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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..
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.
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.
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.
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.
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.
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.
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.
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.
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.
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!
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.
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.
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.
Medical Education and Quality Improvement Experiences
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.
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.
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.
The Pheresis service is run by Hematology-Oncology at our institution, but they are very welcoming to involving us in the care of our patients. There is an opportunity to learn and manage pheresis therapy during the 2nd year of training as an elective.
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.
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.
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.
In this challenging and dynamic time, we are so grateful for the flexibility and collegiality of our fellows. This is the BIDMC culture. While each fellow was certainly called upon to do more work given the high volume of critically ill patients hospitalized during the COVID surge, we always prioritized, and will continue to prioritize, the safety and well-being of our fellows and their families.
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.
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.