Massachusetts General Hospital
Nephrology Fellowship Program

GOALS

The overall objective of the Nephrology Fellowship Program at MGH is to provide vigorous and comprehensive clinical and research training in nephrology for physicians to become productive clinical and basic scientists, and leaders in academic nephrology. The program offers a one-year rotation on the clinical services at MGH and Brigham and Women's Hospital (BWH), and three or more years of training in full-time basic or clinical research at MGH. The training goals to be achieved during each of the four years of training are tabulated.

Clinical Training ProgramThe clinical rotation is designed to help the fellow acquire the knowledge, management and technical skills, clinical judgment and attitudes essential to the practice of nephrology, as outlined in the ACGME Program Requirements for Residency Education in Nephrology. The educational experience includes formal didactic talks, clinical renal practice, acquisition of expertise in a wide variety of renal, hypertensive and fluid-electrolyte disorders, extensive training in renal transplantation, dialysis and extracorporeal therapy and versatility in performing a number of specialized procedures. Clinical learning and experience is largely acquired through one-on-one supervised patient care. The clinical rotation is comprised of three and a half months on the Dialysis service, three and a half months on the Renal Consultation service and three and a half months on the Transplant service. The fellow spends about half the time at each of the two major teaching hospitals (MGH and BWH). A two-week to one-month rotation as the renal consult at the West Roxbury VA Hospital is also included in the clinical rotation. Each fellow will have one half-day a week in an out-patient rotation with a faculty member, during which the fellow is exposed to the spectrum of patients with renal disease, and acquires the management skills needed to treat and follow this patient population. The clinical training experience encompasses therefore the following:

A. General Nephrology Each fellow will spend three and a half months on the in-patient consultation service, two months at MGH and 1 1/2 months at BWH. The consultation service at MGH also covers the Massachusetts Eye and Ear Infirmary. During this period, the fellow is expected to acquire experience in:

1. Disorders of mineral metabolism, including nephrolithiasis, osteoporosis and renal osteodystrophy

2. Disorders of fluid, electrolyte, and acid-base balance

3. Acute renal failure

4. Chronic renal failure and its management by conservative, nutrition and dialytic methods

5. End-stage renal disease

6. Hypertensive disorders

7. Renal disorders of pregnancy

8. Urinary tract infections

9. Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders

10. Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, renovascular disease and microvascular syndromes

11. Disorders of drug metabolism and renal drug toxicity

The Fellow will see all requests for consultation called in to the Renal Consultation service. After seeing the patient, the fellow discusses the problem with the visit for the Renal Consult service, writes an initial note after communication with the attending nephrologist, and follow-up notes as considered appropriate. Medical Residents rotating on the Renal Service may also take this role, and students are also involved in working up and following these patients. A fixed time is designated each day for the fellow (+/- student and resident) to meet with the attending nephrologist to discuss progress and plans. The fellow sees all the Nephrology Division patients admitted to the hospital, whatever the reason for admission is. If patients are admitted to the Renal Visit on the private medical service, the fellow and the visit will act as the primary caretakers (in concert with the medical house staff) during hospitalization. When patients are admitted to the medical ward service or other non-medical services, the fellow acts as a consultant giving input as needed and appropriate. The fellow also manages any problems with peritoneal dialysis patients.

B. Dialysis and Extracorporeal Therapy Each fellow will be exposed to dialysis and extracorporeal therapies during a three and a half months of the training, divided between MGH and BWH. During this rotation, the fellow evaluates all initial consults when hemodialysis is considered even if it is not imminent, supervised by the dialysis attending of the month. The clinical experience includes:

1. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.

2. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options.

3. Drug dosage modification during dialysis and other extracorporeal therapies.

4. Evaluation and management of medical complications in patients during and between dialysis and other extracorporeal therapies, including dialysis access and an understanding of their pathogenesis and prevention.

5. Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis.

6. An understanding of the principles and practice of peritoneal dialysis, including the establishment of peritoneal access, the principles of dialysis catheters and how to choose appropriate catheters.

7. An understanding of the technology of peritoneal dialysis, including the use of cyclers.

8. Assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the indications and interpretation of peritoneal biopsy.

9. An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy.

10. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.

11. An understanding of the complications of peritoneal dialysis, including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, pleural effusions, and other less common complications and their management.

12. An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient.

C. Renal Transplantation The activities on the Transplantation service include transplant donor and recipient evaluation, hospital admission of patients receiving transplants or those with transplants who are suffering from acute or chronic complications, as well as the outpatient management of patients post-transplant. Each fellow will have three and a half months of experience on an active renal transplant service divided between MGH and BWH. The fellow is trained in the pre and post transplant management and follow up of patients. During the rotation, the fellow attends two to three out-patient transplant clinics a week and participates in management decisions. This transplant experience includes the following:

1. Evaluation and selection of transplant candidates.

2. Preoperative evaluation and preparation of transplant recipients.

3. Immediate postoperative management of transplant recipients including administration of immunosuppressive drugs.

4. Clinical diagnosis and management of all forms of acute and chronic rejection including laboratory, histopathologic and imaging techniques.

5. Recognition and medical management of the surgical and non surgical complications of transplantation.

6. Long-term follow-up of transplant donors and recipients in the ambulatory setting.

D. Ambulatory Renal ServiceThe fellow will spend one-half day each week in the ambulatory practice setting, seeing the entire spectrum of out-patient nephrology. The fellow will evaluate the patients and formulate plans and will discuss the case with the attending physician. The fellow is responsible for communicating with referral physicians and for longitudinal follow-up of these patients when appropriate.This rotation will expose fellows to:

1. Evaluation and management of patients with hematuria and proteinuria

2. Evaluation and management of the complicated hypertensive patients

3. Management of patients with chronic renal failure

4. Evaluation and management of patients with nephrolithiasis

5. Evaluation of patients for transplantation

6. Transplant donor evaluations

7. Management of patients following renal transplantation

E. ElectivesA number of electives, usually 2-4 weeks, are available for the renal fellows.These are listed below.

1. Pediatrics This rotation may take place in the second or third year. The fellow will participate fully in the out-patient Pediatric Clinics at MGH, the in-patient consult service and conferences.

2. Radiology This elective is structured with the MGH Department of Radiology. During this elective, the fellow will attend the various renal-focused procedures and the interpretation sessions.

3. Pathology This rotation involves supervised training in the preparation and processing of renal tissues, and in the interpretation of the material by light or electron microscopy. During the elective, the fellow presents the pathology findings during the weekly pathology conference.

F. Technical and Other Skills Fellows will receive hands on training, including the indications, contraindications, complications, and interpretation of results of the following procedures:

1. Urinalysis and uroscopy
2. Percutaneous biopsy of native and transplanted kidneys
3. Peritoneal dialysis
4. Placement of temporary vascular access (subclavian, femoral or internal jugular) for hemodialysis and related procedures
5. Acute and chronic hemodialysis
6. Placement of peritoneal catheters
7. Renal ultrasound (use and interpretation)
8. Continuous hemofiltration, arteriovenous and/or venovenous
9. Hemoperfusion
10. Placement of temporary peritoneal catheters

Fellows are encouraged to acquire the knowledge base (that includes cost-effectiveness) and expertise in the following procedures:

1. Radiology of vascular access
2. Balloon angioplasty of vascular access
3. Therapeutic plasmapheresis
4. Interpretation of renal biopsies
5. Bone biopsy
6. Placement of permanent peritoneal catheters

 

Research Training ProgramThe goal of this three-year program at MGH is to develop highly committed MDs and/or PhDs into mature, broadly educated and independent scientists who will continue in nephrologic research. The program offers ample basic or clinical research opportunities, and an excellent environment towards achieving this goal. The main elements of the research training program at MGH are as follows:

A. Research opportunities Basic and clinical research activities involve several NIH-supported initiatives directed by the Staff of the MGH Nephrology Division. These include:

1. Program in Membrane Biology
2. Program in Leukocyte Biology & Inflammation
3. Program in Renovascular Development and Cystogenesis
4. Program in Dialysis & Transplantation
5. Program in Clinical Outcomes and Epidemiology Research
6. Program in Structural Biology

In addition, research on the induction of tolerance across concordant and discordant species is carried out in the Transplantation Biology Research Center, on the 9th floor of Building 149 in the MGH Navy Yard, one floor above the Reanl Unit's research laboratories. Fellows joining ongoing research projects in any of the above programs will receive intensive training in a multidisciplinary environment and be closely supervised by senior and junior faculty preceptors. There are ample opportunities for training in diverse disciplines of membrane biology, biophysics, immunology, cell adhesion, development, biochemistry, biophysics, cell signaling, structural biology and outcomes and epidemiology research. This provides a multidisciplinary approach in the study of one of the most heterogeneous organs in the mammalian organism -- the kidney. These approaches are applied in many cases to clinically relevant diseases such as nephritis, acute renal failure, electrolyte disorders, polycystic kidney disease, bioincompatibility, allograft rejection and vasculitis.

B. Didactic Training Acquisition of new research tools is most efficiently accomplished through the daily interaction of the fellow with an assigned person who already has the required methodological skills, and is able to transmit this knowledge in a friendly and comprehensive manner. Formal lectures are also offered that introduce the fellow to laboratory or to clinical investigation. In addition, MGH has established "The Society of Fellows". Among the activities of this Society is a formal introduction of fellows to the residents and Staff, a lecture series on grant writing, bioethics, conflict resolution, job hunting, and time management in two career families.At MGH, several such summer/fall programs specifically designed for new post-doctoral fellows are offered. Examples include "Current Techniques in Molecular Biology", a one month intensive course offered in July of each year, and covers the theory and practice of major molecular biology techniques including Bioinformatics. This course is followed by "Introduction to Laboratory Techniques in Molecular Biology", a more specialized two week intensive course offered by the Department of Molecular Biology at MGH. The third course "Issues in Physiologic Investigation" reviews specific principles, tools and methodologies for investigating physiologic questions, paying particular attention to the relative strengths and weaknesses of various methodologies. In addition to the formal course content, participants are exposed to a cadre of physiologic investigators, providing opportunities for faculty interaction and networking. "Design and Conduct of Clinical Trials", surveys the theory and practice of clinical trials, reviews design and conduct of clinical research, and enables participants to conceive, plan, propose and develop effective clinical trials. Content essential to the design and conduct of clinical trials are covered including the components of phase I-IV studies, the design and writing of study protocols, issues regarding patient recruitment and selection, human subjects, the informed consent process and regulatory issues. For additional course lists, see the MGH CRnet. Opportunities are available to further supplement the didactic programs described above; There are a number of opportunities for fellows to enrich their fundamental scientific knowledge with courses at Harvard College, Harvard Medical School, Harvard School of Public Health and Massachusetts Institute of Technology (MIT). A wide choice of relevant courses provides flexibility in structuring the overall fellowship program. In addition to these formal courses, a weekly lecture series, combined with clinical and research journal clubs, weekly laboratory meetings, and daily contacts with the mentor and the Program Director provide the other important venues for enhancing intellectual growth and development of the fellow in clinical investigation and basic research.

C. Choice of Preceptor and Research ProjectTrainees generally choose a mentor prior to beginning the fellowship. During the interview process, they also have the opportunity to learn about the work being done in the various laboratories, to consider specific research projects, and to discuss training and the research environment with current fellows. Clinical fellows with no previous laboratory experience are encouraged to work closely with their chosen mentor to develop a plan for the research years. If, however, such trainees are not able to identify a specific mentor and project area, the decision can be deferred until after initiation of the clinical year of training. To aid in this effort, the Nephrology Division has devised a seminar series during the summer and fall seasons of every year during which preceptors present their respective research. The trainees are then encouraged to meet with all of their potential preceptors in the training program to further discuss their career development plans. In addition, first year clinical fellows are encouraged to discuss their goals with more senior fellows, both for general advice and for more detail about the overall research directions previously chosen by other fellows. In this manner the trainees enter the research training program already familiar with the skills and interests of the entire faculty as well as personal knowledge of potential mentors. This process provides a smooth transition into the research arena, and presents the appropriate environment where enthusiasm among faculty and colleagues can be readily displayed to the young trainees in helping them choose such a career. Fellows are also encouraged to write a brief research grant proposal under the guidance of the mentor, a process that helps crystallize the candidate's research plans, and provides a training forum in grant writing.

D. Guidance and Evaluation During the research years, direct guidance of the trainee is the immediate responsibility of the individual preceptor. Fellows are however encouraged to interact with the other principal investigators and their personnel in the program, a process that will increase their overall knowledge base, and expose them to new fields and techniques that could be invaluable in their pursuit of independent scientific careers.The clinical fellows serving at the Massachusetts General Hospital will meeting with Drs. Arnaout or Bazar formally or informally. During these sessions, any issues relating to the clinical program are discussed, and any necessary refinements/improvements in the program implemented as a result. At MGH, the research fellows also have informal or formal (bimonthly) meeting with Dr. Arnaout, during which any issues relating their research training, environment and progress are reviewed and discussed. The fellows are also given adequate exposure to other faculty through several forums such as the visit of the month rotation, the formal year-round lecture series given by various principal investigators, the weekly presentation of clinical cases at the joint MGH/BWH Renal Grand Rounds, the weekly dialysis, transplantation, pathology and radiology conferences, through participation in the regularly scheduled journal clubs, and the weekly intra- and inter group presentations.The clinical fellowship program is overseen by a supervisory committee made up of two staff members from each Hospital. The committee meets quarterly to monitor progress of the fellows. Evaluations are communicated to each of the clinical fellows to provide them with opportunities for improvement and to help them refine their clinical and technical skills. Feedback to the research fellows is provided on a quarterly basis, after consultation with their preceptors and research colleagues. Each trainee meets several times a year with the Supervisory Committee to evaluate his/her progress and to make any necessary modifications in the program.

 

II. FORMATSTo achieve the Program's overall goals in providing quality training in patient care, teaching and research, several venues are utilized.

A. One-on-one teachingThis is traditionally the core of the learning process. It is carried out on a daily basis both in the clinical (in-patient and out-patient) and research settings.

B. Guided readings These include the following standard texts of Nephrology as well as material assembled into syllabi by faculty.

1. "The Kidney" edited by B.M. Brenner, "Diseases of the Kidney", edited by Schrier and Gottschalk, "Clinical Physiology of Acid-Base and Electrolyte Disorders" by Rose and "Renal Pathophysiology" by Rose and Rennke.

2. An extensive notebook of important articles in each area of general nephrology, emphasizing fluid and electrolyte and glomerular disease, has been organized by the MGH faculty.

3. An extensive Dialysis Curriculum with reprints.

4. Transplant and Transplant Immunology Curriculum with reprints.

5. Dialysis Manual by Daugirdas and Ing (portions)

6. A Manual of Renal Transplantation by Allen and Chapman (portions)

7. Continuous Ambulatory Peritoneal Dialysis Curriculum & CAPD Policy and Procedure Manual.

8. Sixty landmark articles in the field of nephrology selected by MKSAP.

9. The MGH Nephrology Division Nephrology Case Collection. This collection includes some classic cases with pathological correlations and some paper cases for study when an actual patient with a particular condition is not available for observation. It is supplemented by the Nephrology Division slide collection.

C. Independent reading Other texts and journals, as well as bibliographic search capabilities are available in the Nephrology Division library, the housestaff library, the MGH Teadwell library, and the Harvard Countway Library. Bibliographic searches are also available through the hospital's computer system. D. Weekly Conferences

1. MGH Renal Grand Rounds
This is a weekly hour-long formal seminar held on Mondays at noon in Bigelow 10 Conference Room (Rm 1030). A wide range of mainly clinical topics are presented by the MGH- and invited outside faculty.

2. Transplant Seminar
This is a joint seminar series with the MGH Transplant service, held on Mondays at 5 pm in Sweet Room -Gray 4. Formal presentations are given by MGH speakers from the Renal and Transplant Units, as well as by outside speakers. The subject matter addresses both basic and clinical aspects of transplantation immunology.

3. MGH-BWH Joint Renal Grand Rounds
This is a joint Teleconference between MGH and BWH, held on Tuesday mornings in Potts Conference Room- Bigelow 856. Interesting case presentations are reviewed and discussed, alternating with formal presentations in areas of science relating to renal disease.

4. Nephrology Division Seminars
These are held on Tuesdays at 4:00 pm at MGH East, Bldg. 149, 7th Floor Auditorium. Formal presentations are given by local as well as national and internationally-recognized basic scientists. These one-hour seminars cover a wide range of basic topics in membrane biology, cell and structural bioilogy and transplantation, and are designed to give the staff and trainees a braod and up to date exposure to major scientific progress.

5. Radiology Rounds
These are held on Wednesdays at 4:00 pm in the MGH Radiology Department in ACC 2. During these hour-long sessions, radiology reports on active renal patients are reviewed and the findings explained and discussed.

6. Medical Grand Rounds
These are held on Thursdays from 8-9 am in OÍKeeffe Auditorium, Blake 1st Floor.

7. Immunology Seminar series
This is held at MGH on Thursdays at noon at MGH East, Bldg. 149, 7th Floor Auditorium. Formal presentations are given by local as well as national and internationally-recognized immunologists. These one-hour seminars cover a wide range of basic topics in humoral and cellular immunology and inflammation.

8. Clinicopathological Conferences (CPCs):
The Cabot Clinicopathological Conferences (CPCs) are an old Boston medical tradition, published by the New England Journal of Medicine (NEJM) as Case Records of the Massachusetts General Hospital. The CPCs are held Thursdays, 12-1pm, in the O'Keeffe Auditorium, Blake 1st Floor. From a case abstract, an invited speaker (and the audience) must deduce the differential diagnosis for an anonymous MGH patient, arriving at the probable diagnostic procedure and its findings. Faculty from the Nephrology Division discuss 2 CPCs annually. These are held instead of the regular MGH-BWH Joint Renal Grand Rounds.

9. Dialysis Conference
This meeting is held from 1:00-2:00 p.m. on Thursdays in the Dialysis Unit, Bigelow 10, and attended by dialysis physicians, dialysis nurses, dietitians and surgeons. In this meeting, the progress of hemodialysis and peritoneal dialysis patients is reviewed.

10. Research Journal Club
This is held at CNY8 confernece room on Thursdays from 10:00-11:00 with the purpose of reviewing 2 recent scientific publications of broad significance and/or application to renovascular research.

11. Renal Pathology Conference
This is held on Thursdays from 3:00-4:00 p.m. in the Pathology Department, Putschar Conf. Rm, Warren Basement. The goal is to learn how to interpret renal biopsies and make correlations between the clinical and pathological findings. This conference also provides a useful forum to exchange

12. Clinical Fellows Conference
This is held at MGH on Fridays from 1:00-2:00 p.m. at GRB1037 renal conference room from September to June of each year. This forum is used to present problem cases in a group meeting that includes the clinical Staff, listen to formal presentations given by the fellows addressing an in depth review of a topic or of recent journal articles. This conference is directed specifically to the first year fellows. Each of the renal fellows, with MGH as their home base, will present 2 fellows' seminars at MGH and one at BWH. The fellows from BWH will present two at BWH and one at MGH. The objective is to become proficient in clinical practice and up to date in the nephrology literature.

13. Transplant Conference
This is a weekly conference held on Fridays from 7:30-9:00 a.m. in Wellman 1 Conference Room, and attended by the Renal and Surgical Transplant visits in conjunction with the Infectious disease visit and members of the Transplantation Biology Research Center. It reviews current cases, to teach important elements in the immunology of transplantation and in management of rejection and of infectious complications.

14. Nephrology Division Laboratory Meeting
This is held on Fridays from 1:00-2:00 pm at CNY8 renal conference room. Formal presentations by 1-2 research fellows of ongoing work are discussed by the research faculty.

In addition to the formal conferences listed above, a series of lectures is given at the beginning of the academic year on dialysis, transplantation and the care of renal emergencies.

E. Other Meetings Each fellow has the opportunity to attend one national nephrology meeting such as the annual meeting of the American Society of Nephrology or the spring Clinical meetings of the National Kidney Foundation. Research fellows attend these meetings to present their abstracts in oral or poster formats. Fellows may also attend the annual nephrology postgraduate courses held at harvard-affiliated hospitals.

F. Teaching Teaching is a very effective way of learning. As such, the fellows have ample opportunities of teach in this training Program. In addition to the daily bedside teaching of medical students and residents attending renal rounds, fellows also prepare for case presentations during Renal Grand Rounds and the Clinical case conferences, give formal talks that are presented to the Nephrology Division staff on three or more occasions each year, and present their research findings in the weekly laboratory meetings. Many fellows also participate with the MGH and BWH faculty in teaching renal physiology and pathophysiology to first- and second-year medical students at the Harvard Medical School.

G. Project Professionalism & Responsible Conduct of Research

1. Project Professionalism This program, developed by the American Board of Internal Medicine, offers a good forum for examining the various issues associated with caring for patients with end-stage renal disease.

2. Responsible Conduct of Research

The promotion and maintenance of scientific integrity is a basic tenet in the conduct of research. All research trainees are required to participate in a course given annually to new fellows in the responsible conduct of research.

H. The Fellowship Handbook This practical description of the MGH Renal Fellowship is designed to acquaint new fellows with the program structure, environment and expectations. It provides comprehensive details of the specific rotations, responsibility for patient care, coverage and techniques, and is distributed at the beginning of the clinical rotation.

 

III. EVALUATION Research and teaching evaluation is based on the individual's problem solving ability and his/her ability to conceive, design and carry out experiments that best address the question at hand. Other considerations include the fellow's interactive spirit, collegiality and technical assistance to others, and the cohesion and clarity of presentations and the teaching potential. Clinical evaluation by faculty of the trainees takes place through observation, assessment and structured feedback in areas including: acquired body of knowledge, physical examination skills, ability to communicate, technical proficiency, professional attitude and humanistic qualities during consultation, patient management, decision making and analyses of clinical situations.Evaluation of the clinical fellows is performed at the end of each month by the fellow's principal supervisor during that month. These written evaluations are reviewed three times a year by the Fellow Evaluation Committee. Feedback is reported to the fellow at the end of each month's rotation. At the end of the year, the Program Director summarizes the year's comments, including areas of strengths, deficiencies and growth during the year and shares the finding with the fellow. Evaluations are conducted using the following guidelines of the American Board of Internal Medicine.

A. American Board of Internal Medicine Guidelines for Evaluation The board defines the certifiable nephrologist at the completion of required training as being competent to provide comprehensive and specialized medical care based on a high standard of demonstrated component skills. These skills should clearly exceed those demonstrated by the certified internist. Specifically, the Board asks program directors and their faculties to evaluate the following components of clinical competence:

1. Clinical Judgment This is the process by which clinical decisions are made. Good clinical judgment encompasses a) integrating medical facts and clinical data, b) weighing alternatives, c) understanding the limitations of knowledge, d) recognizing complications of disease and side-effects of treatments, e) instituting prompt measures to deal with serious or life-threatening clinical manifestations, f) incorporating the consideration of risks and benefits to the patient, and g) developing a logical plan for evaluation and both immediate and long-term management. It implies that the individual can adapt to changes in medicine throughout his/her career.

2. Medical Knowledge This is defined as the specialized, current knowledge necessary to function as an expert clinical nephrologist. This includes a broad base of knowledge of the pathogenesis, natural history and management of congenital and acquired diseases of the kidney and urinary tract; renal physiology; disorders of fluid, electrolyte and acid base regulation; normal and disordered mineral metabolism; acute and chronic renal failure; the management of patients receiving immunosuppressive therapy; and the management and diagnosis of severe hypertension. The clinical nephrologist also must be proficient in the principles and applications of various forms of renal replacement therapy including the management and systems operations of hemodialysis, peritoneal dialysis and renal transplantation.

3. Clinical Skills These refined abilities include a) obtaining appropriately directed medical histories that are precise, logical, thorough and reliable; b) conducting expert, focused physical examinations that elicit subtle findings and are directed toward the patient's problems; and c) demonstrating understanding and proficiency while minimizing risk and discomfort to patients in the performance of certain diagnostic and technical procedures.

4. Humanistic Qualities These are integrity, respect, and compassion as demonstrated in the care of patients and their families. They include the abilities to be honest, involved, and responsive to the patient's wishes; to respect the patient's need for information; to establish the patient's trust; to provide empathy; and to maintain credibility and rapport with patients and their families.

5. Professional Attitudes and Behavior The attitudes, behaviors and communication skills defined as essential in relating to patients and educating them, their families, and other health care professionals. These include the ability and willingness to describe the diagnosis and likely clinical course to the patient and the family; explain therapeutic options (including benefits and side-effects); accept responsibility; and prepare comprehensive consultation notes in medical records and letters to referring physicians, patients and appropriate agencies.

6. Medical Care The outcome of the integration of the foregoing component skills is the ability to manage patients effectively and responsibly. Excellent medical care results from the consistent ability to apply appropriate, comprehensive care of high quality; to be responsive to the patient's needs; to use laboratory test, consultations and diagnostic procedures efficiently, effectively and in the patients best interest; and to maintain the patient's welfare as the physician's primary concern.

7. Commitment to Scholarship This encompasses the commitment to maintain and update clinical skills throughout one's professional career, to acquire new knowledge through computer access and by reading the current medical literature, to participate in the design and conduct of clinical studies or related research, to attend scientific and clinical meetings for nephrologists and to evaluate critically the new medical scientific information relevant to the subspecialty.

8. Moral and Ethical Behavior

This implies the consistent demonstration of a high standard of moral and ethical behavior expected within the clinical setting and of the medical profession. The ABIM considers it unethical for a physician to refuse to treat a patient solely on the basis of that patient's disease, when that disease is within the physician's area of competence. This philosophy has particular relevance to patients with AIDS or HIV seropositivity.

B. Evaluation of Teaching

At each formal teaching conference, a written sheet documents those attending the conference as well as elicits anonymous comments and ratings of the speaker or seminar leader, as well as the usefulness and practicality of the topic presented. Feedback from the fellows about the quality of the teaching and the general experience is formally elicited by the Program Director at the end of each rotation.

For more information, contact Wendy DeMille, (617) 726-3706, wdemille@partners.org