Clinical Training

The clinical nephrology program at Scott & White involves two years of training at Scott & White and the Texas A&M Science Center College of Medicine. The training experience includes inpatient consultation services, inpatient primary care on nephrology patients, management of end stage renal disease patients (ESRD), transplantation nephrology, education in nephrology imaging techniques, review of urinalyses and review of renal biopsies. Outpatient Nephrology clinical activities include on-going comprehensive care of patients with chronic kidney disease and providing consultations to non-nephrologists.

The fellow will participate in nephrology conferences that include Biopsy Conference, Journal Club, Physiology Conference, Morbidity and Mortality Conference, Internal Medicine Resident Teaching Conferences, Internal Medicine Board Update Conference, and the Teaching Conferences for the residents and students rotating on the nephrology service.

The fellow will also care for ESRD patients on dialysis as a part of the educational environment. This will include being assigned as the primary nephrologist for a small group of hemodialysis patients (10), home peritoneal dialysis (five) and home hemodialysis (two). The fellow's own patients who progress to ESRD will retain the fellow as their primary nephrologist.

The 24-month curriculum consists of six months of acute inpatient consultation and primary nephrology hospital service (Ward Service), six months of outpatient dialysis, three months of transplantation, six months of research, one month of renal histopathology and two months of elective. Fellows receive two weeks of vacation per year in the fellowship. During the elective months fellows may receive additional training and experience in the areas of pediatric nephrology, renal histopathology, radiology, ultrasonography, urology, transplantation or others as approved by the fellowship director. The nephrology fellowship program supports and follows the ACGME requirements for time free of patient care and maximum hours spent in patient care. The fellow will have one day in seven free of any patient care or administrative duties. All night and weekend call is at-home telephone call. There are no in-house call responsibilities for the fellow. View the block rotations on this site.

Nephrology Conference Schedule
The teaching activities include several conferences held throughout the week.

	Monday	Tuesday	Wednesday	Thursday	Friday
0800-0900	Weekend Review1	Weekday Review1	Weekday Review1	Weekday Review1	Weekday Review1
0900-1200			PCC, QI2 Tech
1200-1300	Res Hr3		Div Mtng4, Biopsy Conference, M&M, JC7, Physiol C		Grand Rounds5
1300-1430		HD Rnds6		Home Dial Conf 8

Table 1 -- Nephrology Conference Schedule.

1. Weekend Review of all dialysis patients admitted to the hospital over the weekend.
2. PCC = Patient Care Conference, QI = Quality Improvement, Tech= Review of technical aspects of dialysis.
3. Res Hr = Internal Medicine Resident's Conference
4. Div Mtng = Division meeting, Biopsy Conf = Biopsy Conference.
5. Grd Rnds = Department of  Medicine Grand Rounds.
6. HD = Hemodialysis teaching rounds.
7. M&M = Morbidity and Mortality Conference, JC = Journal Club, Physiol C.= Physiology Conference, Clin Conf =  Clinical Conference.
8. Home Dial Conf = Home Peritoneal and Hemodialysis didactic and management conference.

The senior staff attending on the Hospital Service will conduct the weekday morning review of patients admitted to the Nephrology Hospital Service over the preceding 12-24 hours. This will provide the fellow with an opportunity to review decision-making and care of patients admitted to the service and cared for by another nephrologist.

The Patient Care Conference (PCC) is a mandate by CMS. The head nurse, mid-level practitioners, social workers, dietitians, the PCC nurse coordinator, the fellow and the senior staff attend this conference. All dialysis patients belonging to the fellow and that senior staff will be thoroughly reviewed and both short- and long-term care plans will be generated. There is active participation by the renal dietitian, social worker, nurse practitioners and the registered nurses. All lab values are reviewed and the dialysis prescription changed if needed. This conference allows the fellow to generate the required comprehensive dictation of the patient's status for the preceding month.

The QI conference is a monthly conference attended by the Medical Director of the Watson Wise Dialysis Unit, the fellow, the head nurse, QI nurse, chief technician, social workers and dietitians. This conference provides for the oversight of all care; adherence to federal, state, and local policies and procedures; and a review of all adverse events that have occurred in the dialysis unit over the past month. The primary vehicle for data review uses Statistical Process Control methodology.

Medical Grand Rounds is held on Friday at noon. Faculty from Scott & White and other institutions are invited to discuss clinical topics in medicine. Several times a year Nephrology faculty are asked to present at Grand Rounds.

Clinical Management Conference will be held on the first Wednesday from 1:00 p.m. until 2:30 p.m., alternating every other month with the Morbidity and Mortality Conference. Ongoing, active cases will be discussed. The cases chosen for this conference will address a specific curriculum topic.

Morbidity and Mortality Conference (M&M) will be held on the first Wednesday from 1:00 p.m. until 2:30 p.m., alternating every other month with the Clinical Management Conference. Cases for the M&M Conference are chosen by the senior staff on a rotating basis. These cases examine the management of a difficult case and invite review of the management and improvements that could have been made. The focus will be upon medical management, but will also address ethical issues and self-critique (practice based learning and improvement). This conference operates under the Office of Risk Management and all information discussed at this conference is privileged information.

Journal Club is held on the second Wednesday from 1:00 p.m. until 2:30 p.m. The purpose of Journal Club is to develop the ability to critically analyze data reported in the literature. In general, papers are presented and discussed from high quality clinical journals (such as New England Journal of Medicine, Kidney International, Annals of Internal Medicine, Lancet, Transplantation), and basic science journals (Nature, J. Biol. Chem., Cell, Science, Proc. Natl Acad. Sci., J. of Clin. Invest. Am. J. Physiol., etc.). The division director is responsible for selecting papers to be reviewed and provides the oversight for the analysis of study designs and biostatistics of papers discussed by the fellow.

Renal Physiology Conference is held on the third Wednesday from 1:00 p.m. until 2:30 p.m. During this time basic physiology of the kidney, the application of physiology to clinical nephrology, theoretical and practical aspects of dialysis, electrolyte, fluid and acid-base disorders and transplantation nephrology are discussed. Over a period of two years, all major topics on the Nephrology Subspecialty Board are covered. The fellowship director is responsible for choosing the topics for the Physiology Conference and overseeing the academic integrity of the program, as well as ensuring that all topics have been covered over the two year fellowship. The physiology conference will often be combined with M&M and Journal Club to highlight the interaction of basic physiology and clinical presentations and management of cases.

The third Wednesday of each month from noon until 1:00 p.m. is reserved for Renal Biopsy Conference. This conference is arranged by the renal fellow, pathology chief resident and the pathology senior staff, Doctors Rao and Jones. It is attended jointly by Nephrology and Pathology senior staff (Doctors Jones and Rao), medical students and residents. Renal biopsies performed during the month are reviewed and discussed and similar archived cases are presented as well

Summer Core Curriculum: A core nephrology curriculum is provided at the beginning of each academic year. This two-month curriculum is intended to provide fundamental practical concepts in various topics in nephrology early in the training program. This permits accelerated acquisition of core information used in management of outpatients and inpatients.

Topics include:

• Evaluation of renal function
• Hemodialysis (HD, CRRT) indications and techniques
• Peritoneal dialysis morbidities
• Evaluation and management of patients with acute and chronic renal failure
• Evaluation and management of acid-base and electrolyte disorders
• Evaluation and management of renal transplant patients
• Other topics considered important by the fellowship director

The fellowship director is responsible for assigning the topics to be covered and for ensuring that the conferences have taken place.

Cardiovascular Research Institute Seminars

In order to meet the Nephrology RRC requirements for conferences we have defined the following conferences as meeting the RRC requirements:

Requirement	Met by
1. One clinical conference weekly	Daily moring report; monthly PCC/QI; Biopsy Conference; M&M conference; bimonthly Transplant Grand Rounds
2. One literature review monthly	Monthly Journal Club; bimonthly Transplant Journal Club
3. One research conference monthly	Weekly research conferences in Cardiovascular Research Institute; weekly research conference in research rotation
4. One core curriculum weekly	Monthly physiology conference; M&M conference, bimonthly Transplant Grand Rounds and Journal Club, monthly biopsy conference; Weekly subject review from Contemporary Nephrology (Ed. 2; Johnson  and Feehally) averaged over 1 year.

Following two years of training, the trainee will have confidence in evaluating and managing patients with a wide variety of kidney disorders, and have had in-depth training in acute and chronic hemodialysis, continuous renal replacement therapy, renal biopsy, apheresis, dialysis catheter placement, ultrasound interpretation, and performance of and interpretation of renal biopsies. This experience will also solidify and integrate the fellow's knowledge of Internal Medicine. The fellow will exhibit excellent consultation skills, interpersonal interactions, ethical integrity, professionalism, and the ability to work within a large, complicated, integrated health care system to provide excellent patient care.

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