Competency Based Curriculum

Program: Internal Medicine

Program Director: Mohamed Siddique, MD, FACP

Specialty/Course: Nephrology Rotation PGY2/3

Curriculum Coordinators: 1. Irfan Omar, MD

2. Marc Feldman, MD, FACP

Administrative Support: Carol Maurizio

Carla Marshall

Revised: February 1, 2009

Competency	Objectives Specific	Educational Experiences Knowledge/ Skills Integration/Application	Assessment Tools
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health	To experience first hand the spectrum of disorders commonly seen in an nephrology service and learn how to evaluate, workup and treat such conditions under the supervision of board certified nephrologists .Also the care of out patients with chronic kidney disease.	1) In-patient nephrology consultative service. 2) General medical continuity clinic. 3) Ambulatory office based nephrology practice.	1) Mid and end of rotation evaluation by supervising attending. 2) Performance in monthly and annual in-training examinations. 3) Continuity clinic evaluations
Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to care for patients with kidney diseases.	To learn the pathophysiology, epidemiology, clinical presentation, laboratory and radiographic evaluation and management of important disorders related to renal function, fluid electrolyte balance and blood pressure homeostasis. Learn and practice important measures directed at preventing renal disease such as management of hypertension, diabetes and delaying the progression of established renal disease.	Topic based didactic lectures and case based discussions encountered on consultative rounds and office based practice to include the following disorders. 1) Disorders of mineral metabolism, including nephrolithiasis and renal osteodystrophy 2) Disorders of fluid, electrolyte, and acid-base regulation 3) Acute renal failure 4) Chronic renal failure and its management by conservative methods, including nutritional management of uremia 5) End-stage renal disease 6) Renal vascular hypertension 7) Renal disorders of pregnancy 8) Urinary tract infections 9) Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders 10) Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, and atheroembolic renal disease 11) Disorders of drug metabolism and renal drug toxicity 12) Genetic and inherited renal disorders 13) Geriatric aspects of nephrology, including disorders of the aging kidney and urinary tract	1) Evaluation by rounder of residents knowledge. 2) Performance at monthly and annual in-training examinations.
Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals	To observe and develop required communication skills needed to evaluate patients with renal disease, to discuss concerns related to renal replacement therapies with patients, and the importance of compliance with treatment and to educate patients on diet, nutrition and complications associated with renal disease with particular emphasis on end stage renal disease. To interact with multi-disciplinary team members involved in the management of patient with renal disease including patients on renal replacement therapies.	1) To observe and learn how to communicate the evaluation and management of patients with renal disease during rounds with attending physicians and multi-disciplinary team members. 2) To interact and communicate with health care personnel involved in the care of patients with renal disease including the following: a) Radiology: ultrasound and computerized tomography. b) Pathology about electron microscopy for renal biopsy material, diagnostic radionuclide studies, biochemistry and serologic testing. c) Nutrition support services d) Social services. e) Surgery including vascular surgery and urology. f) Infectious disease specialists.	Attendings and consultant physician evaluate the trainees interpersonal and communication skills and effectiveness of providing care based on direct observation during rounds, reviewing standard and quality of care and feedback provided by patients and ancillary staff.
Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population	To educate residents on the complex professional and ethical principles of care involved in the care of patients with renal disease. To promote excellence in care through self directed motivation to provide the best care for patients under the care of the trainee. To develop an understanding of the concerns of patients developing end-stage renal disease and communicate available treatment options related to renal replacement therapies.	1) Incorporate discussion on ethical principles, standards of care and professional conduct as pertinent to the care of patients with renal disease. 2) To promote the highest standards of professional care though complete and through assessment of patient, thoughtful and complete workup, and compassionate and caring approach to patients with renal disease. 3) Residents receive training in medical ethics and professionalism in the form a dedicated set of conferences delivered at noon time and during the multidisciplinary medicine course.	Evaluate resident performance by direct observation and supervision during rounds and feedback from patients and ancillary staff.
Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care	The resident will be capable of self directed learning to keep up with new developments in the management of renal disease and changes in practice guidelines. The resident will be able to perform a literature search to identify important publications on renal disorders. The resident has the knowledge of important guidelines and resources available on the internet such as practice guideline, knowledge databases and clinical tools. Residents are encouraged to write up interesting cases that they see on rounds for presentation as case reports as regional and national professional meetings. Residents may participate in a dedicated two month research elective if they are in good academic standing from the standpoint of clinical training.	1) Trainees receive specific instruction on clinical epidemiology, statistics and evidence based medicine during the multi-disciplinary medicine rotation. 2) Residents are required to review a selected topic using principals of evidence based medicine and develop a critically appraised review. 3) PGY2 and 3 residents present a topic review at noon conference as part of the resident grand rounds conference series including topics in nephrology. 4) Residents present a review and critique of an article relevant to internal medicine practice including nephrology as part of the journal club conference series.	1) Evaluation during rounds and case discussion of residents performance in self directed learning and capabilities of doing literature searches and critically reviewing selected publications using evidence based medicine concepts. 2) Presentations at regional and national meeting on case reports and research presentations developed during training. 3) At least 3 faculty members would review the resident presentations at resident grand rounds and journal club.
Systems-Based Practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value	Understand, access and utilize the resources, providers and systems necessary to provide optimal care for patients with renal disease with special emphasis for reimbursement and coverage of renal replacement therapies. To develop and awareness of currently accepted criteria for admission of patients with renal disease, coverage for treatments such as erythropoietin and renal transplantation. To develop skills and knowledge necessary to interact with social workers, case managers and utilization review specialist to optimize care for the individual patient	1) Incorporate discussion on systems based practice related to admission criteria, reimbursement for services and referral to community and state sponsored resources for patients with renal disease. 2) Provide an opportunity for trainees to interact with a multidisciplinary team of professionals experienced in providing care for patients with renal disease. 3) Trainees are required to participate in a dedicated series of conferences and seminars delivered throughout the year related to managed care, reimbursement and practice management.	1) Evaluate resident knowledge on resources available to provide care for patients with renal disease. 2) Observe and evaluate resident performance in resource management, interaction with multidisciplinary team members and facilitating appropriate inpatient and ambulatory care of patients with renal disease with particular emphasis on patients with renal replacement therapies.

Specific educational experience expected during nephrology rotation:

1) Acute renal failure and its management including:

a) Diagnosis of etiology of acute renal failure

b) Fluid and electrolyte management

c) Monitoring for complications

d) Indications for emergency renal replacement therapy

2) Chronic renal failure and its management including:

a) Diet

b) Blood pressure control goals and therapy

c) Calcium and phosphorus metabolism

d) Anemia management

e) Metabolic acidosis management

3) Disorders of mineral metabolism, including nephrolithiasis and renal osteodystrophy

4) Disorders of fluid, electrolyte, and acid-base regulation

5) Hypertensive disorders

6) Renal disorders of pregnancy

7) Urinary tract infections

8) Tubulointerstitial renal diseases including:

a) Inherited diseases of transport mechanisms

b) Cystic diseases

c) Other congenital disorders

9) Glomerular and vascular diseases including:

a) The Glomerulonephritides

b) Diabetic nephropathy

c) Atheroembolic renal disease

10) Disorders of drug metabolism and renal drug toxicity

11) Vasculitis and pulmonary renal syndromes

12) Genetic and inherited renal disorders

13) Geriatric aspects of nephrology, including disorders of the aging kidney and urinary tract

14) Indications and complications of renal biopsy

15) End-stage renal disease and Renal Replacement therapies

a) Chronic hemodialysis

b) Chronic ambulatory hemodialyis

c) Renal transplantation

16) Management of toxic ingestions treated with hemodialysis
Resource Materials

Recommended Textbooks:

Harrison’s Textbook of Medicine: Section 2, Part 10: Disorders Of The Kidney And Urinary Tract

Comprehensive Clinical Nephrology: J., Md Johnson, John Feehally

Manual of Nephrology: Robert W. Schrier

Clinical Physiology of Acid-Base and Electrolyte Disorders: Burton David Rose, et al

Relevant Practice Guidelines: Available at www.guidelines.gov

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Management of chronic kidney disease and pre-ESRD in the primary care setting. Veterans Health Administration/Department of Veterans Affairs/Department of Defense. 2000 November . Various pagings.

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K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. National Kidney Foundation. 2002 Feb. 246 pages.

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Clinical practice guidelines for nutrition in chronic renal failure. National Kidney Foundation. 2000 Jun. 121 pages.

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Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. Renal Physicians Association/American Society of Nephrology. 2000 Jan. 124 pages.

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Benefits and risks of controlling blood glucose levels in patients with type 2 diabetes mellitus. American Academy of Family Physicians/American Diabetes Association. 1999 Apr. 39 pages.

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Congestive heart failure in adults. Institute for Clinical Systems Improvement. 1997 Oct (revised 2002 Jan). 71 pages.

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Primary care guidelines for the management of core aspects of diabetes care. New Zealand Guidelines Group. 2000 Jun. 19 pages.

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NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. National Kidney Foundation. 1997 (updated 2000). 58 pages.

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NKF-K/DOQI clinical practice guidelines for peritoneal dialysis adequacy: update 2000. National Kidney Foundation. 1997 (updated 2000). 72 pages.

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NKF-K/DOQI clinical practice guidelines for vascular access: update 2000. National Kidney Foundation. 1997 (updated 2000). 45 pages.

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NKF-K/DOQI clinical practice guidelines for anemia of chronic kidney disease: update 2000. National Kidney Foundation. 1997 (updated 2000). 67 pages.

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Hypertension in older people. A national clinical guideline. Scottish Intercollegiate Guidelines Network. 2001 Jan. 49 pages.

Electronic/Web Based Resources:

National Kidney Foundation: www.kidney.org

PIER clinical guidelines from American College of Physicians: pier.acponline.org

American Society of Nephrology: www.asn-online.org

Hypertension, Dialysis & Clinical Nephrology: www.hdcn.com

Key Articles: Please see nephrology manual available at department of medicine.