PARKLAND MEMORIAL HOSPITAL (PMH) and ZALE LIPSHY UNIVERSITY (ZLU) HOSPITAL RENAL CONSULT ROTATION

Service:

The consult service includes the attending, fellow, 1-2 medical residents, and 1-2 medical students.  The fellow will assign consults to the other members of the team.  The consult fellow will oversee all patients on the service, including those being followed by medicine residents and medical students.  The types of consults include evaluation of acute and chronic kidney disease, glomerular diseases and all types of fluid and electrolyte disorders.  The trainee becomes skilled in the technique of renal biopsy.  If a patient requires dialysis during hospital follow up the consult fellow will continue to manage the patient while receiving renal replacement therapy thus allowing for continuity of care.

Responsibilities:

The clinical fellow typically is assigned to this rotation 4-5 months during the 2 years of clinical training.  The Nephrology consult fellow is responsible for the initial evaluation and subsequent management of all hospitalized patients referred for consultation.  The fellow will perform a history, physical examination, and review the relevant laboratory studies in each case consulted upon.  The fellow will present the patient to an attending physician and, under their supervision, will formulate a diagnostic and treatment plan.  The consult fellow is not responsible for admitting or discharging the patients, all patients are admitted to another service (medical or surgical) and the renal fellow acts in a consultant capacity only.

Expectations:

A.    During this rotation the fellow should become familiar and develop and understanding of the following disease processes.  In addition the fellow will be expected to learn the appropriate treatment and approach to these disorders.  These issues will be accomplished from attending required teaching conferences, daily attending rounds, renal clinic, and evaluating patients as a consultant.

•         Primary and secondary glomerular disease

•         Diabetic nephropathy

•         Tubulointerstitial renal disease

•         Fluid and electrolyte disorders

•         Acid-Base disorders to include metabolic and respiratory

•         Management of hypertension

•         Approach to patients with acute renal failure including those in the ICU

•         Management of the patient with chronic renal failure

•         Urinary tract infections

•         Disorders of Divalent Cation and mineral metabolism

•         Renal Disease in Pregnancy

•         Tools used to assess renal function

•         Pharmacology of drugs in renal disease

B.     The fellow will become familiar with the indications for percutaneous renal biopsy.  The fellow will become skilled in this procedure and be familiar with the risks and complications of the procedure.

C.     In addition to the Parkland Dialysis rotation, the Parkland Consult fellow will also be involved in dialysis therapy.  The fellow will be expected to assess patients and determine when dialytic therapy needs to be initiated and which modality is appropriate.  The fellow will be expected to become familiar with all aspects of continuous forms of renal replacement therapy as implemented in an ICU situation.

D.    The fellow will coordinate the distribution of all new consults to the rotating students and fellows and will be familiar with all patients on the service.

E.     The fellow will be expected to provide guidance and teaching to the students and residents who rotate on the consult rotation.

F.      The fellow will often be contacted by outside clinics regarding scheduling patients in the renal clinic.  The fellow will assign dates for such referrals and make recommendations for initial workup prior to the patients arriving to the clinic.

General Competencies:

During this rotation, trainees are expected to acquire and master the following core competencies:

A.    Patient Care:

Fellows should be able to:

•         Approach new patients and their families with respect and clearly communicate the reasons for the visit and any recommendations resulting from the consultation. 

•         Demonstrate compassion and deliver appropriate and effective care with the goal of promoting health and general well being for the patients.

•         Perform a history and physical examination and review of clinical data relevant to consultation in nephrology.

•         Learn the indications for and interpretation of diagnostic tests used in nephrology including: ultrasound, urinalysis, serum chemistries, blood gas analysis and renal biopsy.

•         Make decisions regarding diagnosis and treatment plans, including modality of dialysis and renal biopsy, based on review of current literature, consultation with attending physicians and counseling of the patient.

•         Counsel and educate patients and their families regarding their options, specifically when choosing a modality for the treatment of end stage renal disease using interactive patient education material.

•         Implement treatment plans, such as initiating acute or chronic dialysis

•         Gain proficiency in procedures including: urinalysis, renal biopsy, placement of vascular access for hemodialysis, prescriptions for acute dialysis and continuous renal replacement therapy, prescriptions for peritoneal dialysis in the ICU and in inpatients.

•         Work with other members of the health care team, including referring physicians from other specialties, nurses, social workers and technicians to implement a treatment plan.

B.     Medical Knowledge:

•         By demonstrating knowledge in established and evolving biomedical, clinical, epidemiological and social-behavioral sciences (as listed above).

•         By demonstrating the ability of applying this knowledge to patient care and understanding complex mechanisms of diseases.

•         By being highly resourceful in developing knowledge.

C.     Practice-Based Learning:

During this rotation, fellows are expected to:

•         Analyze clinical experience and identify and review errors in management.

•         Participate in case management conferences and apply knowledge from these conferences to patient care.

•         Use information technology to obtain and manage medical information relating to the problems seen on the consultation service.

•         Apply information from large studies to improve care of patients, recognizing limitations of study design statistical methods.

•         Use knowledge obtained from the literature and experience to teach colleagues, house staff and students.

Examples of practice-based evaluations that can be performed during this rotation include, but are not limited to:

a.       The use of erythropoietin in hospitalized dialysis patients.

b.      The appropriateness of performing dialysis during late hours.

c.       The proper antibiotic dose adjustments in ESRD patients.

d.      The proper communication with out patient dialysis facilities upon patients discharge.

D.    Communication and Interpersonal Skills:

During this rotation, fellows are expected to develop and demonstrate the following skills:

•         Establish rapport with patients from different backgrounds.

•         Provide appropriate counseling to patients and their families regarding their therapeutic options.

•         Communicate effectively with supervising attending physicians; gain responsibility as experience grows.

•         Interact with physicians on other services while providing consultation, teaching and care and communicate recommendations clearly and effectively.

•         Interact with the staff of the dialysis unit, including nurses, technicians and other support staff to coordinate dialysis and to handle emergencies.

•         Provide teaching to fellows and medical students.

E.     Professionalism:

Fellows are expected to:

•         Demonstrate a commitment to carrying out professional responsibilities.

•         Adhere to ethical principles.

•         Exhibit sensitivity to diverse patient population.

•         Demonstrate respect, compassion, integrity and honesty.

•         Consistently exhibit role model and responsible behavior.

•         Willingly acknowledge errors.

•         Consistently considering the needs of their patients, families and colleagues.

•         Provide support and advice to more junior fellows and house staff.

F.      Systems-Based Practice:

During this rotation, fellows are expected to:

•         Understand the resources and limitations of the dialysis unit.

•         Understand the cost-effectiveness of different modalities of dialysis for acute renal failure (CRRT vs. IHD vs. PD).

•         Understand the role of Medicare in the provision of dialysis services.

•         Understand the resources available for the treatment of uninsured patients and the limitations in their care.

•         Understand the issues involved in the placement of patients in facilities for chronic dialysis and assist in appropriate placement decisions.

•         Assist in developing systems improvement.

Updated November 21, 2007                                                  Created by Megan Johnson