Division of Nephrology

Ambulatory (Clinic) Training

Each fellow participates in a continuity clinic practice one-half day per week. These occur in blocks of time that are 6 months long and coincide with the hospital site that the first year fellow is rotating through. Thus, when the fellow is on the Montefiore Hospital-Moses Campus for six months, the fellow will attend continuity clinic for six months on the Moses Campus. The same will hold true for fellows on the Montefiore Hospital-Einstein Campus.

Each half-day block typically involves 4-6 patient encounters; the fellow is responsible for both new patient work-ups and follow-up visits. Each clinic is mentored by on-site faculty attendings. In addition, during the 6 months rotation at the Montefiore Hospital-Moses Campus, the first year fellow also attends Renal Transplant Clinic, thus obtaining 6 months of continuity in out-patient transplant care with the opportunity to follow at least 20 patients during this six month period.

 
 

Continuity Clinic Rotation Competency-Based Goals & Objectives

Each fellow rotates into the outpatient rotation with assigned nephrology faculty member for a total of 2 years. Each continuity clinic block of time is at least six consecutive months in duration. Fellows evaluate new nephrology consult referrals and follow patients continuously for the entire block. In addition to general nephrology clinics, they also rotate in the transplant clinic while on the inpatient transplant rotation (2 month blocks during 2nd year of fellowship evaluating pre/post transplant patients and donors), and for 6 months while a first year fellow and based at the Montefiore Hospital-Moses division. All of the clinics have a Montefiore faculty mentor assigned for supervision. In the clinics, fellows are expected to make initial evaluations and present the history, physical findings, assessment and plans to the nephrology faculty member. The fellow is expected to help teach and supervise medical residents and medical students who rotate into the clinics.

 

Educational Goals:

The outpatient rotation builds the foundations for a broad knowledge base in outpatient nephrology, by providing fellows exposure and opportunities to patients with a vast array of general nephrology problems, patients with complex forms of hypertension, and transplant patients (both evaluation before and after renal transplant).

  1. The fellow is expected to develop competency in providing compassionate and complete care to a medically and socially diverse group of outpatient general nephrology patients and transplant patients.
  2. Fellows serve as leaders in the clinic and have opportunities to develop teaching, leadership, and management skills with residents and students.
  3. The purpose of this rotation is to provide the fellows with the education and expertise necessary to become proficient in outpatient nephrology. As part of outpatient training they interact and learn about radiology, vascular surgery and pathology issues in patients from these services. Also, this rotation will provide the fellows with the education and expertise necessary to become proficient in outpatient care of general nephrology, hypertension and renal pathology.
 

Objectives:

Patient Care 

Each fellow will rate as valuable the importance of being a nephrologist to a medically and socially diverse group general nephrology patients with various renal disorders

Each fellow will be able to obtain and document a complete history and physical, formulate a thorough assessment and plan, and when appropriate, communicate this assessment to the other care providers (colleagues, nursing staff, dieticians)

Each fellow will demonstrate the ability to make daily assessments of their general nephrology patients. They will also demonstrate the ability to convey that information to the entire health care team through a variety of methods, including daily written progress notes

Specific educational goals are to provide clinical expertise and opportunities to gain experience in:

  1. General outpatient nephrology; and approach to their care (differential diagnosis, radiologic assessment, and treatment);
  2. Outpatient nephrology with its associated co-morbid conditions such as anemia, malnutrition/acidosis, hypertension/hypotension, and renal osteodystrophy and its approach (radiologic assessment, and treatment);
  3. Principles and practice of care for CKD and its complications;
  4. Recognition of short and long-term complications of AKI, CKD and other diseases;
  5. Fluid electrolyte and acid-base abnormalities in ESRD patients and their approach (differential diagnosis and treatment);
  6. Hypertensive and hypotensive disorders in patients;
  7. CKD and its effect on gender issues, including pregnancy;
  8. Dermatologic, rheumatologic and gastrointestinal disorders unique to ESRD patients;
  9. Cardiovascular and cerebrovascular disease in AKI and CKD patients;
  10. Diagnosis and management of anemia, including iron deficiency, EPO resistant states, and appropriate use of intravenous iron and erythropoietin stimulating agents in AKI and CKD patients;
  11. Diagnosis and management of renal osteodystrophy, including secondary hyperparathyroidism, adynamic bone disease, mixed bone disease, and low bone turnover (including interpretation of bone biopsy and other tests such as intact PTH);
  12. Acquired cystic kidney disease and its complications in CKD patients.
 

Medical Knowledge

The fellow will demonstrate a knowledge and understanding of the pathophysiology, diagnostic evaluation, and therapeutic management of a core group of patients with general nephrology as described above.

By the end of the outpatient rotation, each fellow will have attended and participated in the educational activities listed in the teaching methods section.

By the end of the outpatient rotation, each fellow is encouraged to complete some of the recommended readings (see below)

Each fellow will take the In-Training Exam, which will include questions that will cover many of the general nephrology issues covered during the rotation

 

Communication Skills

Each fellow will demonstrate effective communication skills with the attending physician by discussing the evaluation of general nephrology patients in a timely fashion

Each fellow will discuss the ongoing care of each general nephrology patient with the appropriate attending on a daily basis

Each fellow will demonstrate effective teaching and feedback skills with interns, residents and medical students as they relate to the care of general nephrology patients

Each fellow will model effective interpersonal communication skills with patients, families, and allied health professionals, an integral aspect of general nephrology outpatient care that must be learned by all practicing nephrologists

 

Professionalism

Each fellow will demonstrate compassion and understanding to a group of socially, economically and racially diverse group of general nephrology patients

Each fellow will rate as comfortable his/her ability to assume the leadership role on the healthcare team, including medical residents, medical students, nurses, and social workers

Each fellow will model appropriate team function by including allied health professionals in management discussions, particularly at the point of hospital admission, which is critical for patients who need to be safely admitted from the clinic to the hospital

 

Practice-Based Learning and Improvement

The fellow will incorporate basic knowledge of evidence-based medicine in evaluation and management of general nephrology patients with multiple medical problems

Each fellow will utilize training in the care of anemia, renal osteodystrophy, hypertension, and cardiovascular disease in patients with CKD

Each fellow will model practice based learning and effective information seeking in the daily care of general nephrology patients

 

Systems-Based Practice

The fellow will demonstrate competence in the integration of outpatient care, and a systems approach to care, by demonstrating appropriate follow-up plans for all general nephrology patients he/she has evaluated

The fellow communicates key general nephrology patient information upon admission to the accepting hospital physician (including change in dialysis prescription, new medications, etc)

The fellow will demonstrate an awareness of issues cost-effective medicine in general nephrology patient care, by discussing the cost implications of a case/month with the attending physician

Each fellow will rate as valuable the contributions of other members of the health care team into management plans for general nephrology patients

Each fellow will routinely evaluate the socioeconomic needs of his/her general nephrology patients, including health insurance and access to care necessary to provide care

By the end of outpatient rotation, each fellow will have assumed care for general nephrology patients of colleagues who transferred care of his/her own patients from the hospital to the outpatient clinic

 

Educational Methods and Teaching Tools

Teaching methods include direct patient contact with the nephrology faculty member. All general nephrology patient issues are reviewed with the faculty member, and findings are confirmed by the faculty member. In addition, radiological studies obtained are reviewed and if needed direct consultation is obtained from radiology faculty member (renal ultrasound, CT scan and MRI/MRA of kidneys, nuclear medicine scans. There are didactic sessions pertaining to the specific educational goals in the Core curriculum series (see the list below).The nephrology faculty member may give didactic sessions to members of the outpatient clinic fellow. Suggested reading may include papers distributed at the start of fellowship covering key general nephrology and CKD topics, and papers supplied by the nephrology faculty member during the outpatient rotation. There is access to PUBMED, Cochrane, AECOM library on-line and Up-To-Date as well as other electronic medical literature databases in the fellows’ office and at all computer stations in the clinics.

 

Types of Diseases:

Diseases encountered on this rotation include general nephrology from multiple causes (diabetes, hypertension, chronic glomerulonephritis, chronic tubulointerstitial disease, genetic kidney diseases [polycystic kidney disease and others], HIVAN, SLE) as well as other multiple other diseases. Co-morbidities of CKD are encountered including anemia, iron deficiency, cardiovascular diseases, renal osteodystrophy, hypertension/hypotension, dermatologic disorders (NSF, CUA, uremic pruritis, etc), rheumatologic disorders (B2-microglobulin amyloidosis, gout, chondrocalcinosis, OA, etc), infectious complications (bacteremia/endovascular, joint, bone), peripheral vascular disease, uremic pericarditis/pleuritis.

 

Clinical Encounters:

Patients are seen in the Montefiore clinics in the CFCC (Einstein division) and MAP building (Moses division).

 

Patients' Characteristics:

Patients followed are those admitted Montefiore Medical Center outpatient clinics and the Renal Transplant Clinic. These patients may include:

  1. General nephrology patients in the outpatient clinics previously noted.
  2. General nephrology patients with electrolyte, acid base and divalent disorders.
  3. General nephrology patients with the anemia, renal osteodystrophy, and other co-morbidities
  4. Hypertensive general nephrology patients (including hypertensive emergency/urgency) and other disorders.
  5. Out-patient transplant patients for follow-up and evaluation.

The number of patients seen in general nephrology clinic average 8-10 patients per clinic (2 new patients). For Transplant Clinic each fellow is afforded the opportunity to follow at least 20 patients longitudinally over the 6-8 months that they attend clinic. Many patients over the age of 70 are included in this rotation and fellows experience aspects of geriatric nephrology.

 

Services:

Fellows on this rotation will be asked to take care of patients by providing an outstanding standard of care as stated by the six core clinical competencies. Procedures involved are for patient care purposes. Fellows may facilitate care by phone calls for scheduling purposes; however, other health care professionals will perform the most of these calls.

 

Procedures:

Procedures may include performance of urinalysis and urine microscopy as well as interpretation of various laboratory, pathologic, and radiologic studies. Proper use and interpretation of renal ultrasound, CT scan and MRI/MRA evaluation of patients are taught to the fellows. Fellows are taught the appropriate out-patient work up in specific settings. The nephrology faculty member evaluates the procedures performed by the fellow.

 

Goals and Objectives

(reviewed with fellow at beginning of each rotation)

  1. Learn the skills of a renal consultant including the following:
    1. Patient assessment in the outpatient clinic setting
    2. Case presentation to the attending
    3. Write consultative reports with conclusions and recommendations; forward written reports to referring doctors as indicated.
    4. Communicate recommendations/care-plan with referring physicians, nurses, and social workers
    5. Follow the patient longitudinally with ongoing progress notations and communications in subsequent continuity clinic visits
     
  2. Develop an appropriate knowledge base in the following areas:
    1. Diagnosis, evaluation and treatment of renal parenchymal disease including diabetic nephropathy, tubulointerstitial diseases, glomerular diseases, genetic renal diseases
    2. Evaluation, diagnosis and treatment of acid-base disturbances including anion gap and non-anion gap acidoses
    3. Evaluation, diagnosis and treatment of electrolyte disorders
    4. Evaluation, diagnosis and treatment of hematuria and proteinuria
    5. Evaluation, diagnosis and treatment of divalent disorders including hypo- and hypercalcemia, hypo- and hyperphosphatemia, hypo- and hypermagnesemia
    6. Evaluation, diagnosis and treatment of disorders of water metabolism including hypo- and hypernatremia
    7. Evaluation, diagnosis and treatment of acute kidney injury including causes of pre-renal, intra-renal and post-renal renal dysfunction
    8. Evaluation, diagnosis and treatment of cystic diseases of the kidney
    9. Evaluation, diagnosis and treatment of chronic kidney disease including the complications associated with this disorder (progression of kidney disease, anemia, renal osteodystrophy, acidosis, malnutrition) and preparation for renal replacement therapy (vascular access, peritoneal dialysis catheter)
    10. Evaluation, diagnosis and treatment of hypertension including evaluation and management of primary and secondary forms of hypertension
    11. Evaluation, diagnosis and treatment of urologic issues including obstructive uropathy, renal masses, and renal malignancy
    12. Evaluation, diagnosis and treatment of mineral metabolism disorders
    13. Evaluation, diagnosis and treatment of nephrolithiasis
    14. Evaluation, diagnosis and treatment of glomerulonephritis and nephritic/nephrotic syndrome including renal histopathology
    15. Ordering and evaluation of diagnostic imaging modalities employed in consultative nephrology including ultrasound, nuclear medicine imaging, CT scan and MRA of the kidney; and renal angiography in the evaluation of renal artery Stenosis
     

Division Chief

Michael RossMichael Ross, MD 

Chief, Division of Nephrology
Albert Einstein College of Medicine
Montefiore Medical Center
1300 Morris Park Avenue

Ullmann 615-C
Bronx, New York 10461
Telephone: 718-430-8768
Email: michael.ross@einsteinmed.org 


 

 

For Patient Appointments Call:

Nephrology Patient Referral Line
1.866.633.8255

 
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