The Penn Renal, Electrolyte and Hypertension Division Nephrology Fellowship Program

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1 QUESTIONS FOR NEPHROLOGY FELLOWSHIP APPLICANTS Jeffrey S. Berns, MD and Stuart Linas, MD The Penn Renal, Electrolyte and Hypertension Division Nephrology Fellowship Program Program Leadership and Faculty 1. How old is the fellowship program? How long has the program director been in that position? The Penn Renal, Electrolyte and Hypertension Division has been around since the early 1900 s (with various names over the years). Dr. Jeffrey Berns has been Program Director since Dr. Larry Holzman, our Division Chief since 2009, was the Nephrology Fellowship program director for many years at University of Michigan before coming to Penn. 2. Is the program director a regionally or nationally recognized expert in specific areas of clinical nephrology, scholarly research, quality/patient safety, or medical education? Dr. Berns has been involved in medical education for most of his career. His very involved in national societies (ASN, NKF, ABIM) and is recognized regionally and nationally for his clinical expertise, teaching excellence, and leadership in medical education. Of note, the American Journal of Kidney Diseases (AJKD) is moving its editorial office to Penn in January, 2017 with Dr. Berns as Deputy Editor and other Penn faculty as Editor-in-Chief (Dr. Harold Feldman) and in other senior editorial positions. We expect that this will provide opportunities for our fellows to participate in the editorial process. 3. Does the program have teaching faculty who are regionally or nationally recognized experts in specific areas of clinical nephrology, scholarly research, or medical education? We have around 30 faculty members, many of whom are regionally or nationally recognized in one or more of these areas. For questions 4 through 6, please click on the following link 4. Who are the key clinical faculty for the program? 5. What is their training and clinical background? What are the primary clinical, research, and educational roles of these faculty? Most of our faculty trained at Penn or similar programs. All of the key clinical faculty have many years of clinical experience and many are engaged to some extent in research. All are deeply devoted to medical education, and many are involved in teaching of medical students and residents as well as fellows.

2 6. Who among the key clinical faculty demonstrate evidence of productivity in scholarship, specifically via peer-reviewed funding and/or publication of original research, review articles, editorials, or case reports in peer-reviewed journals, or chapters in textbooks? Can the program provide some examples of this scholarly work? What of this work includes program fellows? In the past academic year, more than half of our clinical faculty published over 40 peer review articles and over 20 textbook chapters, excluding other high impact papers published by our primarily clinical, epidemiology, and basic science research faculty. These can easily be reviewed by a PubMed search (and some will be displayed at the time of interviews in our office) or from each faculty member s profile from the link above. About half of our fellows publish peer-reviewed articles; most have had an abstract, poster presentation, text book chapter or other scholarly activity. Resources 7. 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? We have a full-time fellowship-trained renal pathologist with back up when he is not available. Both native kidney and transplant biopsies are all read in-house and are available for review by fellows and faculty, usually within 24 hours (for light microscopy and immunofluorescence; EM takes a bit longer). 8. If fellows rotate to more than one hospital, who are the supervising faculty at each? Our fellows rotate to the Hospital of the University of Pennsylvania (HUP; with an ICU Service, a Transplant Service, and a Consult/Chronic Dialysis Service, the Philadelphia VA Medical Center, and Penn Presbyterian Medical Center (PPMC). All are within a minute walk of each other. Each hospital has full-time attending staff who are all on the faculty of the Perelman School of Medicine of the University of Pennsylvania. There are no private nephrologists at any of the hospitals. 9. Does the program utilize midlevel practitioners such as Advanced Practice Nurses or Physician Assistants? What is the responsibility/relationship of the fellows to these providers? We do not at this time, except on the HUP transplant service at times, and in two of our five dialysis facilities. We are actively considering this to help with care of chronic dialysis patients who are admitted to HUP. Educational Experiences 10. What is provided for fellow education in physiology, pathology, immunology/transplantation, clinical pharmacology, ethics/palliative care, renal imaging? Who provides this education? We have an extensive series of

3 conferences that cover all of these topics. Regularly scheduled conferences include a Fellow Case Conference (with Journal Club, Clinical Epidemiology, and other topics), Transplant Conference, Renal Grand Rounds, and Core Topics in Nephrology and Dialysis. These are taught by faculty in the Division, others from Penn (imaging, ethics/palliative care, pathology), colleagues from Children s Hospital of Philadelphia (with joint conferences several times per year), and visiting professors (typically at least 8-10 times per year). Dr. Berns co-directs a two-day regional symposium for first year renal fellows in early July. There is also a summer conference schedule for first year fellows. The Division also sponsors two home dialysis seminars and a CME program each year for area nephrologists which our fellows attend. 11. What simulation experiences do fellows participate in? We do simulation experiences for kidney biopsies and hemodialysis catheter line placement in the early part of the first year. We also have a new standardized patient (SP) experience for first and second year fellows that is run in conjunction with the Hospice and Palliative Care Division focused on discussing goals of care for patients in need of dialysis. This program was developed by one of our second year fellows who is joining the faculty. 12. What is the educational program and clinical experience of fellows in vascular access and peritoneal dialysis access? There are several conferences each year for fellows about dialysis access for hemodialysis and peritoneal dialysis; some are provided by interventional radiology, others by members of our Division. There is a HD access conference with Interventional Radiology once per month at both HUP and PPMC. Dialysis access is also discussed regularly as part of the Friday Core Topics in Nephrology and Dialysis conference. Fellows may spend time at HUP or PPMC with Interventional Radiology or do an elective at a free-standing access center in a nearby suburb in New Jersey. 13. How does the program prepare fellows for the business aspects of subsequent careers including private practice, academics, dialysis unit medical directorship, etc? This is covered thoroughly as part of our regular conference series (Renal Grand Rounds, Friday Core Topics/Dialysis Conference) and with on-line resources. 14. What is provided for fellow education in the principles, practice, and technology of dialysis? Who provides this education for fellows? This is covered thoroughly as part of our regular conference series (Renal Grand Rounds and Friday Core Topics/Dialysis Conference) by faculty members of the Division. 15. 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

4 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? We have approximately 450 in-center HD patient, PD patients, 20 nocturnal incenter HD patients, and home HD patients. Fellows get ample clinical exposure to each dialysis modality during their second year. Each fellow rounds in one of the out-patient facilities one day per week for 6 months on an assigned shift with a single attending and is also assigned a minimum of 4-6 home dialysis clinics. When rounding in the in-center unit, the fellow sees patients and writes notes with progressive independence under faculty supervision. Many fellows do additional home dialysis clinics. Faculty complete evaluations that are reviewed by the Clinical Competency Committee to assure that all fellows are skillful in their care of chronic dialysis patients. 16. Are kidney transplants done at the program s hospital(s)? 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) posttransplant 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 200 kidney transplants are performed at HUP each year including living and deceased donor as well as paired-exchange transplants. HUP is also a major referral center for liver, lung, heart, and other solid organ transplants and has a large oncology service with bone marrow/stem cell transplants. Fellows spend two months on the in-patient transplant service at HUP working closely with an attending; there may also be nurse practitioners and there is usually a nephrology transplant fellow as well. Fellows spend time in pre- and post-transplant clinics during their first (research track fellows) and second (research and clinical track fellows) fellowship years. Competency is determined through evaluations provided by our transplant faculty using milestonebased assessments. 17. If transplant is not done at the program s hospital(s), where do fellows go for the experience and what is the structure of the away rotation? If transplant is not done at the program s hospital(s), what experience is provided at the program for education and clinical care of patients pre- and post-transplant? Who provides this education and supervision? N/A; transplants (kidney, heart, lung, liver, bone marrow, stem cell, and others) are all done at HUP. 18. 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 hands-on experience allowed the fellows when doing supervised biopsies? How is competency in performing biopsies determined? Each fellow typically performs 8-10 or more native kidney biopsies and a similar

5 number of transplant biopsies. The biopsy experience occurs during both first and second years. Most biopsies are supervised by a nephrology faculty member assisted by an ultrasonographer. Competency is determined on the basis of evaluations by the supervising nephrologist. 19. 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? Our fellows do relatively few catheters but enough to be competent and comfortable with the procedure. While fellows are welcome to do as many as they please, most are done by others. Fellows can be supervised by renal faculty or others. We consider experience placing central lines during residency or other experiences in our assessment of competency during fellowship. We have a simulation experience for first year fellows with a plan to repeat this for second year fellows also. 20. 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? First year fellows typically spend about 12 weeks on the HUP ICU service (which has 2 fellows); there is ample ICU experience at PPMC and also, though to a lesser extent, at the VA. At HUP, there are several faculty with special interest in ICU nephrology. All fellows have extensive exposure to CRRT. We also periodically invite participation in conferences by various critical care faculty. Second year fellows may do a 2-4 week ICU elective (Cardiothoracic ICU). 21. What is the experience provided in interpretation of urinalysis, renal imaging, and renal pathology? How is competency in these demonstrated? Fellows get ample experience doing urinalysis with appropriate faculty supervision and evaluation. Fellows review kidney biopsies (native and transplant) for any their patients and patients they biopsied even if not their patient. We also have regular conferences to review renal pathology, including fellow-only conferences. Renal imaging is learned in the course of patient care and at conferences. Images can be viewed on all health system computers. 22. 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? Each first year fellow has one continuity clinic per week at either HUP or PPMC; second year fellows have two, keeping their first year clinic and adding a VA clinic. The non-va clinic is cancelled when they are on service. Fellows see a wide variety of patients, very similar to those seen by faculty. Fellows have primary responsibility for their clinic patients, with supervision by an assigned faculty preceptor.

6 23. 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 nonrenal transplants, etc? Fellows will have exposure to all of these conditions to some extent. We see pregnant women with kidney disease in the hospital and clinics. We have a relatively large pediatric to adult transition program given our location next door to Children s Hospital of Philadelphia. There is a large population of oncology patients cared for at Penn, including many with the newest and most advanced therapies available. We also have a large population of patients with kidney disease and non-renal transplants. 24. 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? Other than the first couple weeks of the first year, we generally schedule 4-6 patients for first year fellows and a few more than that for second year fellows. There is typically one faculty member for 1-3 fellows in clinic. 25. 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? We have specialty clinics in GN/lupus, complex hypertension, endocrine hypertension, kidney stones, and for transplant follow up. Fellows have ample opportunity to participate in all of these. Each clinic has a regional or nationally recognized expert. 26. What is the educational and clinical experience provided in plasmapheresis? Who supervises the clinical experience? We offer one or two lectures on plasmapheresis each year and fellows may do an elective block in the first or second year with the HUP Apheresis Service. 27. Does the program offer a renal Palliative Care didactic and/or clinical experience? We typically will have a 2-3 lectures and workshops per year on palliative care topics. As noted above we have a new standardized patients (SP) experience for first and second year fellows focused on communication with patient/family about goals of care, end of life matters, and dialysis initiation.. Scholarly Activities 28. Does the program have a research requirement for fellows in a 2-year clinical track? What are the expectations of the fellow? Who supervises this experience? How are mentors determined? Is there protected time for research?

7 If so, during which years, how much time, how is this time allocated and structured? All fellows in the clinical track are strongly encouraged to participate in scholarly work; some participate in research with a faculty member, others co-author review articles, book chapters, or other publications with faculty. Second year fellows have about 30% of their time free from clinical activities to pursue research, other scholarly work, QI projects, research in medical education, etc. Mentors for specific projects are generally selected by the fellow based on their individual interests. We have just started an annual Research Day where fellow on the both the clinical and research track present their scholarly work. 29. Does the program have a bibliography of scholarly work by fellows? Of such work, how much is published in peer-reviewed journals? How much is abstracts and/or case reports/case series only? We have a brag board in the Nephrology Division Office at HUP which displays recent publications by faculty and fellows. The Fellowship Coordinator maintains a list of publications by fellows which is available during an interview visit or any time at request. These include original articles, review articles, book chapters, abstracts, and case series, many in major journals and textbooks. 30. 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? Research track fellows must be eligible for a position on an NIH training grant. Our research track fellows are supported initially for a minimum of 2 years on one of two available training grants. The training grants provide support for our fellows in basic science research and those seeking a Masters Degree in Clinical Epidemiology, Translational Research, or Health Policy Research. Many fellows remain at Penn for one or more years following their training grant support with other research funding from the NIH or other sources. 31. How is it determined who 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? The Division currently has three very active basic science laboratories, several faculty who devote most of their time to epidemiologic/clinical or translational research, and others who are primarily clinicians but participate in clinical trials. We actively encourage our research track fellows to work with any of the vast number of Penn investigators outside our Division who best match their research interests and who can provide mentorship and collaboration.

8 32. Is there a research mentoring committee? What is their role? There is a mentoring committee that meets with each fellow early in the first year at which time a primary mentor for that year is assigned, regardless of track (clinical or research). As the interests of fellows crystalize, the assigned mentor may change in second year. For research track fellows, a mentoring committee is developed for each fellow that is designed to help the fellow maximize their research experiences and productivity. 33. Are there required courses in research design, methods, statistics and ethics? Are there tuition costs to fellows for these courses? For those fellows on a training grant, such courses are included as part of either the basic science laboratory experience or as part of the curriculum for a Masters degree. There are no tuition costs to fellows for these courses. Miscellaneous 34. Does the program have a Clinician Educator Track or offer Master s Degrees programs to fellows? What courses, experiences, advanced degrees are offered? The Department of Medicine offers a Medical Education track for second year fellows. 35. What sorts of quality improvement and/or patient safety activities are expected of fellows? All of our second year fellows, excluding those in the research track, participate in a QI project supervised by one of the faculty. The fellows select the project. 36. What do fellows do after graduation from the program and where do they go? Fellows enter a variety of career paths, including private practice and full-time clinical activities at major academic centers after training. Our fellows are highly successful in obtaining outstanding job opportunities. Some engage to various degrees in clinical, epidemiologic, or basic science research and/or have significant and important medical education responsibilities. Many of our current faculty were former Penn Renal Fellows. Practical considerations 37. Does the program provide clear information about benefits, call, money for dues, subscriptions, books? Is there support for meeting travel? Information will be provided about benefits at the interview. Fellows are provided an i-phone and pager. There is a parking/public transportation benefit. Each fellow has an annual professional expense account available to them for meetings and other expenses. We provide reimbursement for transportation if needed at night or when fatigued.