All rotations will comply with the American Osteopathic Association and American College of Osteopathic Internists guidelines for postgraduate clinical core training. Rotations will follow similar general formats. The trainee will work under the direct supervision of a nephrology faculty member. The fellow will be responsible for the initial evaluation of the patient. After formulating recommendations for additional diagnostic studies and treatment, the case will be reviewed with the attending physician who will assist in the formulation of the final treatment plan. The fellow will be encouraged to assume greater decision-making responsibilities as they develop additional experience and increased depth of medical knowledge. Faculty will conduct daily rounds designed to provide careful and direct clinical teaching and supervision.
The major component of the clinical training will be devoted to carefully supervised patient care in a wide variety of practice environments. Specifically, clinical experiences will occur in the following settings:
This service will provide the nephrology fellow the opportunity to gain experience in the diagnosis and management of renal disorders encountered in a tertiary care hospital.
The following clinical rotations will comprise the inpatient experience:
- Consultation service
- The “consultative team” consisting of the nephrology fellow, internal medicine resident and two medical students, will perform comprehensive nephrology consults for all medical services including the intensive care, general medical and surgical, inpatient acute dialysis and obstetrical units.
- Rotations on this service will result in the acquisition of clinical skills as well as the experience required to provide a comprehensive consultation meeting the standards of excellence expected from a clinical nephrologist.
- Nephrology service
- The nephrology fellow will be responsible for the management of all patients admitted to the Nephrology service.
- Rotations on this service will provide the fellow experience required to manage the complex medical needs of patients with end stage renal disease. This will include managing dialysis therapy during the hospitalization.
- Non-base Institution service
- The University of Oklahoma Health Science Center or an equivalent training program, will serve as an additional training site. During rotations at this site, the fellow will have the opportunity to gain intensive exposure to a wide variety of renal, electrolyte, acid-base, and hypertensive disorders including acute and chronic renal failure.
- In addition, the fellow will participate in all aspects of medical management of renal transplant recipients including the acute presurgical and postoperative care, initiation of immunosuppression, diagnosis and therapy of rejection, as well as acute and long term complications requiring subsequent hospitalization.
Outpatient Ambulatory Clinic
This service will provide the nephrology fellow the opportunity to gain experience in the evaluation and management of ambulatory patients. This clinic will feature longitudinal care of ambulatory patients with a wide variety medical problems including, renal disease, diabetes mellitus, hypertension and existing renal transplants.
The fellow will participate in an outpatient clinic at least two half-days every week during all rotations based at Tulsa Regional Medical Center. In addition to providing an opportunity to follow-up with patients recently discharged from the hospital, the outpatient clinic will allow the trainee to perform evaluations of patients referred for a nephrology consultation.
At least one attending physician will provide direct supervision and instruction during all clinic activities. In addition, a nurse will be available to assist with patient care during all clinic visits. To facilitate effective patient care, a medical chart will be generated for all clinic patients. Laboratory data, diagnostic tests and imaging studies will be available through a computerized medical record system with network links to Tulsa Regional Medical Center.
In addition, during non-base institution rotations at the University of Oklahoma Health Science Center or an equivalent training program, the fellow will participate in the renal transplant clinic at least one-half day per week. The trainee will gain experience in managing patients with existing renal transplants, including diagnostic evaluation of graft dysfunction and therapeutic interventions.
Outpatient Dialysis Service
A well-equipped ambulatory dialysis center serves as the centerpiece for this clinical experience. Six months are dedicated to the outpatient dialysis service. During this rotation, trainees will be exposed to all aspects to the management of end stage renal disease. This rotation will provide an opportunity to develop the necessary medical knowledge, clinical judgment and skills required to function as a nephrologist delivering dialysis therapy. Faculty will conduct daily rounds designed to provide careful and direct clinical teaching and supervision.
With the approval of the program director, the fellow has the opportunity to spend up to three months on elective rotations. Available rotations include:
- Pediatric nephrology: This rotation will provide an opportunity to develop the necessary medical knowledge, clinical judgment and skills, to adequately diagnose and manage renal, electrolyte, and hypertensive disorders within a pediatric population. Full-time faculty in pediatric nephrology will provide teaching and close supervision.
- Renal Pathology
- Interventional nephrology: This rotation will provide an opportunity to develop and refine technical skills required in the management of hemodialysis vascular access. Placement of tunneled and cuffed catheters will be performed under direct supervision.
The fellow will be required to write a clinical paper during the two-year training program. The clinical paper will be submitted in a format suitable for publication. The manuscript may be based on a case study and review of the literature or an original research project.
Technical and Other Skills
History and physical examination
Emphasis will be placed on developing excellent physical diagnostic skills. These skills will facilitate the accurate diagnosis of renal disease by allowing rapid recognition of specific clinical manifestations associated with the disease process.
Imaging and renal function testing
Fellows will be encouraged to develop knowledge and expertise in the following areas, including indications, contraindications, complications, and interpretation of results of:
- Chest x-rays
- Renal radiology
- plain film
- intravenous contrast
- Duplex scanning
- Computed tomography
- Magnetic resonance imaging
Faculty, including attending radiologists, will facilitate instruction in the interpretation of radiographic studies.
In addition to demonstrating technical proficiency, the fellow will learn the indications, contraindications, complications and interpretation of results for each of the following procedures:
- Percutaneous renal biopsy: Fellows should perform at least fifteen renal biopsies under direct supervision.
- Placement of temporary vascular access catheters: Fellows should place at least thirty temporary vascular access catheters under direct supervision.
- Acute and chronic hemodialysis
- Acute and chronic peritoneal dialysis
- Continuous renal replacement therapy
Educational goals are achieved through a formal reading program, didactic lecture series, journal club, renal grand rounds and specific specialty conferences. Further, teaching is an essential component of the fellow’s duties and serves as a powerful learning tool. Fellows will make presentations at morning report, grand rounds, journal club and other conferences. When on the consult service, trainees are expected to provide ongoing, informal, “one-on-one” or small-group teaching sessions for internal medicine residents and students.
Each week trainees read one or more chapters in a comprehensive nephrology text and meet with a faculty member to discuss the highlights of their readings.
- A series of twelve lectures will cover the basic aspects of renal physiology. The lectures will be attended by the nephrology fellow during their first year of training
- A nephrology conference will be held twice a month. Nephrology fellows, medicine residents, and students rotating through clinical rounds will attend this conference. Topics will include clinical case presentations, lectures and discussions designed to emphasis the medical knowledge and clinical skills necessary to diagnosis and manage a diverse range of renal disease.
A monthly journal club review serves to increase the nephrology fellows’ familiarity with the renal literature and to provide additional experience in critically reviewing original research reports. Journal articles will be selected by the program director.
Renal Grand Rounds
This conference, held quarterly, is designed to review a selected topic of importance in clinical nephrology. The presentation will be made by a faculty member or by a nephrology fellow under supervision of a faculty member. Topics for presentation are updated periodically.
Faculty Evaluation of Trainee
The trainee’s clinical and technical competence is observed on a daily basis by the nephrology faculty. A formal evaluation will be preformed at the conclusion of each rotation. A standardized evaluation instrument, approved by the ACOI, is completed by the supervising faculty member and reviewed with the fellow. Included in this evaluation are the trainee’s knowledge base, clinical and procedural skills, professionalism and overall clinical judgment.
In the event of an unsatisfactory evaluation, trainees will be offered the opportunity to address the judgment on their academic deficiencies or misconduct before an independent clinical competence committee outside the Section of Nephrology within the Department of Medicine.
Finally, the program director will meet with the fellow twice yearly to provide feedback on performance and develop a plan to deal with any inadequacies.
Procedure and Consult Logs
Fellows are required to maintain a log of all cases, invasive procedures, and consultations. The log should document the following information: 1) date, 2) name, 3) medical record number, 4) diagnosis, and 5) type of procedure (if applicable). The log will be reviewed by the program director every six months. Further, for purposes of program review and approval in this specialty, the fellow will be required to submit his/her log to the ACOI Council on Education and Evaluation annually.
Trainee Evaluation of Faculty
The fellow will complete a confidential written evaluation of the faculty member supervising his/her training. These evaluations will be completed monthly utilizing the ACOI-approved form for “Faculty Evaluation”. The results of these evaluations will be collated by the program director and used to counsel faculty as indicated. In addition, participating faculty will meet frequently with program fellows to discuss the quality of their clinical experiences and obtain feedback on faculty’s performance and teaching effectiveness.
The program director shall provide an annual report to the Director of Medical Education. The report will outline the academic progress of each nephrology fellow. Also, the compliance of the program with the standards outlined in the “Basic Standards for Subspecialty Fellowship Training in Nephrology” guidelines (approved by both the American Osteopathic Association and American College of Osteopathic Internists) will be documented.
The assessment of the educational environment for the program will be preformed on a quarterly basis during the Internal Medicine Faculty meeting. In addition, the Program Directors of the Nephrology and Internal Medicine Departments as well as the Director of Medical Education will meet with the nephrology fellows on a quarterly basis to review the program, work environment and potential issues in terms of the training program.
Facilities and Equipment
An office will be available for professional use. This will include desk and storage spaces. Also, the office will be equipped to facilitate Internet access for purpose of performing online research.
A medical library, meeting the minimum requirements for Internal Medicine residency training, is located on the second floor of the hospital. A full time librarian is available to assist with research between the hours of 7:30 am to 5:00 pm Monday through Friday. The library resources are available during other hours through keypunch entry access.
The library features a computer room, several private study rooms and a library collection which includes 3,000 medical and clinical books, a current collection of reference texts, 124 print journal subscriptions, 500+ online electronic journals and 26 medical and related databases (including Medline, UpToDate, OSTMED).