Special Clinical Areas

It is critical to emphasize the importance of psychosocial and economic issues confronting patients with renal disease, ethical issues relevant to care of patients with renal disease, optimizing the relationship of the nephrologist with other health care providers, and optimizing mechanisms towards achieving life-long learning as a nephrologist. These issues are covered in detail in the other curriculum; however, they are not always clearly identified in the curriculum’s goals as being of paramount significance. These special aspects of the curriculum are discussed below:

• Dialysis initiation, discontinuation and end-of-life issues
  • Fellows are given lectures by the division faculty on dialysis discontinuation and end-of-life issues. In addition, the issues surrounding dialysis initiation are discussed. These issues are also addressed on the inpatient service and in the clinics. The RPA/ASN Clinical Practice Guidelines for Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis form part of the discussion basis.
• Geriatric assessment
  • Fellows are given didatic lectures by the renal division faculty devoted to the physiology and pathology of the aging kidney, altered drug metabolism with aging, and drug toxicity in the elderly. In addition, fellows read the American Society of Nephrology on-line geriatric nephrology curriculum and review this with the faculty.
• Medical ethics
  • Fellows attend conferences during the course of their fellowship devoted to renalrelated ethical issues. These focus on dialysis initiation and withdrawal, dialysis funding, renal transplant donor and recipient selection, kidney transplant availability, and other renal-related issues. The social and economic impact of their decisions and the need to be the patient’s advocate are discussed.
• Health care policy and legal medicine
  • In addition to health policy issues related to end-of-life care, fellows attend lectures on health care policy and legal medicine, focusing on dialysis and renal transplant.
• Physician impairment, risk management, patient safety
  • At the time of initial hire, all fellows spend a full day in the GME office. During this time, they are given instruction in physician impairment, OSHA, infection control, risk management, and HIPAA compliance.
• Quality assessment and quality improvement
  • These processes are addressed by relevant projects as described in each section (General Nephrology, Transplant and Dialysis) above.
• Medical genetics
  • Fellows are given several lectures focusing on renal-related medical genetics issues, including discussion of relevant techniques, single gene mutations, and polygenic disorders.
• Pain control
  • This issue is discussed with fellows in the sessions on pharmacology in dialysis and CKD patients.