The ultimate judges of a fellow's competence are the Renal Faculty, employing prospective criteria from the ABIM as guidelines. Competence is assessed in clinical and cognitive skills, problem-solving ability, knowledge base and its application, patient-care attributes, exhibition of humanistic, ethical, and moral qualities, and in technical-procedural skills. These evaluations are used for constructive and instructive purposes, but also serve as passages for Board Eligibility.
General competencies endorsed by the ACGME, which will ultimately be developed into nephrology specific competencies, are noted below: Fellows will be required to develop competency in these 6 areas to the level of a new practitioner to meet nephrology board eligibility. The six competencies are:
- Patient Care
Fellows must demonstrate compassionate, appropriate and effective care of patients with kidney disease and other nephrologic issues. This population has both complex medical diseases as well as complicated social issues that require this type of patient care practice.
Nephrology faculty observe fellows as they deliver patient care both in the hospital and in the outpatient clinic. The fellows also work closely with our renal social workers; their feedback is sought in monitoring how fellows provide care to this group of patients. Faculty provide verbal assessment of this aspect of fellow training at faculty meetings and on the nephrology rotation evaluation form. The Program Director summarizes the evaluations and documents them in each fellow’s evaluation. These aspects of training are also discussed with each fellow at the 6 month meetings with the Program Director.
- Medical Knowledge
Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences associated with nephrology. Also, the application of this knowledge to the care of patients with kidney disease and other nephrologic issues, must be demonstrated by fellows.
Nephrology Fellows develop knowledge in the various area of nephrology through didactic lectures, bedside teaching rounds, and hands on patient care. Medical knowledge is assessed by the faculty attending on the service that the fellow is rotating through. The fellow’s knowledge in general nephrology, transplant nephrology and ESRD-based nephrology is discussed at faculty meetings and documented in the evaluation form filled out by faculty attending on the various services. Periodic written exams (NephSap) and weekly questions are given to the fellows to assess their medical knowledge in nephrology. Minimum standards are set which the fellow must acheieve on these exams. The Program Director summarizes the faculty discussion and reviews the evaluation forms to assess fellow medical knowledge. This is documented in the 6 month evaluations with the fellows and discussed with them.
- Practice-Based Learning and Improvement
Fellows must demonstrate the ability to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their patient care practices. This is essential in the care of patients with kidney disease and end stage renal disease as well as patients with other nephrologic issues.
Nephrology fellows develop practice-based skills through instruction on various disease-specific diagnoses in patients with chronic kidney disease (CKD) and end stage renal disease (ESRD). As an example, anemia management is an important aspect of care in these patients. Fellows receive didactic lectures on etiology of anemia in CKD/ESRD, treatment options for correction of anemia, and the acute and chronic management of the anemia in these patients. Also, fellows present cases at a weekly clinical case seminar where patient assessment and outcomes are discussed with co-fellows and faculty. These skills are assessed and documented in each fellow’s evaluation. This is discussed with each fellow with the Program Director.
- Interpersonal and Communication Skills
Fellows must demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates. This is a particularly important area in the provision of care for patients with complex diseases such as patients with kidney disease and end stage renal disease on renal replacement therapy (hemodialysis, peritoneal dialysis) or patients who have received a renal transplant.
Nephrology fellows’ interpersonal and communication skills are assessed by our acute hemodialysis nurses in the hospital dialysis unit. The fellows and nurses work closely in the care of patients who require both acute and chronic hemodialysis treatments while hospitalized in the Montefiore Hospitals. Also, fellows work closely with our kidney disease dedicated social workers. Their feedback is also sought in monitoring fellow interpersonal and communication skills. This allows a programmatic assessment of fellows by nurses/social worker and vise versa. The program director obtains verbal feedback from both nurses and fellows and documents this in the fellows’ evaluations.
Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse population. Patients with kidney disease require such practice standards as they are often highly dependent on society for much of their care.
Nephrology fellows are educated about these issues in our patient care conferences. Feedback from dialysis staff and social work, as well as faculty observation of fellows as they interact with patients and coworkers. This is documented in their evaluations and discussed with each fellow.
- System-Based Practice
Fellows 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 optimal value. Patients with kidney disease consume huge amounts of resources as a result of their complex disease state. It is imperative that fellows gain competence in this aspect of nephrology training to allow optimal patient care utilizing resources in a judicious fashion.
Nephrology Fellows practice system-based medicine during their nephrology training. Fellows optimally utilize hospital resources and facilitate efficient and safe discharge of ESRD patients from the Montefiore Hospitals. They utilize a variety of discharge specific forms and computer based information, with specific ESRD discharge information/communication form, and verbal contact to facilitate more prompt yet safe hospital discharge for ESRD patients as they transition back to the hemodialysis and peritoneal dialysis units.
If recurrent deficiencies in a trainee's clinical performance are noted, remedial teaching and consultation exercises with patients under the direct supervision of an attending Nephrologist may be required. This will be subject to the judgment of the Program Director, the Faculty, and the Section Chief.
Candidates for the Nephrology sub-specialty board examination should note the following policies of the American Board of Internal Medicine, which the Section Chief and Program Director must observe:
- A candidate with an unsatisfactory or low satisfactory demonstration of humanistic qualities and/or ethical behavior will not be admitted to examination until it has been demonstrated to the Board's satisfaction that the candidate meets the Board's standards in these areas.
- A candidate judged to have unsatisfactory or low satisfactory clinical competence at the end of twelve months of sub-specialty training will be required to take an additional six to twelve months of acceptable clinical training in that sub-specialty before admission to examination. In this context, it is the responsibility of the Program Director and Faculty to provide the necessary remedial training.
- The Board requires a trainee who changes programs to inform the new Program Director of any previous unsatisfactory ratings. Candidates who neglect to inform a new Program Director of unsatisfactory ratings or who do not complete the required additional training in the sub-specialty will not be admitted to the examination.
- Candidates whose clinical competence have improved and are judged by the Program Director to be satisfactory after the additional training will be admitted to the examination.