University of Texas at Houston Pediatic Nephrology Fellowship Program

Faculty	Staff	for Patients	Scientific Research	Department
Fellows	Clinics	for Physicians	for Fellowship Applicants	Links

We typically take 1 or 2 fellows per year starting July 1st. We train fellows in either pediatric nephrology and hypertension or in Med Peds. We encourage interested applicants to contact us 12 to 18 months before the anticipated start time. Please apply through ERAS.

The description below of each year of training represents the schedule for the average subspecialty resident. The content requirements are strictly adhered to but we remain flexible to the subspecialty resident’s needs and allow modifications of the schedule. In all clinical activities, the subspecialty resident works directly with one of the pediatric nephrologists who are available for advice and teaching, but strive to let the subspecialty resident think through the problems independently. The attending physician is ultimately responsible for patient care and must see each patient daily and write meaningful progress notes.

The first year of training serves to provide the subspecialty resident with a solid clinical base in pediatric nephrology, to take the required rotations outside of the division, to begin basic course work and acquaint the subspecialty resident with research opportunities to help them decide on a mentor and research project. Both the med-peds and pedi subspecialty residents take 5-6 months on service seeing our inpatients at Children’s Memorial Hermann Hospital (CMHH) and consultations at CMHH, MD Anderson Cancer Hospital and LBJ Memorial Hospital which is a part of the Harris County Hospital District.

Subspecialty residents attend their continuity clinic every week even when on service. Typically this is a general nephrology clinic at UTPB. The outpatient experience has become critical in the era of managed care. Each fellow receives our pediatric nephrology syllabus, the latest edition of the Pediatric Nephrology text, Pediatric Hypertension text and Pediatric dialysis text. Full internet access along with reference manager is also supplied all at no cost to the subspecialty resident who is also provided a stipend to purchase books, journals or to pay for memberships or trips to meetings.

Other rotations in the first year include two week rotations with our pediatric urologist, where the fellow can observe urological procedures, cystoscopy, urodynamic studies (and their interpretation) and attends their clinics including enuresis clinic. During this time, they spend a great deal of time reviewing the radiological procedures required for urologic care with the urologist and pediatric radiologists. These procedures include ultrasonography, nuclear scans, VCUG, retrograde studies, percutaneous nephrostomies, MRI and MRA and CT scans. They will also learn the cost efficient utilization of these studies. Another two weeks is spent with our renal pathologists. The time is spent studying the preparation and interpretation of renal biopsy and nephrectomy specimens. The fellows also review a wonderful file of teaching slides with the pathologist to cover cases not seen during that month. It is also common that the fellows perform case series or case reports resulting from these months that lead to education about medical writing and publishing expertise.

A month is spent with the medical director of the pediatric dialysis unit, learning the principles of pediatric dialysis including hemodialysis, peritoneal dialysis and acute renal replacement techniques. This month includes spending the entire time in the unit learning the technical aspects of dialysis procedure with the dialysis nurses, learning about vascular access, learning to set up and run the dialysis machines and troubleshooting. This education is supplemented by a detailed 3 volume dialysis syllabus developed by our own Dr. Swinford as well as the above mentioned Pediatric Dialysis text. Fellows work with intervention vascular radiologists and vascular surgeons, in addition to the interventional nephrology program in the adult nephrology division.

The fellow will also identify their chosen research tract: basic or clinical scientist. They also select members of the Scientific Oversight Committee (SOC), and begin the early phases of their research project.

For the med-peds subspecialty resident, the rest of the first year is spent on adult nephrology service. For the peds subspecialty resident, the remaining four months are spent beginning their research program. During research months, the subspecialty resident has only one half day of clinic per week to attend for continuity of care.

The second year of fellowship includes 2-4 months service time and continuation of their research program for 8-10 months. The fellow is given more responsibility for decision-making based on their ability although supervised at all times. The med-peds fellow finishes 6 months of adult nephrology, 2-3 months of pediatric nephrology service and the balance in research or any pathology or urology rotation they didn’t complete in the first year.

For the pediatric fellow the third and final year is spent doing mostly research with the chosen mentor. The fellow should be obtaining enough data for abstract submission and presentation at a national meeting. The research mentor will train the fellow in this process. Again the department has all of the necessary computers, software and slide makers for presentation preparation. The Division pays for the fellow’s trip to the meeting. The clinical months now include more responsibility and the fellow is an acting attending for these clinical months. Teaching now becomes a larger part of their responsibilities as well. We also spend more time on the administrative aspects of pediatric nephrology including how to run a clinic, dialysis unit and transplant program. The med-peds fellow has concluded most of his/her clinical work and will spend 9-10 months in research. By the third year, the fellows who have throughout their training been introduced to the principles of managed care, insurance authorizations, Medicaid and Medicare rules are responsible for including the evaluation of these social issues into patient care.

The fourth year for the med-peds fellow is similar to the third year. For the basic science focus, the fellow has been working in the laboratory and producing data for presentation and grant application. The clinical scientist will be completing their MPH or other clinical research course work and have an established research project in progress. We also spend more time on the administrative aspects of pediatric nephrology including how to run a clinic, dialysis unit and transplant program.

Yes. We are fortunate to have at least one senior (3^rd year) med-peds resident on our team. Senior pediatric residents often choose to join the team as a subspecialty elective. Occasionally there will also be a 4th year acting intern. The fellow and the attending supervise these residents. The resident team focuses only on nephrology for a month although their call can be in various units. They care for the inpatients; perform all consults at each different hospital and attend the majority of our clinics as well.

The fellow are considered to be supervisors for the house officers. While the fellow clearly has hands on contact with the patients every day, they are also being trained to teach and supervise. As an example, on the inpatient service, we ask fellows to refrain from writing orders but rather transmit their wishes and the rationale for them to the residents. This ensures that the residents know what is transpiring with their patients and the reasons behind the order. The fellow rounds each day with the house staff and they make their plans before rounding with the attendings.

The first year fellow, ie, the first 5 months of service time, acts as team leader ensuring all of the necessary information about the patient is obtained, patient assessment and evaluation accomplished and management plan that was coordinated with the attending is carried out. Procedures are done in concert with the attending including biopsies, line placements, and acute renal replacement therapies. During the second year of fellowship (service months 6 and 7) the fellow takes on more decision-making responsibilities. The fellow begins to teach more for the residents and students on the team and now makes diagnostic and management decisions but still needs approval from the attending before implementation. In the final year of fellowship (months 8 and 9 of service) the fellow becomes the acting attending. He/she is responsible for teaching the residents, interacting with all of the service consultants and care providers, organizing patient evaluation and management checking with the attending when they feel it is necessary but must defend their decisions. They are free to consult the attending at any time. The resident rounds with the attending daily to discuss patient care.

Call for the on-service fellow is taken from home. They have the responsibility for making their own call schedule for weekends. In the unusual instance when the fellow is in house overnight for a sick child, they are not allowed to work more than 30 consecutive hours. The fellows are also not allowed to average more than 80 hours per week over a two week period. Moonlighting hours are included in the 80 hour work week limit. The attendings will monitor if the fellow is becoming fatigued or has had several days of home call where they have not slept well due to frequent phone calls. If that is the case, the attending will cover for the fellow or the fellow will request anther fellow to assist on their own initiative. Fellows average 5-6 days per month without clinical responsibilities while on service.

When on service, fellows take call each weeknight from Monday through Thursday from home. Weekend coverage beginning Friday night through Sunday night is shared by all fellows regardless of rotation and average one weekend per month. There is always an attending on call with the fellow.

Participation in division/hospital-wide conferences begins in a student role and gradually throughout the course of the fellowship becomes a teacher. Fellows are required to attend all the conferences, unless they are out of town, on the medicine nephrology service or with a critically ill patient.

The conferences serve two main purposes. The first is to educate the fellows about pediatrics, nephrology, transplantation, and hypertension; the second is to teach them how to become an effective communicator and teacher themselves. Each year the fellow gives at least 1-2 renal grand rounds, 4 journal clubs, presents patients at clinical, uroradiology and biopsy conferences. Case presentations are to be accompanied by excellent articles from the literature and typed reviews of the topics. Finally, there is a board review course taught by the fellows and faculty which covers all objectives specified by the American Board of Pediatrics for board certification in Pediatric Nephrology.

All presentations are done in Powerpoint using an LCD projector. Every technological advantage is available to the subspecialty residents and faculty ranging from state of the art computers, laser and color printers, scanners, LCD projectors, palm computers, and to lap tops with the latest software. Fellows even in their first years are required to give lectures to pediatric residents and students during the ‘nephrology month’ for resident teaching. Faculty attend and provide feedback to their residents about their lecture style and content.

Research is an integral part of our pediatric fellowship. The subspecialty residents begin their research in the first year by observing the faculty, deciding the kind of research they may wish to perform and identifying a mentor. With their mentor and now their Scientific Overview Committee (SOC), they begin the preparation for their research – background reading, course work, hypothesis generation and learning techniques and procedures. They have formal research training through courses previously discussed. These include the clinical and basic research core courses. These courses include instruction in biostatistics and data analysis. These techniques are best learned by performing it in relation to their own project. The mentor and SOC are the main sources of education and guidance. Those getting their MPH or MCR are obviously educated by the fine faculty at UTSPH. The research conference for data presentation allows the subspecialty resident to receive feedback about the progress of their project.

Two years will be spent in research. The subspecialty resident may choose one of two tracts:

Basic science: the subspecialty resident will spend two years in the laboratory. The subspecialty resident is expected to interview possible mentors in both the adult and pediatric nephrology divisions by the middle of the second year. The subspecialty resident is not limited to these divisions but may seek out mentors based on their own interests within the medical school and medical center. They then form their SOC with approval from the Program Director and the Division Chief. The criteria are that the research be nephrology based, must be approved by the division director, mentor have adequate resources and track record of excellence in training subspecialty residents to assume this role and be willing to sign an agreement of mentorship. The subspecialty resident in this tract is still expected to perform a clinical research project in one of the two renal divisions during their 3-4 years and write a case report or case series.

Clinical Research: A 2-year period is generally too short to accomplish a complete clinical research project. Thus, the subspecialty resident needs to receive formal education in clinical research. The subspecialty resident will participate in the UCRC sponsored statistical analysis and study design course. The subspecialty resident will then complete the master’s of clinical research. The subspecialty resident may either 1) design his/her own clinical research project and initiate it with the hope that it can be completed in a short time, or 2) join a study in progress or be involved in the data analysis and reporting. The goal is for the study to be a clinician-scientist with the ability to ask thoughtful and careful questions about disease origins, pathogenesis and management. Their decision will be approved and supervised by their SOC with at least reports on his/her progress every 6 months.

For either tract, the subspecialty resident must show research proficiency by the ABP criteria. This would include successful grant funding or a first authored research paper published or accepted for publication in a peer-reviewed journal or a thesis accepted for a degree program.

We have a full time data management/computer specialist, Tim Poffenbarger who assists the subspecialty resident in building a data base for their research and assisting in data analysis. Further, we have a full-time statistician, as well as two biometrists and an epidemiologist at the School of Public Health, who assist in data analysis and interpretation.

Fellows receive the same benefits as residents at the University of Texas. See UT System Medical Foundation website for details.

Yes. Four of our fellow alumni were trained in both adult and pediatric nephrology. Clinical requirements for both fellowships must be met as well as the research requirement. See the Division of Nephrology website for the Department of Internal Medicine for more details on the adult nephrology program. This program typically takes 4 years. These fellows are frequently sought out during and after their fellowship for transitional care of our adolescent and young adult patients.