III. Clinical Training
Georgetown nephrology fellows receive training as they rotate through the inpatient, outpatient services and the clinics, and through a series of lectures delivered by faculty and fellows. Fellows should expect to accomplish the following:
- Become confident in all aspects of nephrology practice and a wide range of problems encountered by patients with kidney disease, renal transplant or hypertension. Fellows receive instruction in taking an appropriate history, performing a complete physical examination and generating an appropriate differential diagnosis.
- Understand the pathophysiologic basis of kidney disease and hypertension.
- Develop a full understanding of the laboratory and imaging methods used to evaluate patients with kidney disease.
- Understand the principles of hemodialysis, peritoneal dialysis, home hemodialysis, home over-night hemodialysis, plasmapheresis, continuous renal replacement therapies and how to write both acute and chronic dialysis prescriptions.
- Learn to diagnose and treat a variety of primary and secondary kidney diseases.
- Understand the principles of immunosuppression and how to evaluate the potential renal transplant donor and recipient.
- Acquire a thorough understanding of the management of the renal transplant recipient.
- Learn to critically evaluate a scientific publication.
The first year of fellowship focuses heavily on clinical training. Medstar Georgetown University Hospital encompasses three ICU’s (medical, surgical, and neurosurgical), several IMC units, a solid organ transplantation ward. Kidney, Pancreas, Liver, and Multi-Visceral/Small Bowel Transplants recieve their care. An oncology ward, and many other general medical and surgical ward floors. This creates a well balanced environment providing a wide variety of clinical cases for inpatient training. The goal is to provide a first class clinical training but also to respect fellows time and to provide good opportunity for reading. In order to limit the patient load of each individual fellow and allow adequate time for didactics on rounds, the services are divided into three teams, each with its own fellow and attending:
- Acute Inpatient Service – this service manages episodes of acute kidney injury, acid base disorder, electrolyte disturbances, hypertensive disorders, onco-nephrology, and pregnancy related disorders in non-dialysis and non – transplanted patients
- Chronic/Dialysis Inpatient Service – This service focuses on the care of established dialysis patients (both hemodialysis and peritoneal dialysis) in the inpatient hospital setting
- Transplant Service – This service cares for all renal transplant patients and for renal disease in many other solid organ transplant patients including liver transplants, small bowel/multi-visceral transplants, pancreas transplants, and lung transplants.
Each team is comprised of one fellow, one Attending, and rotating Georgetown or visiting internal medicine residents, and medical students. Medstar Georgetown has four certified transplant nephrologists who run the Transplant service. Chanigan Nilubol M.D., is a full time faculty member in the Division of Nephrology and Hypertension and a trained and experienced transplant nephrologist. There is also a surgical transplant team with its own transplant surgery attending to provide a multi-disciplinary environment for these complex patients. There is a strong focus on clinical teaching while rounding. The aim is to provide an environment that is thought provoking with an open forum for questions and opinions. The inpatient teams form consultative services since medical patients at Georgetown are admitted by Department of Internal Medicine hospitalists. This permits the fellows to concentrate on the nephrology problems of the patient. Fellows receive training in many clinical services and procedures including: inpatient hemodialysis, inpatient peritoneal dialysis, continuous renal replacement therapy modalities in the ICU, slow continuous ultrafiltration, urine sediment microscopy, temporary hemodialysis catheter insertion (with real time ultrasound guidance), kidney biopsies (native and transplant), and plasmapharesis.
Each fellow participates in a rotating continuity outpatient clinic at Georgetown University Hospital throughout their training. The clinic is typically one half day a week. The fellow rotates every 6 months to interact with different faculty and specialty clinics. A few clinics focus on some selected nephrology topics including chronic kidney disease, resistant and secondary hypertension, oco-nephology, and kidney transplantation. Other clinics see general nephrology with a mix of different pathologies.
The second year of fellowship focuses on outpatient dialysis modalities, outpatient clinics, and on research. Fellows typically will rotate through the DC Department of Veterans Affairs Hospital for one of their outpatient clinics. Outpatient dialysis training is undertaken at the Georgetown University DaVita Dialysis units at Union Plaza and the “Home Only” unit at Wisconsin Avenue and at the Department of Veteran Affairs Hospital. Georgetown has the first “Home only” dialysis unit in Washington DC specializing in peritoneal dialysis, home hemodialysis and home over-night hemodialysis training. Fellows receive training in these rapidly expanding modalities.