceA. Description: A monthly one hour session where the nephrology, urology and radiology faculty and fellows review cases who have had radiographic evaluation of the urinary tract and difficult management issues.

B. Purposes:1. To provide clinically relevant review of the latest techniques in radiographic evaluation of the urinary tract2. To discuss the management of children with urologic disorders

C. Core Competencies Obtained: PC, MK, PBL, SBP, ICS


2004 37

E. Evaluation Tools : WE, LSR, DFO, PCF

11.Pediatric Renal Topic ReviewA. Description: A monthly one hour didactic session where a subspecialty

resident, faculty, or visiting professor presents topics related to pediatric nephrology. These conferences are a practical review of a topic at a fellow level and the expectation is the presentation will review current knowledge of a topic but is not expected to be cutting edge but a review of current practices.

In addition, the lecturer should provide a list of 5-7 pertinent learning issues relevant to the topic, and a bibliography of appropriate articles.

B. Purposes:3) To provide clinically relevant reviews on topics important to pediatric

nephrologists4) To strengthen the teaching and oral presentation skills of the

subspecialty resident.



OTHER CONFERENCES

1. Pediatric Grand Rounds : Weekly didactic lecture by faculty or visiting Professors on a wide range of topics, many relevant to nephrologists.

2. Internal Medicine Clinical Pathologic Conference (CPC) : Weekly presentation and discussion by faculty of medicine, radiology and pathology of an interesting case. Nephrology faculty discusses many of the cases.

3. Department of Pediatrics Morbidity and Mortality Conference .Monthly conference for review of M&M for the department. Fellows and faculty are encouraged to attend especially when renal cases are presented

4. Department of Pediatric Morning Report : Three day a week conference for pediatric residents. Nephrology fellows on service are encouraged to attend as time permits. Monthly there is a renal case presentation by the renal attending and fellow with the on service pediatric residents.

ETHICS/MEDICAL LEGAL

1. Subspecialty residents are required to attend a risk management course on medical documentation and communication. These are often provided through the medical


2004 38

school on line. The Department of Pediatrics also provides many of these conferences during the year.

2. Subspecialty residents and faculty are required to read and report on selected journal articles on topics ranging from withdrawal of dialysis to the importance of the doctor – patient relationship.

3. Subspecialty residents on service are expected to attend and participate at the weekly Patient Care Conferences ( PCC ) a multidisciplinary conference that addresses the medical, social, psychiatric, nursing and dietary needs of renal patients admitted to Memorial Hermann Children’s Hospital. Core Competencies Obtained: PC, MK, PBL, ICS, P, SBPEvaluation Tools: WE, OE, AEF, CSC

Documents

[ ] Fellowship Goals Medi