Nephrology Postgraduate Program Rotations

Ambulatory Care Clinics

During these 2 months, residents attend about 7 half-day clinics per week. One of these must be a Progressive Renal Insufficiency (PRI) clinic; the others may include any attending staff’s general Nephrology clinic, or a specialty clinic such as renal stones or pregnancy in renal disease. It is recommended to the trainees that they attend the same clinics each week so that they can get a follow-up on the patients that they see. There are at least three clinics scheduled at any time (except for Friday afternoons), which gives the resident quite a choice.

Consultation Service

The two-month rotation is at the Civic site. This site does not have any in-patient Nephrology beds, patients presenting to the Civic ER with a Nephrology related problem are transferred to the General site. The Ottawa Heart Institute is a rich source of consultations to Nephrology as are the vascular surgery and internal medicine services. The clinical experience here is primarily with acute renal failure, often in the intensive care setting with hemodynamically unstable patients. This exposure will provide you will valuable experience in the modality of CRRT. The Nephrology service here does not take non-Nephrology trainees (except in rare circumstances) and therefore the Nephrology resident, along with the supervising staff, is responsible for all consults and their follow-up. There are on average 12 new consults per week. The one to one nature of the staff-trainee relationship on this rotation allows for appropriate supervision and teaching at the PGY 4-5 level.

The Clincal Teaching Unit (CTU) team at the General also provides consultations, primarily to the oncology, ICU, general surgery and internal medicine services. The Nephrology trainee involvement in consultation is variable and usually depends on the workload on the ward. Typically, the trainee will be involved with all ICU consults but if the ward is very busy the staff will often handle the other consults alone. This service sees an average of 15 consults per week.

Hemodialysis

There are dialysis units at each site of The Ottawa Hospital. The division has also been very effective in moving dialysis into the community, nearer to the patient. The division has medical directorship over dialysis units in Cornwall, Hawkesbury, Winchester, St Vincent’s Hospital and central Ottawa (Fisher and Baseline Rd). Division Nephrologists visit these satellite units on a regular basis. The trainees primarily spend time at the Civic and General site dialysis units. The General unit has 32 dialysis stations and 192 patients per week.  The Civic has 18 regular stations and a 4 station new start unit to give 192 patients per week.  We also have multiple satellite units where residents can get additional exposure in their second year as an elective.

The model of care at the in-hospital units is that the physician does a complete round on every patient at least once a week and is available to review blood work and deal with any medical problems at each patient visit. Typically one Nephrologist works in the unit Monday/Wednesday/Friday and another Tuesday/Thursday. The resident usually follows three shifts of patients per week – typically every morning and one set of afternoon patients. The resident provides primary care under the supervision of the attending staff. This includes the investigation and management of acute and chronic medical problems and complications of dialysis, regular review of routine blood work and adjustment of the dialysis prescription. Teaching about the mechanics of dialysis, the working of the machines, water supply etc, is done by the attending staff and/or nurses or technical staff where appropriate. A list of topics for review is presented to the resident and supervisor as part of the rotation specific objectives.

The trainees usually start their Nephrology residency with two months of hemodialysis at one of the sites. This gives them early exposure to the aspects of Nephrology that are most unknown to them and therefore the most intimidating. The third month is typically scheduled for the end of the first year at the other hospital site. This scheduling is deliberate in order to give the resident a different clinical experience at a time when they are able to take on more responsibility. They also receive a longitudinal experience in dialysis by caring for the same dialysis shift over the 6 months that they take call at the Civic site.

The residents are encouraged to travel to one of the satellite units with the attending staff at least once per month; this is not mandatory however. The residents are also encouraged to attend the weekly vascular access clinic and vascular access rounds. This is a multidisciplinary clinic and rounds where decisions about fistula, graft and tunneled line placement and repair are made.

Home Dialysis

Home dialysis (which includes primarily peritoneal dialysis but also the few patients on home hemodialysis in the region) consolidated at the General site in 2001, and has since moved to the Riverside site.

The Home Dialysis unit trains patients that will be doing peritoneal dialysis or hemodialysis at home. It also follows these patients through clinic visits approximately every 4-8 weeks. There are about 140 prevalent peritoneal dialysis patients and 31 home hemodialysis patients as of October 20,2010.

The unit is used as the training site for the Peritoneal Dialysis rotation. During this rotation, the resident attends every clinic (full days Wednesdays and Thursdays), reviews all lab work on any HDU patient and is available to deal with any acute medical problems (i.e. peritonitis). Teaching sessions are held regularly with the supervising Nephrologist to discuss the mechanics and complications of peritoneal dialysis. The trainee’s involvement in the home hemodialysis, daily hemofiltration, daily short dialysis and nocturnal dialysis programs is not mandatory. An elective in those areas is offered in the second year.

Renal Transplantation Service

The renal transplant program in Ottawa consolidated at the General site in 1998. The program is now based at the Riverside for all its out-patient activity, with in-patients cared for on the CTU at the General site. There are five transplant follow-up clinics and two potential donor and recipient evaluation clinics per week. The program follows approximately 700 patients and about 70 new transplant operations are performed each year.

The trainee receives his/her in-patient experience in transplantation during the CTU rotation. The CTU admits all patients receiving a renal transplant as well as any patient with a renal transplant who requires admission for a non-surgical problem. During their two month CTU rotation, a Nephrology trainee will typically care for 5-10 new transplants. The call schedule is also organized so that the first year trainees typically take call on Thursday nights – which is the weekday that the living related transplants occur. As these are scheduled about once per week, this greatly increases the new trainee’s exposure to post-operative management of renal transplants.

During the two-month transplant rotation, the resident is primarily involved in the outpatient medical care and follow-up of renal transplant recipients. Clinics are held five mornings per week. Lab work on those patients is reviewed that afternoon. In 2008, these clinics saw an average of 276 regular visits per month.

There are also 2 weekly evaluation clinics that see 8-10 new consults per week, living donor or potential recipient. The trainee usually sees three of those consults each week. Residents are asked to be involved in the process of organ allocation when a cadaveric donor becomes available; however, as this is not a planned event, and typically occurs in the middle of the night, a self-learning module has been developed for the trainee and supervisor to work through.

The trainee is also encouraged to spend one day in the tissue typing lab, usually a day when the lab is doing the crossmatch for an upcoming living donor operation. A day with the organ donor coordinator is also suggested. Finally, some trainees also choose to attend one of the surgical procedures.

Ward

There are no other hospitals that admit patients who require acute dialysis in eastern Ontario. As such, the CTU at the General hospital receives referrals and transfers from hospitals as far away as Cornwall in the east, Renfrew, Arnprior and Pembroke in the west and Smith Falls to the south. Last year the nephrology service at the General hospital had an average of 60 consults per month.  The General campus is the location of an 18 bed Nephrology CTU.  There were approximately 3000 in-patient hemodialysis treatments.  Approximately 100 patients were treated with some form of CRRT (CVVHD or CCVHDF). These numbers include patients with known chronic renal failure admitted for management of complications or initiation of dialysis, patients with previously unknown renal disease admitted for investigation and management, patients with acute renal failure admitted for investigations and management, patients on dialysis admitted for management of complications of their disease, patients with overdoses of dialyzable substances, patients receiving renal transplant and those with renal transplants admitted for management of intercurrent illness or complications. The CTU team is also responsible for providing consultation services to the hospital. These consultations are requested mostly by the ICU, Oncology, General Surgery and Medicine services.

Call

Civic Campus

The main educational objective of call at the Civic campus is longitudinal dialysis.  As much as possible, trainees will be on call on the same weeknight (ie Monday/ Wednesday or Tuesday/ Thursday).  The first year usually entails 6 consecutive months of coverage of the same evening shift.  Call averages about one in four and is from home.  In addition to dialysis coverage, trainees may be called about new consults from the floors or ER or with questions about consults being followed by the team.

General Campus

The main educational purpose of call at the General is to provide an acute care experience in Nephrology.  Call averages 1 in 4.  The trainees may be called to see new consults in ER or on floors/ICU.  They also cover the patients admitted to Nephrology and consults being followed.  Call is meant to be at home but there may be instances when trainees chose to stay in house; for example new transplants, sick patient on floor.   As much as possible, a junior resident will be scheduled to cover first call and trainees will do second call.   When that is not possible trainees cover first call.

Sample Schedule

 

 

 

 

 

Mandatory Content of Training

 

 

 

 

 

 

Elective Content of Training