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How old is the fellowship program? How long has the program director been in that position?
Our fellowship was established in the early 1970s! Dr. Lecker has been the program director since 2005.
Does your faculty have regionally or nationally recognized experts in specific areas of clinical nephrology, scholarly research, quality/patient safety or medical education?
We are a uniquely well rounded program with both excellent clinical and research training opportunities. Our institution is a national leader in medical education and quality improvement as well. Please refer to the faculty bios for specific information about each faculty member’s areas of interest and specialty.
Is there an on-site pathologist with expertise/fellowship training in renal pathology? Are renal biopsies (native and transplant) read in-house or sent out? Do fellows and faculty review biopsies directly with the pathologist? How soon after a biopsy is this available?
All renal pathology is done on-site by our renal pathologists Drs. Stillman, Rosen and Heher. Fellows review all biopsies with our pathologists in small groups or one-on-one at multi-headed teaching microscopes, usually one to two days following the procedure. Many are presented at our weekly conference as well with a pathologist present to present the biopsy findings.
If fellows rotate to more than one hospital, who are the supervising faculty at each?
During the first year, all work is done at the main hospital (BIDMC in Boston). In the second year, there is the option to spend outpatient time at the Joslin Diabetes Center and optional exposure to pediatric nephrology at Children’s Hospital Boston, a world-renowned hospital located just down the block from BIDMC in the Longwood Medical Area.
Does the program use physician extenders such as advanced practice nurses or physician assistants? What is the responsibility/relationship of the fellows to these providers?
Our Renal division does employ a nurse practitioner who specializes in nephrology and dialysis, and she is an excellent resource for dialysis-related issues.
What is provided for fellow education in physiology, pathology, immunology/transplantation, clinical pharmacology, ethics/palliative care, renal imaging? Who provides this education?
Our faculty provides didactic sessions in all these areas. This teaching takes place in real-time at the bedside as well as during noon conferences that are reserved for these topics.
What simulation experiences do fellows participate in?
At the beginning of the first year, we have simulation sessions in performing renal biopsies, placing central venous dialysis catheters and troubleshooting the dialysis procedure itself.
What is the educational program and clinical experience of fellows in vascular access and peritoneal dialysis access?
We have a vascular access center on-site that performs procedures (fistulograms and thrombectomies), and through which, fellows rotate in their second year.
How does the program prepare fellows for the business aspects of subsequent careers including private practice, academics, dialysis unit medical directorship, etc?
We have some didactic sessions and are trying to develop more innovative programs along these lines. Our faculty do have varying experiences in private practice and dialysis unit medical directorship, as well as academics and research experience.
What is provided for fellow education in the principles, practice and technology of dialysis? Who provides this education for fellows?
We have a dedicated renal replacement therapy curriculum that runs over the course of the year. Much of our clinical faculty is well versed in all modalities of dialysis, including conventional intermittent hemodialysis, home hemodialysis, peritoneal dialysis and continuous renal replacement therapies for ICU patients.
How many in-center hemodialysis, peritoneal dialysis, nocturnal hemodialysis and home hemodialysis patients are cared for by the primary teaching faculty of the program? What is the clinical experience fellows get in the care of each of these types of dialysis? Who oversees the teaching of fellows in each dialysis modality? What is the continuity experience with the care of patients with each dialysis modality? Do fellows follow their own cohort of chronic dialysis patients? If so, for how long and in what capacity do they function? How is competency in care of patients with each dialysis modality demonstrated?
Approximately 250 HD patients, 40 PD patients, 15 home hemodialysis patients. Fellows experience outpatient dialysis in their second year because our main HD site is one mile from our hospital and, as such, difficult to schedule into daily activities in the hospital. Our core faculty precept fellows in the dialysis experience during their second year.
Are kidney transplants done at the program’s hospital? If so, how many transplants are done per year and what is extent of the experience and role of the fellow in the care of transplant patients (a) at the time of transplant, (b) post-transplant outpatient, (c) when hospitalized post-transplant? What is the continuity experience with transplant patients? How is competency in the care of pre- and post-transplant patients demonstrated?
Approximately 75-100 / year. All care is co-managed with our transplant nephrologists and transplant surgeons who have a great working relationship. While on the inpatient transplant service, our fellows are exposed to immediate post-transplant care for recipients, acute complications such as graft rejection/failure, adverse effects of immunosuppression and transplant-related infectious diseases. In the outpatient transplant nephrology clinic, both pre- and post-transplant patients are evaluated. Additionally, all first-year fellows participate in transplant curriculum led by our experienced faculty. Our Transplant Institute also offers an ATS-accredited renal transplant fellowship following a general nephrology fellowship.
How many kidney biopsies are typically performed with supervision by each fellow (native and transplant)? Who performs the biopsies (i.e. nephrologist or radiologist)? What is the nature of the hands-on experience of the fellows when doing supervised biopsies? How is competency in performing biopsies determined?
Approximately 15-30. A fellow performs all biopsies with an attending supervision and with radiology providing real-time ultrasound guidance. Competence is determined by a faculty assessment and numbers performed. Fellows are responsible for logging their procedures and supervisors.
How many dialysis catheters are typically placed by each fellow during the course of a day/week/month/year? Who supervises this? How is it determined that a fellow can do this with only indirect supervision?
Approximately 10-20 over the course of training, depending on how motivated the fellow is to perform this procedure. All access lines for surgical patients are performed by the primary team. For patients on a medicine service (i.e. MICU or CCU), the renal fellow may defer line placements to the primary team of residents or to the interventional radiology service. Trainees with a strong interest in procedures may, therefore, choose to perform more line placements. Supervision is provided mostly from critical care faculty, though some members of the renal division are credentialed to supervise and perform line placements as well. Our institution believes in supervision for any trainee performing an invasive procedure until competence has been demonstrated and documented by these supervisors.
What is the ICU clinical experience provided? Does the program have clinical faculty with specific interest and/or expertise in the care of ICU patients? What is the experience provided with CRRT?
Approximately 60 ICU beds. Approximately 5-15 ICU patients covered by the inpatient renal teams at any given time. We have 6 CRRT machines with most in use at most times. We do not have a dedicated ICU nephrology faculty or rotation. The ICU patients are dispersed among the consult, dialysis or transplant services, depending on their renal history.
What is the experience provided in interpretation of urinalysis, renal imaging and renal pathology? How is competency in these demonstrated?
Urinalysis: daily performance with faculty, and then independently. Imaging: dedicated rotations in the second year, if desired. Pathology: see prior question above under “Resources.” Every second year fellow will complete a rotation with our renal pathologists in which the fellow “reads-out” renal biopsies with renal pathology faculty supervision.
What types of patients are seen by fellows during their continuity clinic experience? To what extent do fellows have primary responsibility for ambulatory continuity clinic patients? Do fellows see patients similar to or different from those seen by teaching faculty? What is the teaching/supervision structure for this clinic experience? Who does the teaching?
Continuity clinic: longitudinal experience, one afternoon/week over the first two years of fellowship. Each fellow is partnered with one of the core clinical faculty for the entire experience (same faculty for both years). The fellow develops independence over the first year to the point where they primarily manage patient care in their second year.
What is the experience with the care of kidney diseases in specific populations such as women during pregnancy, children transitioning from pediatric to adult nephrology care, patients with advanced malignancy and/or who are treated with newer therapies, patients with kidney disease and non-renal transplants, etc?
As a fellow in a large academic center/tertiary care institution, our fellows will see consult patients on the bone marrow transplant service, liver transplant / end stage liver disease service, labor and delivery / obstetrics and trauma ICU. Much of the pioneering work in preeclampsia was performed at BIDMC.
How many general nephrology clinics are there per week other than fellow continuity clinics? What is the ratio of faculty to fellows in these clinics?
Approximately 10. Fellows are primarily in the continuity clinics. Some clinics (e.g. transplant, diabetes) are attended by fellows as elective experiences in their second year.
What specialty clinics/referral clinics does the program have (i.e. complex hypertension, GN/SLE/renal vasculitis, stones, PCKD, other genetic renal diseases, etc)? What is the clinical experience of fellows in the care of patients with such diseases in both in-patient and ambulatory settings? Does the program have regionally or nationally recognized experts in any of these specific areas?
As one of five major teaching hospitals in the surprisingly small Boston metro area, it is difficult to attract enough patients of any one kind to perpetuate a focused renal specialty clinic. All of the above areas are represented in our general nephrology continuity clinics. As such, no matter who your clinic preceptor is, you will see a large variety of renal diseases.
What is the educational and clinical experience provided in plasmapheresis? Who supervises the clinical experience?
Both nephrology and pathology (blood bank) manage aspects of plasmapheresis care at our institution. There is an opportunity to learn and manage pheresis therapy during training.
Does the program offer a renal Palliative Care didactic and/or clinical experience?
Yes. There are didactic experiences and a one-day communication workshop developed by Dr. Robert Cohen in which these issues are addressed and specific skills modeled/practiced.
Does the program have a research requirement for fellows in a two-year clinical track? What are the expectations of the fellow? Who supervises this experience? How are mentors determined? Is there protected time for research? If so, during which years, how much time, how is this time allocated and structured?
Fellows in a two-year clinical track are expected to take part in scholarly activity, to be decided upon mutually by the fellow and Dr. Lecker, the program director. Mentors are chosen individually and based upon the interests of the fellow. There is generally at least six months in the second year for research work.
Does the program offer extended research track positions beyond 2 years of fellowship? Are fellows guaranteed a third and other additional years for research if productive during the first research year? What requirements are there for receiving research support for a third or other additional years of research? How are research fellows funded? Is there a training grant available for eligible fellows?
Yes. Funded through an NIH Training Grant (T32) for eligible fellows. For those not eligible because of visa issues, all efforts are made to secure funding through foundation and institutional sources. We like to say that we have never been unable to support a fellow who wanted to continue to pursue investigative research!
How is it determined whom the fellows work with during their research years? How many basic and clinical research scientists are in the Division? Are fellows able to do research with scientists who are not members of the Division?
Selection of a research lab / project is a deeply personal decision. We are all about providing you with information, guidance and choices, but the decision is yours. Our division has a variety of basic/translational and clinical researchers that are ready and willing to serve as mentors. We have embraced the idea of fellows working for scientists that are not members of our Division, either within the BIDMC system or elsewhere in the scientific community of Boston.
Is there a research mentoring committee? What is their role?
We pair each fellow with a career mentor (separate from their clinic preceptor or research PI), whether they are on a clinical or a research track. That individual can provide career advice, but during research years can also serve to ensure grants are applied for, manuscripts written, etc., and that the laboratory experience for the fellow is optimized.
Are there required courses in research design, methods, statistics and ethics? Are there tuition costs to fellows for these courses?
There is boundless availability of courses in the Boston biomedical sphere. Many are freely available (i.e. Harvard Catalyst). Courses at the Harvard School of Public Health can be taken and tuition can be provided by our Training Grant in some cases.
Does the program have a Clinician Educator Track or offer Master’s Degrees programs to fellows? What courses, experiences, advanced degrees are offered?
We do offer an Education track, but do not offer a Master’s Program at this time. Educational opportunities abound at BIDMC. Please see the “Education Track” description for further details.
What sorts of quality improvement and/or patient safety activities are expected of fellows?
Each fellow is expected to perform a root cause analysis of a medical error and help to develop and implement a quality improvement project during their training. We typically have four ongoing projects in place that the entering fellows join. During their second year, the fellows continue with the projects they started in year 1 and orient a new fellow to the project to maintain continuity. If you have a particular interest in Quality Improvement, please see the description detailed in the “Quality Improvement” track.
What do fellows do after graduation from the program and where do they go?
About half remain in academic settings and half practice nephrology in the community. Click here to see a list of where all of our graduated fellows have gone!
Are there opportunities for teaching during my fellowship?
Yes. Residents and medical students are often present on our consult services as they rotate through clinical electives. There are ample opportunities for teaching at the bedside, on walk rounds, or “chalk talks.” If you have a particular interest in resident or medical student education, please see the Education Track description and approach one of the faculty mentors for information on how to be even more involved in teaching at BIDMC.
Do fellows receive funding for extracurricular scholarship, such as attendance at ASN Kidney Week?
Second year and advanced fellows have a travel and educational allowance for attendance at the annual meeting of the American Society of Nephrology or other scientific meetings. Unfortunately, first year fellows are the backbone of our hospital coverage during this time. Funds are available for the purchase of textbooks, enrollment in courses or other educational endeavors.
What is the on-call structure for fellows?
During the first year, the four fellows will each take a weeknight of pager (at-home) call – Monday through Thursday. For Friday through Sunday, each first-year fellow will cover two of the inpatient services once a month (with the other two services covered by a second-year fellow). The first-year fellow covering the weekend will cover the pager on Friday and Saturday nights, while the second-year year will take the pager call on Sunday night. Call schedules are decided amongst the fellows and program leadership. All fellows will have three weekends OFF per month, on average. Holiday coverage is also decided among the fellows.
What is the program’s policy about work-hour restrictions?
We strongly believe that a well-rested fellow is a better doctor! While the first year of fellowship is busy, we acknowledge that there may be times when a fellow is called in overnight to assist in the management of a sick patient and cannot safely stay for another whole work day. When these situations occur, we deal with them on a case-by-case basis. Collegiality is in the fabric of our fellowship and both attendings and co-fellows will find a way to get you home to rest.