Nephrology

The Nephrology Program is pleased to offer a complete program for training to the nephrology resident.  This would include in center hemodialysis, home hemodialysis, peritoneal dialysis, ICU based dialysis delivery including CRRT,  plasmaphoresis, a full transplantation service, Chronic Kidney Disease clinic and a supervised longitudinal outpatient clinic experience. 

We have the capacity to train individuals who wish to pursue a career in an academic center or prefer a clinical/community focus.

The nephrology training program with the University of Saskatchewan is very much one that puts the resident as the center of the focus and the theme is to provide a balanced level of responsibility between exposure to patients in all clinical situations and an opportunity for independent study. 

Nephrology Residence Training Program, Example Schedule (pdf)

There is a graded level of responsibility in the program overall as well as in each year the program as the resident moves through the carefully selected experiences which include both an inpatient and outpatient experience.

The outpatient experience in particular is carefully structured so that there is a growing level of responsibility with appropriate supervision through the 2 years of a trainee’s experience that sees more careful supervision in the initial exposures but towards the end of training sees an independent management occurring with the appropriate review from an attending nephrologist.  Types of patients and the volumes of patients are carefully selected so that the trainee has an exposure to all ambulatory clinic experiences from glomerulonephritis, lupus, vasculitis, hypertension, polycystic kidney disease, diabetes and hereditary renal issues. 

Throughout both years of training there are highly structured and organized educational rounds, conferences that the residents are expected to attend.  Residents are protected from clinical duties to attend these educational sessions.  Funding is available for each trainee in the program to attend both the Canadian Society of Nephrology and the American Society of Nephrology conferences as well as additional conferences as additional requests are received.

Royal College of Physicians, Letter of Approval (pdf)

National Syllabus of Training Objectives for Nephrology Trainees (pdf)  

Throughout the 2 year experience of a Nephrology Fellowship at the University of Saskatchewan there are routine academic half days which are structured and protected for the trainee.  The seminars are presented either by staff nephrologists on a wide variety of topics which will touch on the learning objectives for the Nephrology Training Program which are also included in this description (see Royal College Training objectives).  The sessions will also see the trainee present sessions to an attending nephrologist and this typically happens in a one to one environment which allows for tailoring of the educational experience and tutoring of the trainee which is a unique experience for most trainees.

Please see below for the topics for Academic Half Day sessions.  These are usually held every other week on Monday afternoons with the alternate Monday being set aside for the trainee’s longitudinal ambulatory clinic.

Emergency Lecture Series - - In the summer the traditional academic half day is arranged so that the trainee is presented with a series of presentations on matters of more urgent and emerging care within areas such as hemodialysis, peritoneal dialysis, plasmaphoresis, transplant complications, acid base, fluid and electrolyte issues, etc.  Please see also the goal and objectives provided on these different areas within the overall Royal College and University of Saskatchewan nephrology training objectives.

The nephrology trainee call responsibility to the University of Saskatchewan is 1 in 4 nights on call that is home based. 

The resident is expected to self-schedule these responsibilities including one weekend a month but no more.  While on call the resident is responsible for overseeing the nephrology team (including junior internal medicine residents, residents from other training services as well as undergraduate medical students) for reviewing and providing care to acute consultations, admissions to hospital of renal patients as well as management of renal transplant patients.  This would also include delivery of acute dialysis, plasmaphoresis, continuous renal replacement therapy, managing the unstable dialysis patient, rounding on the evening shift of dialysis patients in conjunction with the on call consultant. 

Internal medicine residents (PGY1-3) are first call for nephrology ward and inpatient services at St. Paul’s hospital and the nephrology trainee serves as a second call for the St. Paul’s hospital inpatient services with full time back-up from the nephrology consultant who is required to not be more than 15 minutes away from site.  The nephrology trainee is also expected to address issues from the outpatient hemodialysis units for third shift as well as being the 2^nd call for nephrology consultations at Royal University Hospital as a subspecialty consultation resident is available for first call.  Saskatoon City Hospital nephrology consultations are done by the nephrology trainee and back up at both city hospitals and Royal University hospitals provided by the on call attending consultant.  Transplant issues would be addressed by the nephrology trainee on call with back-up from the transplant consultant on call. 

The nephrology service at the University of Saskatchewan is not an admitting service.  The nephrology service follows the renal patients in conjunction to their primary service to which they are admitted.

Over a two year period the Trainee is assigned two supervising Nephrologists who, with the Trainee, coordinate the Trainee’s longitudinal clinic. The Trainee is provided with their own Dictaphone and compute as well as remote access to the General Nephrology Groups EMR (Accuro Ò).  The trainee is expected to follow and manage the patients with an increasing degree of independence with the supervising Nephrologists.  Instruction and guidance in the real life clinical setting is given with regards to clinical management, communication strategies with patients and their families, physical examination, performing urinalysis, interpretation of clinical lab and renal biopsy investigations etc. Specific instruction is given with regards to how to create a clinical letter, dictation feedback from MD and office staff as well as feedback from referring MDs and patients.  Guidance and training as it relates to the practical elements of clinic (how to schedule patients, how long a clinic encounter is, economic considerations and submission of clinical billings) is included.
  
Careful construction of a clinic matrix re: diagnoses is performed by clinic supervisors to ensure the Trainee is exposed to a broad range of clinic problems in the outpatient setting. (see clinic matrix).

Various methods of examination and evaluation are incorporated into the two year training period. 

• Multiple choice examinations
• Ethical scenarios
• Real life scenario reports
• Short answer question based examinations
• Clinical scenarios
• Physical examination/clinical skills
• Hands on sessions re:central line insertion

Applicants who are interested in the University of Saskatchewan Adult Nephrology Residency Program would be expected to match through the CaRMS process and the residency training committee which includes the Nephrology Program Director, Chief of the Division of Nephrology, a nephrology trainee representative, a renal transplant representative, a home based therapies consultant representative as well as the organizer for Academic Half Day and a faculty member from the Regina Program, would review the application.  The ranking of trainees is performed by the committee and then submitted to CaRms with the highest ranked individual matching.  Our program is a guaranteed position for one trainee and given the opportunity to compete for an additional position.

An office for Renal Trainees is available on the 4^th floor of Saint Paul’s Hospital.  It is secured and contains modern furnishings with a separate computer and printer for Renal Trainees with access to University library on line.

This rotation has recently been re-structured as of the academic year 2016/2017

Pathology Teaching sessions are held twice a month over the academic year on the first and third Mondays at noon.  All the topics and objectives of training will be addressed in these sessions one of which will take the form of a “mini biopsy round”.  The Trainee will be responsible (paired with an assigned Attending Renal Pathologist) to prepare a short case with Pathology slides and present them to a small group in an informal setting.  The Trainee will take the group through the case, the appropriate slides and describe the relevant Pathological features of the medical condition as well as explain the specimen preparation techniques when appropriate.

Supervisors for the rotation are Dr. Rajni Chibbar and Dr. Tama Banerjee.

The pathologist will review the cases with you and provide instruction and teaching around the cases.  Where possible, the case will reflect what content is being taught in the corresponding Academic Half day (i.e. if membranous GN is being taught in Half Day the Pathology teaching that week will also address membranous GN)

Medical Expert/Clinical Decision-Maker

• Develop ability to evaluate renal biopsy specimens and recognize the histopathologic characteristics of both normal kidney and disease states as outlined below.
• Familiarize oneself with the various preparations for renal biopsy
  • Light
  • IF
  • Electron microscopy
• Explain and understand he different types of stains such as hematoxylin and eosin (H&E), congo red , methyl violet, periodic, acid Schiff (PAS), Trichrome (Masson), silver-stains, elastin stain, immunoperoxidase staining etc.
• Using real cases the trainee will seek to recognize the histopathologic characteristics of the following disease states on LM, IF, and EM

1. 1. Minimal change disease.
   2. Diabetic nephropathy
   3. Membranous GN
   4. Membranoproliferative GN
   5. Focal glomerulosclerosis
   6. Renal vasculitis
   7. SLE (ie WHO classification)
   8. IgA nephropathy
   9. Amyloidosis
   10. Myeloma kidney
   11. Interstitial nephritis, chronic and acute
   12. ANCA vasculitis  idiopathic RPGN
   13. Anti-GBM disease
   14. Post-infectious GN (especially PSGN and SBE)
   15. Scleroderma kidney
   16. Hypertensive nephropathy/nephrosclerosis
   17. Thrombotic microangiopathy
   18. Acute tubular necrosis
   19. Transplant

1. Acute cellular rejection
2. Acute vascular rejection
3. Calcineurin toxicity

Communicator/Collaborator

• Appreciate the importance of communicating the appropriate clinical scenario and lab investigations to the pathologist when requesting a renal biopsy
• Demonstrate ability to work and consult effectively with other physicians and health care professionals.

Manager

• Utilize resources effectively recognizing the need to expeditiously address patient needs but also individual educational and outside work needs.

Health Advocate

• Identify the germane determinants of health affecting patients with renal disease and appreciate the impact through the renal biopsy.
• Recognize and respond to those issues where advocacy is appropriate

Scholar

• Demonstrate ability to develop, implement and monitor a personal learning strategy that embraces a philosophy of lifelong learning.
• Critically appraise sources of medical information.
• Facilitate learning of patients, peers, colleagues and other health professionals.

Professional

• Endeavor to deliver the highest quality of care possible with integrity, honesty and compassion.
• Consistently practice ethical medicine as it relates to confidentiality

 

Medical Expert/Clinical Decision Maker

During the transplant rotation, the resident will be involved in various aspects of the care of transplant patients.  The resident will attend assessment clinics in which they will perform history and physical examination of patients referred for transplant suitability.  The resident will determine whether these patients are suitable to undergo kidney transplantation and will be involved in the formal evaluation of this, i.e. specific investigations required.  The resident will also determine the suitability of potential kidney donors.

The resident will be involved in the care of de novo renal transplant recipients and all aspects of their care (eg: immunosuppression selection and monitoring, immediate post-transplant management).  The resident will attend weekly clinics in which all patients with kidney (and kidney-pancreas) transplants are followed.  This will allow the resident to manage patients early after transplantation and in the late post-transplant setting with specific concerns for each patient group.

The resident will be trained to perform screening ultrasound on kidney transplants and will become proficient in performing renal transplant biopsies (including indications and contraindications).

Communicator
During the transplant rotation, the resident will develop skills as an effective and accurate communicator.  The resident will obtain accurate information from patients and families from the history and physical exam.  This will then be summarized to the consultant and all health care team members in the form of verbal communication or dictated letters.  The resident will utilize their communications skills and discuss the risks and benefits of transplantation and chronic immunosupression with the patient and family members.

Health Advocate
Renal transplantation serves to decrease the burden of chronic kidney disease.  When patients are assessed for suitability of renal transplantation as recipients or potential donors, the nephrologists is advocate for these people.  Nephrologists need to continually advocate for ongoing resources and community involvement in the awareness to organ donation.

The resident will be fundamentally involved in these processes by assessing patients in clinic.  The resident will also strive for knowledge towards organ donation awareness by attending various meetings of national and international societies.

 Manager
Managerial skills are critical in determining the appropriate use of investigations for screening of potential transplant recipients and donors.  The resident will learn to apply evidence-based guidelines to determine what investigations and in which patient population such resources should be utilized.

Furthermore, the resident will be a manager of their time devoted to clinical duties, continuing medical education and personal time.

Scholar
Research activities specific to transplantation will be encouraged.

Professional
Residents will value the ethical considerations specific to renal transplantation.  The resident will care for patients in an ethical manner and be respectful of donor issues.

The renal program aims to promote peritoneal dialysis as the first choice for renal replacement modality for suitable individuals.  The target is for 30 percent of renal replacement patients to be using peritoneal dialysis as a modality.

A similar program exists within Regina’s Renal Program.

At the end of their rotation in peritoneal dialysis, the trainees will be able to:

Medical Experts/Decision Maker

• Function effectively as a consultant, integrating CanMEDS roles to provide optimal, ethical, and patient-centered care related to peritoneal dialysis.
• Establish and maintain basic science and clinical knowledge, skills, and attitudes appropriate to peritoneal dialysis.
• Perform an appropriate history and physical examination, develop a differential diagnosis, and arrange appropriate diagnostic investigations for the patient on peritoneal dialysis, or soon to require peritoneal dialysis.
• Determine indications for and contraindications to utilization of peritoneal dialysis
• Demonstrate knowledge of indications and risks of peritoneal dialysis catheter insertion.
• Recognize and manage emergency conditions, including, but not limited to catheter exit site infection, peritoneal dialysis associated peritonitis, catheter malfunction/malposition, peritoneal membrane or ultrafiltration failure, dialysate leak, hernia development, and electrolyte imbalances.
• Develop an appropriate management plan and prescription (which includes therapy and prevention) for the patient requiring peritoneal dialysis.
• Demonstrate knowledge of the physiology of the peritoneal membrane, catheter connectology and dialysate solutions.
• Demonstrate skill in dealing with the psychological and ethical issues related to patients receiving peritoneal dialysis, including the ethical issues of death, discontinuation of dialysis and grieving.
• Seek appropriate consultation from other health care professionals, recognizing the limits of their expertise.

 Communicator

• Demonstrate the ability to establish therapeutic relationship with patients that emphasize rapport, trust, and ethics.
• Demonstrate the ability to communicate effectively with patients and their families regarding their kidney disease, as well as with colleagues and other professionals.
• Develop a common understanding on medical issues, problems, and plans with patients, families, and other professionals in order to come up with a shared plan of care.
• Provide a clear and thorough explanation of diagnosis, investigations, and management plan.
• Produce written reports of patient assessments in an expedient, thoughtful, and concise manner.
• Discusses problems related to the initiation and withdrawal of dialysis, and the management of death from renal failure in an effective and ethical manner.

Collaborator

• Effectively participate in interdisciplinary team activities.
• Interact with other members of Renal Services including vascular surgeons, vascular access nurse, interventional radiologists, transplant program, and hemodialysis program, as patient require interventions or changes in renal replacement modality.
• Interact with other health care facilities that assist in the provision of temporary, respite or long-term peritoneal dialysis.

Manager

• Assumes the care of the peritoneal dialysis patients while on the rotation.
• Demonstrate management skills effectively for maximal patient care, and by working effectively within the health care organization.
• Demonstrate the ability to manage one’s practice and career effectively and efficiently.
• Allocate finite health resources wisely.
• Serve in administrative and leadership roles, as appropriate.

Health Advocate

• Respond to individual patient needs and issues as part of patient care.
• Effectively work with other health care professionals to prevent, negotiate, and resolve inter-professional conflicts in patient care.
• Identify important determinants of health affecting patients, communities, and populations, including poverty, unemployment, social support systems.
• Recognize when advocacy is appropriate, and articulate a plan of advocacy.
• Promote the health of individual patient, communities, and populations.
• Be sensitive to the needs of marginalized patients and those from different cultural backgrounds such as the aboriginal patient.

Scholar

• Demonstrate an understanding and commitment to the need for continuous learning.
• Develop a personal CME strategy, including the demonstration of critical appraisal skills.
• Facilitate learning of patients, house staff, and other health professionals, and serve as an effective role model.
• Participation and presentation for weekly Renal Grand Rounds.
• Contribute to the development of new knowledge by participating in scholarly activity including original research, case reports, and continuous quality improvement (CQI).

Professional

• Demonstrate a commitment to patients, the profession, and society through ethical practice and through participation in profession-led regulation.
• Demonstrate a commitment to physician health and sustainable practice.
• Meet deadlines, be punctual, monitor patients, and provide follow-up.

During the Rotation on the Ward the Renal Resident will be involved in all aspects of the care of the renal patient.  In Saskatoon Health Region the Nephrology Service does not admit to themselves but rather follows all patients in consultation with another physician. The approach to care of the patient deviates very little however from the traditional model of the Nephrologist as the most responsible physician. It is expected that all patients will be seen each day and a note written.

The Team for in-patient care is comprised of an Attending Nephrologist, the Renal Trainee and, although not consistently, a number of Core Internal Medicine Residents (PGY1-3) as well as an undergraduate medical student (Clinical Clerk/JURSI).

Medical Expert/Decision Maker

• Function effectively as a consultant with regards to the nephrological issues of the patient
• Expected to have an in-depth understanding of:
  •     Acute kidney injury
  •     Chronic kidney disease
  •     Evaluating renal function
  •     Acid-base disorders
  •     Fluid and electrolyte disorders
  •     Overdose management
  •     Care of the renal patient in the Critical Care unit
  •     Continuous renal replacement therapies
  •     Placement of central venous catheters so as to facilitate acute hemodialysis
  •     Management of complicated patient presentation including sepsis, vasculitis, systemic lupus, rhabdomyolysis etc
  •     Anemia
  •     Clinical presentation, management of, investigation for and pathophysiology and pathology of glomerulonephritis
  •     Indications for renal biopy
  •     Approach to proteinuria and hematuria
  •     Approach to hypertension- secondary and primary
  •     Effect of diabetes on the kidney
  •     Management of peritoneal dialysis technique and complications of ie. Peritonitis
  •     Management of complications of hemodialysis vascular access

Communicator

• The resident will develop skills in eliciting information from patients and families as well as discussing with patients and families the consequences, impact, and treatment of various renal diseases. These communication skills will help to eestablish good relationships with patients/families.
• Communication skills will be assessed through the trainee’s ability to take an accurate and cohesive medical history from the patient as well as use of (where appropriate) parallel history’s from family members associates etc.
• Communicate effectively with Nursing and other Allied Health Care professionals in a multidisciplinary team approach to the care of the patient with renal issues.
• Recognize listening as an integral part of communication
• Be expected to demonstrate excellent written communication skills as demonstrated in their consultation, progress and procedure notes.
• Convey respect and dignity to patients and their families as well as to other members of the multidisciplinary Team
• Be sensitive to the cultural and gender issues that arise in the care of the inpatient

Collaborator

• Recognize that the care of the renal patient is complicated and is best provided through a multidisciplinary team approach
• Attend the multidisciplinary team rounds where patient issues are presented and discussed by all members of the team
• Learn to develop a care plan for the patient with renal issues that is reflective of the opinions and input of all members of the multidisciplinary care team
• Be able to recognize the roles and responsibilities as well as strengths and abilities of other members of the health care team
• Effectively communicate with the members of an interdisciplinary team in the resolution of conflicts, provision of feedback, and where appropriate, be able to assume a leadership role.

Health Advocate

• Be expected to recognize the importance of the determinants of health as it relates specifically to the development of kidney disease and he challenge of living with and management of renal disease including end stage renal disease.
• Recognize their role as a nephrologists in advocating for their patients for access to care, new developments in care, and to decrease the burden of disease for those conditions (medical, societal, environmental, and cultural) that contribute significantly to the development of renal disease.
• Identify those patients who are at risk for the development of renal disease

Manager

• Utilize investigations appropriately and in a timely fashion as it relates to the  diagnosis and management of the patient with renal disease
• Manage time wisely to address the needs of the patient as well as their own educational, career and personal needs.
• Understand their role as a manager in the care of the renal patient ie. Decisions made by them as it relates to dialysis, biopsy, use of medications etc
• Have a sense of the economic impact of their decisions ie. use of scarce resources such as on call nurses, dialysis technology, radiology/surgical procedures etc and to balance these with the genuine medical needs of the patient

Scholar

• Recognize the importance and develop strategies to address one’s commitment to continuous learning.
• Develop an approach to continuous professional development with an emphasis on building critical appraisal skills.
• Participate in and facilitate the educational and learning for patients, house staff, and other health professionals
• Serve as an effective role model for junior members of house staff
• Participate in scholarly activities such as CQI and case reports.

Professional

• Demonstrate an ethical commitment to one’s patients, the practice of nephrology and to society.
• Demonstrate a commitment to physician health and sustainable practice.
• Meet deadlines, be punctual which demonstrates respect for others one works with and provide follow-up on patient orientated management plans.

The Chronic Kidney Disease Program Saskatoon Health Region is committed to providing comprehensive kidney care to those individuals with identified chronic kidney disease.  This care is provided through an active inter-disciplinary health professional clinic together with Outreach Programs to Northern Saskatchewan.

The Nephrology Trainee will be a full partner in the CKD program and by the end of the two-year training period will have acquired the skills necessary to manage this complex patient group. 

Medical Expert
In-depth understanding of Chronic Kidney Disease including:       

•     Definition of CKD
•     Epidemiology of CKD
•     Methods of estimating kidney function
•     Risk factors for development of CKD
•     Identifying patients with CKD, including recommendations for how to screen for CKD
•     Managing conditions relating to progression of CKD (ie. Blood pressure, blood sugar, and proteinuria)
•     Managing complications of CKD (ie. Anemia, mineral metabolism, cardiovascular disease, acid-base disorders, malnutrition)
•     Timely referral for dialysis access and renal transplantation
•     Appropriate discussion regarding advance care directives and end of life care

The Nephrology Trainee will also develop expertise in continuous quality improvement in the CKD program.  The Nephrology Trainee will attend regional, national and international conferences related CKD.

Communicator
The Nephrology Trainee will develop the necessary skills to:

•     Establish rapport with patients and families in the CKD clinic
•     Elicit accurate clinical information and patient/family concerns/beliefs/expectations about their condition
•     Deliver accurate and comprehensible information to patients and families in a culturally sensitive manner
•     Communicate effectively with other members of the inter-disciplinary team, including the primary care physician
•     Ensure written communication is prompt, accurate and informative and advances the care of the CKD patient
•     Convey respect and dignity to all
•     Deliver “bad” news

The Nephrology Trainee will attend communication workshops provided by the Saskatoon Health Region.

Collaborator
Comprehensive management of Chronic Kidney Disease requires multiple interventions by many members of the health professional team, patient support groups, families and friends.  The Nephrology Trainee will be required to:

•     Develop a case management plan with other members of the CKD team to ensure optimal care for the patient
•     Participate in inter-disciplinary team meetings in a collegial, respectful manner
•     Participate in the CKD Outreach programs with other members of the team
•     Interact with patient support groups ie.  Kidney Foundation of Canada
•     Interact with other members of Renal Services including vascular surgeons, interventional radiologists

Health Advocate
The Nephrology Trainee will learn the skills necessary to promote healthy behaviours as related to CKD by:

•     Identifying important determinants of health in regards to CKD ie poverty, lack of social support, cultural issues
•     Assess and manage a patient/family’s ability to access health services in Northern Saskatchewan including both urban and rural areas
•     Educate patient/family/public about healthy CKD behaviours
•     Participating in regional and national groups/societies to decrease the burden of illness (ie.  Saskatchewan Medical Association, Tribal Councils, CSN, KFOC)

Manager
Through involvement with the CKD clinic and Outreach Programs, the Nephrology Trainee will learn to:

•     Utilize Telehealth to advance health professional knowledge about CKD
•     Utilize Telehealth to improve care delivery through CKD clinics and educational sessions for patients/families
•     Utilize resources effectively and efficiently
•     Priorize multiple demands by patients/families and the rest of the inter-disciplinary team
•     Have a basic understanding of how to operate a nephrology practice

Scholar
The Nephrology Trainee will participate in Continuous Quality Improvement in the CKD program and will be encouraged to develop a clinical research project with members of the inter-disciplinary team. 

Professional
The Nephrology Trainee will display empathy, compassion and act in a highly ethical manner in all aspects of the CKD management.  This will be facilitated by discussions with all members of the CKD team on an ongoing basis. 

The Longitudinal Fellow Clinic and Ambulatory Care Clinic rotation is a general nephrology clinic.  Trainees will learn about a variety of nephrology disorders including hypertension, diabetic renal disease, renal stones, inherited kidney diseases (ie:  Alport’s, PCKD, Fabry’s, IgA nephropathy), primary and secondary glomerulonephritis, renal vascular disease, reflux nephropathy, disorders of body water and electrolytes and tubulointerstitial diseases.  Trainees will learn a comprehensive approach to the investigation and treatment of these disorders.

Supervisors:  Dr. J. Kappel, Dr. R. Stryker, and Dr. J. Barton

Location:  St. Paul’s Hospital, Saskatoon

Medical Expert

•     Demonstrate the skills of outpatient management to allow timely and efficient management of outpatient consultations
•     Learn when there is a need for urgent inpatient management
•     Develop an understanding of the pathophysiology and risk factors for different types of kidney disease, including diabetic renal disease, hypertensive nephrosclerosis, genetic renal diseases etc
•     Determine the etiology of chronic kidney disease and identify potential reversible factors.
•     Demonstrate in-depth understanding of the factors associated with chronic kidney disease progression and their management
•     Demonstrate an understanding of the therapeutic targets and treatment options for various kidney disorders, utilizing published guidelines
•     Develop dictation skills
•     Develop independence in the management of common kidney disorders over the two years of fellowship
•     Develop the ability to prioritize patient care issues and plan followup appropriately

Communicator

•     Communicate clearly and effectively with the patient and family about the diagnosis and management plan
•     Communicate clearly and effectively with the referring physician about the diagnosis and management plan
•     Document each patient encounter either by oral or written communication (including disclosure of side effects or risks of treatment) to the patient and/or family and other health care providers as needed
•     Participate and assist in multidisciplinary patient care meetings as required

Collaborator

•     Develop expertise in the supervision and implementation of patient care decisions in the context of a multidisciplinary kidney team
•     Work closely with patients and families to promote adherence to the management plan

Manager

•     Learn the skills needed to arrange care both within and outside the office setting to allow timely and efficient patient care
•     Demonstrate an understanding of how to operate an outpatient practice
•     Priorize multiple demands of outpatient care and in-hospital medicine

Health Advocate

•     Identify some of the determinants of health in kidney patients and opportunities for advocacy and health information
•     Identify patient/family resources to assist patients/families to maximize health benefits
•     Demonstrate an understanding of government funding of kidney related therapy
•     Identify barriers (financial, social, psychological) to patient care and develop plans to ameliorate these barriers

Scholar

•     Identify personal learning needs and develop a strategy to address these needs
•     Appropriately use resources (written, online and conference) to allow ongoing personal education
•     Assist in the education of others – patients, families, other health care professionals

Professional

•     Deliver quality care with integrity, compassion and honesty
•     Demonstrate attitudes and behaviours consistent with a consultant
•     Balance professional and personal priorities to ensure sustainable practice

Medical Expert

•     Determine the indications for acute and chronic hemodialysis
•     Be familiar with the Canadian Society of Nephrology  and K-DOQI guidelines for institution of dialysis, etc
•     Be proficient in writing hemodialysis orders and modifying same as needed and have knowledge of dialysis adequacy
•     Be familiar with the workings of the hemodialysis machine and the mechanics of hemodialysis
•     Understand the water treatment system
•     Dialysis membrane choices
•     Access planning, creation, revision/problems
•     Placement of acute hemodialysis lines
•     Management of poisonings by hemodialysis
•     The dialysis diet
•     Anticoagulation of the hemodialysis patient
•     Management of anemia
•     Drug dosing in hemodialysis
•     Mineral and bone disease management
•     Vaccinations and the dialysis patient
•     Intradialytic and other medical complications and their management
•     Learn the principles and manage the care of the home hemodialysis patient
•     Understand the principles and become proficient in the performance of continuous renal replacement therapies in the intensive care unit setting

Communicator

•     Establishes relationships with hemodialysis patient and their families.
•     Discusses the impact of dialysis on the patient and their families
•     End of life discussions
•     Communication with the Clinical Coordinator and dialysis access coordinator

Collaborator

•     Works together with the clinical coordinator to schedule hemodialysis
•     Works with the dialysis access nurse and surgeons to plan hemodialysis access in a timely fashion
•     Works with the radiologist to manage dialysis access problems
•     Participates in weekly multidisciplinary hemodialysis rounds
•     Participates in monthly dialysis access rounds with the access coordinator, radiologist and vascular surgeon
•     Works with the pharmacist and dietitian reviewing monthly dialysis laboratory results

Health Advocate

•     Identify the important determinants of health such as poverty, unemployment, social support system for the hemodialysis patient and adapt their management accordingly
•     Recognize the role of the nephrologist as an advocate for hemodialysis patients regarding access to satellite hemodialysis, transportation issues etc.
•     Be sensitive to the needs of marginalized patients and those from different cultural backgrounds such as the aboriginal patient

Manager

•     Balance time between patient care, on-going learning, and outside activities.
•     Support the house staff with expertise/backup/feedback
•     Assumes the care of the hemodialysis patients while on the rotation

Scholar

•     Research Project  in the hemodialysis unit
•     Participate in quality initiatives; attend weekly dialysis rounds, monthly radiology rounds, satellite dialysis patient clinic.
•     Participation and presentation for weekly Renal Grand Rounds and teaching of medical students, internal medicine and anesthesia residents.

Professional

• Care for each dialysis patient in an ethical and compassionate manner

Medical Expert

•     Learn critical appraisal of pertinent literature
•     Develop a working knowledge of statistical methods
•     Attend at least one national or international kidney conference

Manager

• Develop an understanding of budgetary processes in relation to research

Communicator

•     Present research at local level and Resident Research Day.
•     Submit abstract or poster at national or international nephrology meeting

Collaborator

•     Work with staff Nephrologist to determine relevant and feasible studies to undertake
•     Interact with other health professionals, eg. Pharm D etc, to develop research protocols of both short and long term duration
•     Network with other Canadian fellows re research interests

Scholar

• In association with staff Nephrologist perform quality assurance audits in the Division

Professional

• Interact with Ethics (IRB) regarding research study protocols

Health Advocate

•     Participate in research programs with other Divisions or research groups.  Participate, if asked, in public forums to describe research activities as they pertain to kidney disease
•     Under supervision of staff Nephrologist interact with funding agencies