VETERANS ADMINISTRATION (VA) RENAL CONSULT ROTATION

Service:

The consult service consists of one attending, one 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 consult service follows any patients except the patients who receive chronic dialysis at the VA.  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.  Biopsies scheduled from the clinic and inpatient biopsies are performed by the consult fellow.

Responsibilities:

The clinical fellow typically is assigned to this rotation 3-4 months during the 2 years of clinical training.  The 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 the 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 expectations 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. The VA 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.

VA Clinics

While rotating on the VA consult service the fellow will not attend the PMH continuity clinic but will attend the following VA clinics.

A. Renal stone and glomerulonephritis clinic (Tuesday afternoon)

The clinic will allow the fellow to become familiar with evaluation of metabolic stone disease, learn how to prevent it, and learn radiology of stone disease.  The Fellow will see patients with kidney stones and present them to the attending physician. Key literature will be reviewed as well as current guidelines for stone disease management.  The case mix of renal stone disease is extensive and includes calcium oxalate and calcium phosphate stones, uric acid stones, struvite stones, renal tubular acidosis, medullary sponge kidney, primary hyperparathyroidism, enteric hyperoxaluria, urinary tract infections. 

This clinic will also consist of patients with various forms of primary and secondary glomerulonephritis.  Examples of the case mix include Lupus nephritis, ANCA-associated glomerulonephritis, post-streptococcal glomerulonephritis, and infectious related glomerulonephritis.

1. General renal clinic (Wednesday morning)

This clinic provides fellows with an opportunity to serve as outpatient nephrology consultants on a diverse patient population in an urban VA hospital.  The clinic provides extensive exposure to a wide variety of renal diseases and hypertension as well as related diseases.  The clinic provides fellows with a continuity experience while rotating at the VA.  Fellows present all patients to an attending and receive direct feedback.  

There is a complete range of kidney diseases represented in this clinic with the most common disorders being diabetic nephropathy, chronic kidney disease stages 3-5, hypertension associated with CKD, and chronic tubulointerstitial diseases.  Renal transplant patients are also followed in this clinic.  Much time is spent helping patients choose a dialysis modality and preparing patients for dialysis. This consists of interdisciplinary discussions with social workers and nutritionists.

VA Conferences

While rotating at the VA the fellow will attend the following conferences:

1. Renal Journal Club (each Friday)
2. Renal biopsy conference (every 4^th Friday)

C. Monday Renal grand rounds and Thursday Basic Science conference which occur at UTSWMC are transmitted live to the renal office for the fellows rotating at the VA.  This transmission allows for full interaction such as questions and answers to take place.

General Competencies:

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

1. Patient Care:

Fellows should be able to:

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

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

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

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

5. 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

6. 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

7. Implement treatment plans, such as initiating acute or chronic dialysis

8. 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

9. 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

1. Medical Knowledge:

The fellow will be expected to acquire an extensive knowledge base of general nephrology described in detail above:

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

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

3. By being highly resourceful in developing knowledge

1. Practice-Based Learning:

During this rotation, fellows are expected to:

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

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

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

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

5. 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

1. The proper antibiotic dose adjustments in ESRD patients

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

1. Communication and Interpersonal Skills:

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

1. Establish rapport with patients from different backgrounds

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

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

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

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

6. Provide teaching to fellows and medical students

1. Professionalism:

Fellows are expected to:

1. Demonstrate a commitment to carrying out professional responsibilities

2. Adhere to ethical principles
3. Exhibit sensitivity to diverse patient population
4. Demonstrate respect, compassion, integrity and honesty
5. Consistently exhibit role model and responsible behavior
6. Willingly acknowledge errors

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

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

1. Systems-Based Practice:

During this rotation, fellows are expected to:

1. Understand the resources and limitations of the dialysis unit

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

3. Understand the role of the Federal VA system in the provision of dialysis services

4. Understand the resources available for the treatment of VA patients

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

6. Assist in developing systems improvement