Clinical Experience

Overview

First Year

During the first year, fellows rotate at several sites within the UC San Diego Health System.  At Jacobs Medical Center in La Jolla, fellows gain exposure to a large academic health system rotating on the inpatient consult service and, separately, inpatient transplant service.  At Hillcrest Medical Center, fellows rotate on the inpatient consult service at a safety net hospital in San Diego County.  Lastly, fellows rotate at the Jennifer Moreno Department of Veterans Affairs (VA) Medical Center in La Jolla, with simultaneous inpatient and outpatient responsibilities designed to mimic real-world nephrology practice.  Fellows function as a consultant on all rotations and are responsible for coordinating care with primary and other clinical services.  During their outpatient rotations, fellows attend clinics at UC San Diego and the VA Medical Center, exposing them to all aspects of nephrology including acid-base and electrolyte disorders, glomerular disease, resistant hypertension, acute kidney injury, and chronic kidney disease.  Didactics are delivered twice weekly to discuss core content, discuss clinical cases, present journal articles, and review quality improvement measures.

Second Year

During the second year of the two-year clinical fellowship, time is divided between additional inpatient training and outpatient electives tailored to the interests of the trainee. These have included additional exposure to peritoneal dialysis, apheresis, bone biopsies, joint rheumatology-nephrology lupus clinic, and transplantation.  In additional, fellows can rotate outside the division in areas of interest such as palliative care, pediatric nephrology, urology, or interventional radiology.  During their second year, fellows become the primary nephrologist (supported by a paired faculty physician) for a hemodialysis shift at the VA Medical Center, providing care to all patients on that shift throughout the year.

Clinical Rotations

Hillcrest Inpatient Consult Service

Consultations involve patients with acute kidney injury (of all causes), chronic kidney disease, electrolyte disorders, hypertension, toxicological emergencies, and patients requiring acute apheresis therapy. Fellows obtain extensive experience with all aspects of inpatient nephrology with a concentration on ICU care and intermittent and continuous dialysis for acute kidney injury. The consultation service usually consists of medical students, medical residents, the nephrology fellow, and a nephrology attending (faculty) physician. The fellow supervises and instructs the student and resident, and formulates a diagnostic and treatment plan for each consultation. These formulations are discussed with the nephrology attending physician during daily consultation rounds.

Kidney Transplant Service

During the transplant rotation, the fellow is exposed to all aspects of kidney transplantation. At UCSD, the nephrology service maintains a strong relationship with the transplant surgeons. We provide care from the pre-operative period, through the post-operative hospital stay and in short- and long-term follow-up outpatient clinics. The transplant program has an accredited renal transplant program with dedicated faculty to further focus and improve the quality of the training received by the fellow. Additionally, the fellow attends the pre-transplant patient selection meetings and is exposed to the kidney transplant selection criteria. Transplant biopsies are reviewed with our on-site kidney pathologists.

VA Medical Center 

The VA rotation most closely mimics the experience of practicing nephrologists. The fellow balances their time between the care of chronic hemodialysis and peritoneal dialysis patients, an inpatient consult service' and several weekly clinics. The VA has a state-of-the-art dialysis center with a chronic hemodialysis population of seventy patients. The inpatient consultations present a wide range of kidney disorders with a high percentage of electrolyte disorders, acute kidney injury, and chronic kidney disease. Clinics focused on hypertension, chronic kidney disease, transitioning to dialysis, and peritoneal dialysis are attended by the fellow.

Jacobs Inpatient Consult Service

This is also a consult-only service. As with the Hillcrest rotation fellows will obtain extensive experience with all aspects of inpatient nephrology with a concentration on ICU care and intermittent and continuous dialysis for acute kidney injury. Apheresis modalities are frequently used such as stem cell collection and photopheresis. The patient population includes those with rare hematologic and cancer disorders, heart disease requiring advanced therapies, and patients transferred from throughout the Southwestern region for specialized care.

VA Outpatient Dialysis Shift

The fellow takes primary responsibility for patients receiving chronic hemodialysis on their designated shift at the VA Medical Center. With over 120 patients total, the fellow is educated in all aspects of the provision of chronic outpatient dialysis, including access complications, dialysis adequacy, anemia, and renal osteodystrophy management. Fellows are also exposed to the administrative side of maintaining an accredited and successful outpatient dialysis program including water treatment, patient selection and transition from CKD to ESRD, and performance improvement. The fellow works as part of a multidisciplinary team including the attending physician, nursing staff, social workers, dieticians, and dialysis technicians all dedicated to providing quality care for patients with ESRD.