Career: Lifelong caring

THE UK’s aging population presents many healthcare challenges, one of which is an increase in the number of people with kidney disease. This rise has seen continued expansion in the specialty of renal medicine where doctors provide care across a wide range of clinical need, from acutely ill patients to those with chronic conditions.

It is this opportunity to provide long-term treatment that holds much appeal for specialists in the field who often care for patients over many years, allowing a partnership to develop between the patient and the renal multidisciplinary team.

There is great variety in the medical conditions that nephrologists treat, from diabetes to scleroderma, and amyloidosis to liver failure. Nephrologists are also increasingly sub-specialising in areas such as transplantation, while academic nephrology provides many opportunities to drive new research and improve patient care in renal medicine, dialysis and transplantation.

Entry and training

Doctors who have completed foundation training can enter renal medicine via core training (usually two years), choosing either core medical training (CMT) or acute care common stem in acute medicine (ACCS-AM). This is followed by higher specialty training for at least three more years.

The specialty training curriculum for renal medicine from the Joint Royal Colleges of Physicians Training Board (JRCPTB) details what is required to achieve a certificate of completion of training (CCT). (This includes payment to enrol with JRCPTB.)

The JRCPTB describes core training as providing physicians with: the ability to investigate, treat and diagnose patients with acute and chronic medical symptoms; and high quality review skills for managing inpatients and outpatients. Higher specialty training builds on these core skills to develop the specific competencies required to practise independently as a consultant in renal medicine.

Renal medicine has primary responsibility for the management of patients with kidney disease and specialists treat:

• disorders that primarily or solely affect the kidneys (such as some forms of glomerulonephritis)
• disorders that affect the kidney as part of a multi-system disease (such as diabetic nephropathy)
• disorders that are linked to changes or abnormalities in renal physiology (such as acid-base disturbances).

The curriculum requires competency in two main procedures - renal biopsy under ultrasound guidance (though this is not essential for CCT and trainees can opt not to gain this competency) and the insertion of temporary vascular access for haemodialysis, which is essential for CCT. Some nephrologists also become competent in the insertion of tunnelled catheters for haemodialysis vascular access and in the insertion of peritoneal dialysis catheters.

For a renal physician to participate in the acute medical take and to be responsible for the care of unselected, acutely ill general medical patients as a senior medical appointment, the JRCPTB requires dual CCTs in renal medicine and general internal medicine (GIM). It is also possible to dual accredit with other related specialties such as intensive care medicine. Dual accreditation means specialty training will usually be extended to seven years.

The job

The job of a nephrologist is both varied and challenging. Most work in renal units based in district general hospitals or in university teaching hospitals, where renal transplantation most commonly takes place. Many renal units also provide care in satellite haemodialysis units, either in other hospitals, independent treatment centres or in community-based facilities. Nephrologists who manage haemodialysis patients will also regularly visit a dialysis unit, either within the main renal unit or at a satellite unit. This can take up to half a day each week.

In larger renal units, consultant nephrologists often spend fixed blocks of time on-call looking after all renal inpatients on behalf of all the nephrologists in the unit. These arrangements typically last around two weeks, but vary depending on the size of the unit.

A growing aspect of the work of renal physicians, in partnership with primary care and some secondary care specialties, is the early detection of kidney problems and the prevention and management of progressive kidney disease. There is currently a national drive to improve the recognition and management of acute kidney injury (AKI).

Specialists work as part of a multidisciplinary team, particularly with renal nurses, pharmacists, dieticians, psychologists and social workers. There is also close involvement with other specialties such as vascular access and renal transplant surgeons, cardiologists, paediatricians, diabetologists and palliative care physicians. Patients with acute renal failure are often jointly managed with intensive care physicians and anaesthetists.

Renal patients are also prone to conditions such as sleep problems, weak bones, joint problems and depression and specialists will be expected to recognise and manage these appropriately.

The curriculum calls on doctors to appreciate that “patients have physical, social, spiritual and psychological needs”, highlighting the importance of promoting good communication with the patient and their family.

While the majority of people with chronic kidney disease will not develop progressive kidney failure, some will progress to end-stage kidney failure. It is in circumstances such as this that renal physicians must be able to offer the information and support that is needed by patients and families facing death.

The curriculum states that “renal physicians deliver effective patient-focussed care for patients with kidney disease throughout the patient journey from diagnosis to end-of-life care. This enhances patient care and facilitates high quality complex long-term decision making.”

Sources/Useful links:

• Joint Royal Colleges of Physicians Training Board - www.jrcptb.org.uk/specialties/renal-medicine
• The Renal Association – www.renal.org
• NHS Medical Careers - www.medicalcareers.nhs.uk

Dr Alison Brown is a consultant nephrologist and secretary of The Renal Association

Q&A Dr Sian Griffin, consultant nephrologist based in Cardiff

What first attracted you to renal medicine?

I rotated to nephrology when meandering through my medical SHO rotation with no clear plan and was immediately hooked. I’ve been lucky to work from the beginning with a group of committed and inspirational registrars and consultants. I was attracted by the uniquely close and lifelong relationship between patients with renal disease and their doctors, and the need to clearly understand both clinical and laboratory medicine. It was also very appealing to have available a blood test to tell you just how bad the situation was and access to a big shiny machine to fix it!

What do you enjoy most about the job?

Having dialysis or receiving a kidney transplant can be overwhelming for people. I enjoy providing an explanation and reassurance so patients and their relatives can regain a feeling of control over their situation. My research area has been renal immunology, and applying this to optimise the opportunities for renal transplantation and their outcome is very exciting. The impact of renal disease reaches beyond the patient into many areas of their and their family’s lives. Being part of a cohesive team that works to address these issues is one of the most rewarding aspects of the job.

What do you find most challenging?

Finding enough hours in the day!

Has anything surprised you about the specialty?

On the plus side - the rapid progression of legislation to allow altruistic organ donation, and the number of selfless individuals who have donated a kidney to a stranger. On the downside – I’ve been optimistically anticipating a cure for diabetes and hence the disappearance of diabetic nephropathy for years, but I think it’s still going to be the leading cause of end-stage renal failure for some time yet. What do you consider the most important attributes of a good renal medicine specialist? A nephrologist needs to be able to combine the ability to keep a clear head and make quick decisions in emergency situations, but also maintain long-term interest and engagement with patients. You need to work well with members of the multi-disciplinary team, and medical colleagues from many other specialties.

Is there any advice you could give to a final year or FY trainee considering renal medicine?

Do it! The specialty offers the opportunity to develop skills in the management of both acute, lifethreatening emergencies and chronic disease. There are unrivalled opportunities for research and working abroad – which might involve epidemiological studies, the unravelling of complex ethical issues, cutting edge clinical and basic science or disaster response. There’s never a dull moment.