UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF MEDICINE
DIVISION OF NEPHROLOGY AND HYPERTENSION
GOALS AND OBJECTIVES
JAMES A. HALEY – USF DIALYSIS AND
MOFFITT CANCER CENTER ROTATION
Dr. ______
Date: ______
Dear Dr. ______:
Included are the specific Goals and Objectives for your new rotation. Please save this electronic document on your computer’s hard drive or on a diskette, as it contains important http-links you will need to access periodically during this rotation. To access any http link provided below (in blue characters and underlined), using your mouse, drag your cursor over the link and press the CTRL key and click to follow the link. As you will realize by reviewing this document, it is clearly impossible to master dialysis after only one month rotation on a dialysis service. We have outlined a progressive approach that spans over your two years of fellowship. You will acquire the required knowledge and skills in chronic dialysis at this and other sites during your fellowship. You are encouraged to use this electronic document extensively over the next two tears, and use it as a learning tool. The best way to familiarize yourself with chronic dialysis, is to frequently “surf” the websites provided in the links below.
INTRODUCTION:
To reach proficiency in the practice of nephrology, the trainee needs to develop the proper attitudes, master the required skills, and acquire a spectrum of knowledge spanning physiology, pathology, epidemiology, anatomy, internal medicine, immunology, health sciences, and other sciences. Proficiency in Chronic Dialysis is the cornerstone of the subspecialty of nephrology. The practicing nephrologist has been granted the unique privilege, and authority to prescribe life-sustaining chronic dialysis therapy for his/her patients with chronic kidney disease (CKD). Precisely because of their chronic condition, patients with CKD, and their families, will inevitably regard you as their principal physician. Therefore, your input cannot be restricted to that of a specialist who merely gives his/her advice in one facet of their long-term care. Rather, you will take long term responsibilities that go far beyond merely prescribing their dialysis therapy. You must therefore acquire the skills, attitudes, and knowledge that will allow you to function as a patient’s advocate in all aspects of their care, including their medical, socio-economical, psychological, and cultural needs. The goal of this rotation is to prepare you for this life-long commitment.
NOTE: Before you are allowed on this dialysis rotation, you must provide the James A Haley VAMC office off nephrology with a copy of the certificate attesting that you have taken the mandatory training course detailing the Veterans Health Administration (VHA ) Privacy Policy. This VHA certificate can be obtained at the following VHA Training Web Site: http://www.vhaprivacytraining.net/frame.htm.
THE PARTICIPATING INSTITUTIONS AND TEACHING FACULTY:
During this rotation you will cover the James A Haley- and USF Dialysis Units, and The Moffitt Cancer Center. You will mainly be centrally located at the James A Haley VAMC. Division of Nephrology and the Tampa VA Dialysis Unit are located on the 7th floor of this Participating Institution (PI). The nephrology trainees on this rotation have access to a day-room (Room 7A-725) next to Nephrology Office. Teaching material (textbooks, tapes, CD-ROM) is available in this room. You will be given a key to this room at the beginning of your rotation. The dialysis head-nurse will give you a tour of the Dialysis Unit the first time you start this rotation. Directions to the USF dialysis unit and the Moffitt Cancer Center will also be provided by USF faculty and/or yo0ur colleagues.
The USF-approved Teaching Faculty and other teaching personnel for this rotation include:
James A. Haley VAMC:
· Dr. A. Peguero, Chief Section of Nephrology at the James A. Haley VAMC
· Second USF-approved Staff Nephrologist: Dr. A. Hung.
· Third USF-approved Staff Nephrologist: Dr. Craig Courville.
· Other USF-approved Nephrologists with staff privileges at the James A. Haley VAMC include Drs. Ramon Lopez, Nash Purohit, and Jacques Durr.
· Other dialysis personnel participating in your educational experience in hemo- and peritoneal dialysis include a dialysis dietician, a social worker, and the dialysis nurses and technicians.
· Other, non-dialysis James A. Haley personnel contributing in your educational experience in dialysis-related fields include, among others, the radiologists, an interventional radiologist, the vascular surgeons, the urologists, infection disease specialists, and the department of pathology.
USF Dialysis Center:
· Dr. Ramon Lopez, Medical Director, USF Dialysis Unit.
· Second USF Dialysis Nephrologist, Dr. Christopher McFarren
· Additional USF nephrologists: Drs. Nash Purohit and Jacques Durr.
Moffitt Cancer Center:
There is on permanence one of the following USF nephrologists on call for this Participating Institution:
· Dr. Jacques Durr
· Dr. Ramon Lopez
· Dr. Christopher McFarren
· Dr. Nash Purohit
THE SCOPE OF YOUR TRAINING:
The scope of your training should include:
· The six General Competencies, as they relate specifically to the practice of nephrology/dialysis.
· The Specific Program Requirements for Nephrology, as requested by ACGME, including, where applicable, the General Program Requirements for internal medicine.
A. THE SIX GENERAL COMPETENCIES:
We have elected to adopt the six competencies proposed by ACGME (see below) to assess whether our trainees have reached the training level expected of a new practitioner in nephrology:
a. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
b. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
c. 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
d. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
e. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
f. Systems-Based Practice, as manifested by actions that 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 of optimal value
For more information on the General Competencies, please go to the ACGME Web-site at: http://www.acgme.org/outcome/comp/compHome.asp.
Please take some time during this rotation to periodically review these competencies, as you will have to learn how they pertain to your goal of becoming an independent and proficient practicing nephrologist.
B. THE GOALS AND OBJECTIVES:
The learning Goals and Objectives for your training are both general, and rotation-specific in nature.
1. The General Goals and Objectives:
The complete list of General ACGME Requirements for Nephrology can be reviewed at the ACGME Web-site at: http://www.acgme.org/ (select “nephrology”). Please review briefly the condensed version below, as this participating institution (PI) has entered into a formal agreement with the Division of Nephrology, at USF, “to make available all its resources to facilitate our goal of providing you with formal instruction, clinical experience, and opportunities to acquire expertise in the prevention, evaluation, and management of 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. Hypertensive disorders
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
14. Renal transplantation,
15. Dialysis and extracorporeal therapy, and to acquire
16. Some technical and other skills that are related to the practice of nephrology, including a meaningful research experience.
(ACGME: September 2000 Effective: July 2001).
For further information, you can obtain, upon request, a copy of the Letter of Agreement from our division administrator, Debbie Powell.
2. The Rotation-Specific Goals and Objectives:
During your training you will send a total of four months on this rotation in one month blocks each. Three months during your second year and one month during your first year. There are two major rotation-specific goals and objectives for this rotation.
a. You will familiarize yourself with all the activities of a dialysis unit. You will be actively involved in the decision making for patients undergoing chronic dialysis. As the dialysis patient’s primary care physician and advocate, you will participate as a key player in the monthly interdisciplinary dialysis meetings with the nurses, technicians, social workers, pharmacists, psychologists (if available), and the USF nephrology staff assigned to the dialysis unit. You will learn the basic principles of chronic dialysis therapy, as practiced in a VA teaching institution (James A. Haley VAMC), as well as practiced in the community (USF Dialysis Center).
b. You will acquire, over the cumulative four month period, extensive experience with nephrology issues as they relate to oncology. These include obstructive uropathy, “tumor-lysis syndrome”, “vascular-leak”- “systemic inflammatory reaction syndrome”, HUS-TTP-like syndromes associated with bone marrow transplants/stem cell transplants and-or immunosuppressive chemotherapy, chemotherapy and antibiotic-related nephrotoxicity (cysplatin, amphotericin, etc), the entire spectrum of renal manifestations of multiple myeloma and renal invasions by a variety of local and/or systemic neoplastic disorders, renal manifestations of opportunistic infection in leucopenic patients and sepsis-related ATN, or drug-related acute interstitial nephritis. You will encounter electrolyte abnormalities (paraneoplastic) syndromes including SIADH and tumor-related hypercalcemic syndromes. The extent of exposure to such syndromes is unique to this cancer center and, to be equivalent in extent, would take years in a regular medical center.
i. Practical Experience
The experiences you will gain during this rotation include:
Dialysis:
1. evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options;
2. drug dosage modification during dialysis and other extracorporeal therapies;
3. evaluation and management of medical complications in patients during and between dialyses and other extracorporeal therapies, including dialysis access, and an understanding of the pathogenesis and prevention of such complications;
4. long-term follow-up of patients undergoing long-term dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis;
5. an understanding of the principles and practice of peritoneal dialysis, including the establishment of peritoneal access, the principles of dialysis catheters, and how to choose appropriate catheters;
6. an understanding of the technology of peritoneal dialysis, including the use of automated cyclers;
7. assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the principles of peritoneal biopsy;
8. an understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy;
9. the pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis;
10. an understanding of the complications of peritoneal dialysis, including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, plural effusions, and other less common complications and their management; and
11. an understanding of the special nutritional requirements of patients undergoing hemodialysis and peritoneal dialysis.
12. evaluation and selection of transplant candidates.
13. an understanding of the water purification systems.
Inpatient Moffitt Cancer Center:
1. Depending on the oncology-related renal syndromes outlined above, you will learn not only to recognize these syndromes, but how to diagnose and manage them. This includes:
2. interpretation of an extensive array of laboratory analysis, radiology imaging procedures, including renal ultrasound, histopathology, microbilology, and pharmacological studies.
3. You will gain expertise in treating paraneoplastic electrolyte abnormalities and the tumor-lysis syndrome.
4. You will further gain expertise in continuous renal replacement therapies (CVVH CVVH/D).
ii. Technical Skills
During this rotation, the specific procedural skills in which you will acquire technical expertise (including knowledge of their indications and complications, and interpretation of their results), include:
a. Placement of temporary vascular access for hemodialysis and related procedures;
b. Peritoneal dialysis;
c. Long-term hemodialysis;
d. Acute dialysis (CVVH/D) (Moffitt Cancer Center and Tampa VA)
iii. Other Procedures
The other specific procedures (including their indications, contraindications, complications, and interpretations of results, as well as their cost-effectiveness and application to patient care) you will become familiar with, during this rotation include:
e. Radiology of vascular access
f. Balloon angioplasty (and other interventions) of vascular access
g. Therapeutic plasmapheresis (Mainly at The Moffitt Cancer Center)
h. Bone biopsy
i. Placement of peritoneal catheters
C. THE TOOLS TO ACHIEVE AND EVALUATE YOUR GOALS:
The K/DOQI clinical practice guidelines represent a helpful tool to achieve some of the goals set forth in this rotation and evaluate your success in acquiring the competencies, skills and knowledge you will have achieved during this rotation, as they specifically relate to the practice of nephrology. We have obtained special permission by the National Kidney Foundation Inc., to use the current K/DOQI (Dialysis Outcomes Quality Initiative) clinical practice guidelines, as our major teaching and evaluation tool, (see: http://www.kidney.org/professionals/kdoqi/index.cfm, for more, click on “About K/DOQI”).
Note that these guidelines are based upon the best information available at the time of completion of the structured literature review. They are designed to provide information and assist decision making. They are not intended to define a standard of care, and hence should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will be inevitable and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.