Pediatric Nephrology and Hypertension

Fellowship

FAQ List

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.

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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, 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.

µ 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 anomalies of the genitourinary tract

2. Hypertension

3. Acute renal failure

4. Chronic renal failure

5. New end-stage renal disease

6. Urinary tract infections

7. Renal transplantation

8. Neoplasms of the kidney

9. Fluid and electrolyte and acid base disorders

10. Acute and chronic glomerular diseases

11. Renal tubular disorders

12. Nephrolithiasis

13. Voiding dysfunction and urologic disorders

14. Renal dysplasia and cystic diseases of the kidney

15. Inherited renal disorders

µ Special Experiences

In addition, residents will have experience in the following:

1. Evaluation and selection of transplant candidates

2. Preoperative evaluation and preparation of transplant recipients.

3. Recognition and medical management of surgical and non-surgical complications of transplantation.

4. Dialysis therapy; each resident should have exposure to dialysis and extracorporeal therapies, 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 peritoneal access.

d. Understanding of the special nutritional requirements of hemodialysis of patients.

µ Technical Experiences

Residents 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. Urinalysis

2. Percutaneous biopsy of both native and transplanted kidneys

3. Peritoneal dialysis

4. Acute and chronic dialysis and hemofiltration

5. Renal ultrasound, nuclear renal scans, MRI and MRA, angiography, VCUG

µ 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

µ Order Writing

1. 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.
2. 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.

µ Lines of Responsibility - 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.

µ 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.

µ 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.

µ 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.

µ 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.

µ 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.

µ 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.

µ Policy for Moonlighting

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

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

3. 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.

4. 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.

5. 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 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.

6. 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.

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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.

µ  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 services

II) Outpatient clinics

III) Outpatient dialysis

IV) Patient care conference (PCC) at dialysis

(b)   Evaluation tools that may be used

I)  Direct faculty observations (DFO) using evaluation forms

II)  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)

µ 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 services

2.   Outpatient clinics

3.   Outpatient dialysis

4.   Renal Grand Rounds

5.   Renal Journal Club

6.   Research conference

7.   Biopsy conference

8.   Renal-Urology-Nephrology (RUN) Conference

9.   Transplant conference

10.  Patient care conferences

11.  Resident conferences

12.  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)                      

µ PRACTICE-BASED LEARNING AND IMPROVEMENT (PBL)

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 consults

II)   Outpatient clinics and dialysis

III)  PCC

IV) ESRD conference

V)  Renal Journal Club

VI) 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)

µ 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 consults

II)              Outpatient clinics and dialysis

III)             PCC

IV)            ESRD conference

b)                  Evaluation tools that may be used

I)              Direct faculty observation (DFO)

II)             Associate evaluation form (AEF)

III)            Patient evaluation form (PEF)

µ 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 consults

II)              Outpatient clinics and dialysis

III)              PCC

IV)             ESRD conference

V)              Standardized patient

b)                  Evaluation tools that may be used

I)                Direct faculty observation (DFO)

II)               Associate evaluation form (AEF)

III)              Patient evaluation form (PEF)   

µ 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

· practice cost-effective health care and resource allocation that does not compromise quality of care

· advocate for quality patient care and assist patients in dealing with system complexities

· know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system       performance

a)                  Educational sites/methods

I)                   Inpatient wards and consults

II)                 Outpatient clinics and dialysis

III)              PCC

IV)              ESRD conference

V)                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.

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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 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 obtain

1. Patient Care = PC
2. Medical Knowledge = MK
3. Practice-Based Learning and Improvement = PBL
4. Interpersonal and Communication Skills = ICS
5. Professionalism = P
6. Systems-Based Practice = SBP

 Evaluation Tools

1. Direct Faculty Observation = DFO
2. Oral Examination = OE
3. Written Examination = WE
4. Associate Evaluation Form = AEF
5. Patient Evaluation Form = PEF
6. Computer Simulated Cases = CSC
7. Literature Search Review = LSR
8. Presentation Critique Form = PCF

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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 eleven 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 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 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.  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/F and SLED)

4. Evaluation and treatment of proteinuria and hematuria

5. Evaluation and management of glomerular diseases including immune complex diseases (e.g. SLE) and vasculitis

6. Evaluation and treatment of diabetic nephropathy

7. Evaluation and management of primary and secondary hypertension

8. Evaluation and management of renal diseases in pregnancy

9. Evaluation and management of acid base disturbances

10. Evaluation and management of fluid and electrolyte disorders

11. Evaluation and management of vascular diseases of the kidney

12. 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 Syndrome

14. Evaluation and management of Acute Renal Failure (ARF) in Bone Marrow Transplantation

15. Evaluation and management of paraneoplastic renal syndromes

16. Evaluation and management of ARF associated with biological agents

17. 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. Urinalysis
2. Urine sediment analysis
3. Percutaneous renal biopsy
4. Peritoneal dialysis
5. Hemodialysis
6. Continuous renal replacement therapy
7. 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, CSC

3.        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 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 6 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 3 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.

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 infection

2)   Evaluation and management of gross hematuria

3)   Evaluation and management of vesico-ureteral reflux

4)   Evaluation and management of enuresis

5)   Evaluation and management of incontinence

6)   Evaluation and management of abnormal bladder morphology with specific assessment of function by urodynamics

7)   Evaluation and management of obstructive uropathy

8)   Urologic evaluation and management of nephrolithiasis

9)   Urologic evaluation of congenital renal anomalies

10)  Evaluation and management of prenatal hydronephrosis

11)  Pre-transplant assessment of the bladder

12)  Evaluation and management of hypospadeus and ectopic ureters

13)  Evaluation and management of renal tumors

14)  Evaluation and management of cryptorchidism

15)  Evaluation and management of renal dysplasia and cystic kidney disease from the urologic perspective

16)  Evaluation and management of ambiguous genitalia

17)  The resident will be exposed to observing the surgical management of these pediatric urologic problems

C.     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

• cystoscopy

• urodynamic studies

• renal ultrasound with Doppler

• lasix renogram

• IVP

• CT/spiral CT

• MRI/ MRA

• Whitaker testing

• Percutaneous 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.

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, LSR
3. 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 diseases

2. Tubulointerstitial diseases

3. Cystic diseases

4. Renal dysplasias

5. Vasculitis

6. Acute tubular necrosis

7. Transplant glomerulopathy

8. Transplant rejection

9. Congenital lesions such as congenital nephrotic syndrome

10. Renal tumors

E.      Core competencies obtained: MK, PC

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

1. Light microscopy with all available stains

2. Immunofluorescent microscopy

3. Electron microscopy

4. Special 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.

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
3. 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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RENAL CONTINUITY CLINIC

Each subspecialty resident is assigned 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.

III.  Educational Objectives:

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 6 months for 4 years between adult nephrology and pediatric nephrology continuity clinics. Available clinics include:

A.     The Renal Continuity Clinics takes place in the University of Texas Professional Building (UTPB) at the Kid’s Place located in the Texas Medical Center directly across the street from Children's Memorial Hermann 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 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 hematuria

2)    Evaluation and management of secondary hypertension

3)    Evaluation and management of urolithiasis and nephrocalcinosis

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