Fellows in the Nephrology Fellowship Program at Lankenau Medical Center
will serve a number of inpatient and outpatient rotations during the
2-year program. These rotations are designed to expose the fellow to a
wide variety of nephrology patients, conditions and settings.
Inpatient Consultation Service and Nephrology Service
The major portion of this Fellowship is devoted to clinical nephrology.
There are two categories of acute and chronic patients that the trainee
has responsibilities for: nephrology consultations and nephrology
When performing nephrology consultations the Fellow sees all
consultations first, does the work-up and outlines the management and
treatment plan. He or she is responsible for reviewing the lab work,
radiology studies, urine, etc., and writes up the consult. The patient
(and write-up) is then reviewed by the assigned attending on teaching
rounds and the Fellow communicates the final recommendations to the
medical house staff assigned to the patient who, in turn, calls his own
attending physician (the patient's primary physician). The Fellow then
has the responsibility, working through the medical resident, to be
certain that the recommendations are implemented and that the management
of the case moves forward in a timely fashion.
In many acute cases involving intensive care unit problems, because of
the acuity of the problem, the fellow will, with appropriate
supervision, institute emergency procedures such as insertion of Shaldon
catheters into the femoral vessels or MedComp catheters into femoral
vessels for immediate dialysis access routes. The fellow will also start
acute peritoneal dialysis in an emergency situation. Procedures should
be logged in the Procedure Booklet and supervised as indicated by the
level of experience and expertise of the individual fellow.
Later in the fellowship, the fellow may also communicate the
nephrologist's recommendations directly to the attending physician. In
assuming this role of communicator, the Fellow matures as a consultant.
The fellow's ongoing recommendations are reviewed and confirmed or
revised on a daily basis by the teaching-team attending nephrologist
during the morning patient management rounds, at which time the fellow
writes the daily progress notes countersigned by the attending
physician. The teaching attending will interview patient and write
his/her own confirmatory note as indicated.
The fellow also has responsibilities for acute and chronic nephrology
service patients (a patient admitted to the private service of one of
the staff Nephrologists). When a patient is admitted by the attending
nephrologist, a call is made to the fellow assigned to the appropriate
teaching team to describe the case. In the case of acute care problems
on nephrology service patients, the fellow then sees the patient and
data base and then reviews the patient with the house staff and
recommends management plans subject to the approval of the attending
nephrologist. In the case of nephrology service patients, the day-to-day
care and management is more actively controlled by the fellow since he
or she, in effect, is the representative of the attending nephrologist.
The fellow may initiate diagnostic procedures (lab work, clearances and
x-rays) in conjunction with the medical house staff. All of the fellow's
actions on these nephrology service patients are reviewed daily by an
attending nephrologist during the morning patient management rounds. The
fellow makes every attempt in managing the nephrology service patients
to work through the medical resident. Whether or not he or she writes
the orders, the fellow assumes the responsibility that all orders are
Other responsibilities of the trainee for acute and chronic inpatients
include all procedures relative to the care of the renal patients, such
as intravenous access cannulations, peritoneal dialysis catheter
insertions and revisions, and renal biopsies.
Renal Hypertension Continuity Clinic
Patients seen in Renal Hypertension Clinic (which is open every
Wednesday morning from 10:30 to 12:30) are referred from the Medical
Clinic, or as follow-up appointments on patients discharged from the
hospital who have been followed by Nephrology Consultative Service, from
the Emergency Room or long-term Nephrology Clinic patients. These
patients should be followed also in Medical Clinic or by a private
practitioner for their non-nephrology management. A Nephrology Attending
is assigned to supervise the trainee during the clinic session.
Approximately three to four clinic patients are seen per clinic session.
This typically includes no more than two new patients and two to three
follow-up patients. The Nephrology Fellow attends this continuity based
clinic throughout the entire two-year period except when on rotation at
the Hospital of the University of Pennsylvania or at St. Christopher's
Hospital, both in Philadelphia.
Fellows are required to notify the clinic in advance of any vacation or
conferences that will conflict with clinic schedules and to work out
coverage with other Nephrology Fellows. In addition, nephrology fellows
are encouraged to be actively involved in the Ob/Gyn Lankenau clinic for
cases involving pre-eclampsia, eclampsia, HELLP syndrome, hypertension
and proteinuria. Follow-up is preferably on a continuity basis.
Fellows are assigned to an attending private physician's office for one
or more office session per week. This is readily accomplished since the
private offices are part of the hospital complex and run by the teaching
attending faculty. The Fellow sees and examines the patient and then
discusses the diagnoses and management with the attending. Additional
discussion occurs at the end of the office session to clarify and
emphasize salient points. In the average three-hour session, the trainee
sees four to six outpatients, with not more than one of these being a
new patient per session.
There are two months per year specifically dedicated to the ambulatory
private physician office rotations. Unlike the Renal Hypertension
Continuity Clinic, the follow-up by the fellow, in the private offices,
is less continuous unless the patient goes on to dialysis, in which case
the fellow continues follow-up care in the dialysis unit.
By the end of these rotations, the fellow should be familiar with common
outpatient/ambulatory problems (and management of same) of CKD patients.
Most common among such clinical problems are the diagnosis and
management of renal insufficiency, hypertension, anemia, edema,
electrolyte abnormalities and educational preparation of the patient for
dialysis and erythropoiesis-stimulating agents. During the Ambulatory
Rotation, the Fellow will also cover the ER (for non-inpatient team
Nephrology patients) and spend time with the Nephrology Nurse Educator.
To the extent that there is free time during Ambulatory Rotations, spare
time should be directed toward the fellow's research project.
Outpatient Dialysis Rotation
The Out-Patient Chronic Dialysis Rotation consists of two major parts: peritoneal
dialysis and hemodialysis.
Peritoneal dialysis (PD) further consists of Continuous
Ambulatory Peritoneal Dialysis (CAPD) and Automated or Cycler Assisted
Peritoneal Dialysis (APD). The fellow is expected to become familiar
with both of these PD modalities. The fellow is assigned specific PD
patients who the fellow, along with the primary attending nephrologist
and PD Nurse Coordinator, follows on a longitudinal continuity of care
basis. Patients are typically seen in the PD Clinic. The fellow should
become familiar with the orientation to and initiation of the PD
technique, as instructed by the PD Nurse Coordinator, Nephrology
Attending, reading materials, didactic PD conferences and literature.
The fellow is also expected to attend the insertion of chronic PD
catheter placement by the access surgeon and to be familiar with
possible complications of access care and complications including
management of exit site-related problems. The diagnosis and management
of peritonitis, adequacy of PD dose prescription, fluid management, poor
infusion or drainage, exit site infection, hydro thorax, herniation and
other relevant PD-related complications should be mastered through this
approach. PD patients are typically seen on a monthly basis, but may be
seen more frequently if conditions warrant.
The chronic hemodialysis (HD) rotation takes place concurrently
with the PD experience. Although PD patients, being fewer in number, may
need to be seen during other rotations as part of a continuity approach,
chronic HD out-patient experience is gained largely during the seven
monthly rotations of the two year fellowship. The fellow is expected to
become thoroughly familiar with and competent in the management of ESRD
and HD issues and technology including all types of access placement
(catheter, graft, fistula) and should be present during the insertion of
each of these types of access with the vascular access surgeon in the
operating room. The complications of access, including thrombosis,
bleeding and infection, should also be followed by the fellow, whether
it be in the operating room or radiology department.
The fellow shall become familiar with the setting-up of the dialysis
machinery, lines and needles, as well as the comprehensive dialysis
prescription routine. The management of complications during the HD
(hypotension, cramping, seizures, blood loss, dialyzer reaction and
infection) should all be incorporated into the experience of the
rotation. The diagnosis and management of ESRD-related complications,
including anemia, iron deficiency, osteodystrophy, neuropathy,
psycho-social adjustment, sleep disorders, fluid overload, hyperkalemia
and hypertension, should all be mastered by the fellow as a result of
these rotations, as well as the reviewing of literature and Division of
Nephrology lecture series.
The fellow will round regularly with the assigned attending Nephrologist
for the particular shift of dialysis. It is expected that the fellow
will be an integrated part of the multi-disciplinary team including the
nurses, social worker, dietician and dialysis technician. The fellow
will actively participate in the bi-weekly dialysis multi-discipline
team meetings. In addition, the fellow should become knowledgeable about
the water treatment equipment and related aspects for water delivery
within the dialysis unit rotation. Comprehensive monthly blood work
notes as well as annual history and physicals shall be performed by and
become a routine part of the out-patient dialysis rotation by the
Nephrology Fellows. Routine day-to-day ESRD-related issues for the
chronic out patient dialysis population is also an integral part of this
series of rotations.
Outpatient Renal Transplantation Clinic
The Continuity Transplant Clinic experience at Lankenau Medical Center
takes place weekly for each senior fellow at The Hospital of the
University of Pennsylvania. Each fellow sees approximately 10-15
patients per week over four weeks, or approximately 60 patients at The
Hospital of the University of Pennsylvania.
The fellow is responsible for filling out an evaluation of his or her
transplant rotation experience at the University of Pennsylvania and
submitting the evaluation form to the Lankenau Fellowship Program
Coordinator. In addition, the fellow should see 3-4 patients per week at
the Lankenau Renal Transplant Clinic throughout his or her 2nd year of
fellowship. At the completion of the fellow's training, he or she is
expected to be competent in the diagnosis, physiologic understanding and
therapeutic management of renal transplantation, acute and chronic
rejection, evaluation of living related donors, surgical complications
of donation and implantation of kidney allografts including bleeding,
infection and immunosuppression as well as vascular and genitourinary
complications. A comprehensive understanding of immunosuppressive
therapy and its rationale for use as well as complications of specific
commonly used anti-rejection medications is expected.
Outpatient Pediatric Nephrology
Fellows will rotate for four weeks at St. Christopher Hospital for
Children in Philadelphia. St. Christopher's Hospital has a Department of
Pediatric Nephrology. Fellows will be under the direct supervision of
Dr. Susan Conley, Section Chief of Pediatric Nephrology.
The fellow is responsible for filling out an evaluation of his or her
pediatric nephrology rotation experience at St. Christopher's Hospital
for Children and submitting the evaluation form to the Lankenau
Fellowship Program Coordinator. Upon the completion of the rotation, the
fellow should have an appreciation for common, as well as uncommon,
pediatric nephrologic conditions and their complications including
glomerulonephritis, reflux uropathy, obstructive uropathy, dialytic
issues unique to pediatric patients and metabolic/nutritional aspects of
the pediatric nephrology population. An understanding of genetic and
congenital related renal disease is especially pertinent as a
comprehensive part of this rotation.
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