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2 Specialties Renal medicineAcademic medicineThe RCP’s census of 2011 identified 540 consultants inrenal medicine in the UK. 9 Of these, 11% whoresponded held at least some academic sessions.6 Clinical work of consultantsInpatient workEmergency workEmergency work involves: treatment of AKI investigation and management of fluid andelectrolyte disorders medical emergencies arising among patients on RRT.As well as care of patients on renal wards, this worktypically involves consulting on patients in other wardsand other hospitals, both in person and by provision oftelephone advice.Investigative inpatient nephrologyThis relates to work associated with the immunologicaland metabolic nature of kidney disease, which involvesinvestigative procedures in an inpatient setting.Specialist procedures include renal biopsy; a renal unitcan expect to perform 150–200 renal biopsies permillion population per year.The setting for these beds should always be an acutehospital that offers the full range of supporting services,including imaging, pathology, immunology,haematology, biochemistry and microbiology.Different models for providing inpatient care havedeveloped according to local needs and the numbers ofconsultant renal physicians. In small units with two orfewer consultant renal physicians, consultants mayprovide continuing cover for all inpatient aspects ofrenal medicine. In larger units, individual consultantsmay provide continuing cover for subspecialty interests(eg transplantation and vasculitis) or may rotate coverfor all inpatients, devoting time to other activities (egresearch, management, teaching and audit) when notdirectly involved in inpatient care. The RCP’s workingparty report The changing face of renal medicine in theUK: the future of the specialty 32 recommended aminimum of four consultant renal physicians to make arenal unit autonomous for clinical care, includingon-call commitments.The RCP’s Joint Specialty Committee (JSC) for RenalMedicine has recommended that all patients admittedto a renal unit should be seen by a consultant within 24hours and that all inpatients should be reviewed by aconsultant at least twice a week. Consultant renalphysicians should therefore visit the wards daily to seenew admissions and new referrals from other specialtiesand should perform at least two full ward rounds eachweek.Outpatient workRenal replacement therapyA major element of the work of a renal physicianinvolves preparing patients with advanced CKD for RRTand providing medical supervision of these patients forthe remainder of their lives. Increasingly, they are alsoinvolved with conservative care of patients opting not toreceive RRT. Resources should be sufficient to supportan annual acceptance rate onto RRT of 120–130 newpatients per million population, with free choicebetween modality according to the patient’s needs.Available modalities should include hospital-basedhaemodialysis, home haemodialysis, peritoneal dialysis(including chronic ambulatory peritoneal dialysis(CAPD) and automated peritoneal dialysis (APD)) andkidney and/or pancreas transplantation for a suitableminority. Non-dialysis management requires leadershipby the renal physician of a full multiprofessional team inliaison with palliative care services. The role of, andfunding arrangements to support, ‘assisted APD’, inwhich healthcare workers are employed to helpdependent patients to perform APD, is being defined.PredialysisPatients with progressive renal failure should bemanaged in a clinic with multidisciplinary supportfrom dietitians and specialist nurses. Education andpreparation for dialysis, including referral for timelyformation of vascular access, should be available.TransplantationIn addition to monitoring and optimising kidneyfunction, renal transplant clinics should providemanagement of cardiovascular risk, osteoporosis andpost-transplantation pregnancy, and prevention anddetection of malignancy, especially skin cancer.General nephrologyOther outpatient activity is concerned with investigationand management of the wide range of kidney problemsthat do not necessarily lead to progressive CKD. In largeC○ Royal College of Physicians 2013 219
Consultant physicians working with patientsrenal units, further specialist clinics (often shared withother disciplines) may focus on specific clinical issuesfor people with kidney disease – eg clinics for peoplewith diabetes, pregnancy, lupus and vasculitis.A whole-time equivalent (WTE) consultant renalphysician should expect to work in three clinics perweek, which is likely to reflect a mixture of generalnephrology, predialysis, haemodialysis, CAPD, renaltransplant and specialty clinics. The number of patientsseen will vary considerably according to the clinic andthe support staff available. For example, a new patientwith established kidney failure may require 1 hour of aconsultant’s time if seen in a clinic without support staffbut might spend half an hour with the consultant andhalf an hour with other staff, including a specialist nurseand a dietitian, in a dedicated low clearance clinic.Similarly, a follow-up patient with established renalfailure may need to spend 10–30 minutes with aconsultant, depending on the availability of specialistsupport staff, who might advise on management ofanaemia, access for dialysis and diet. The need forongoing multidisciplinary specialist input into manylong-term renal conditions means that the ratio offollow-up appointments to new patient appointments isunusually high.Specialist investigative proceduresSpecialist procedures undertaken by renal physiciansinclude renal biopsy, placement of temporary andpermanent central venous catheters, and insertion ofcatheters for peritoneal dialysis. The procedures areoften shared with specialist nurses, radiologists andsurgeons.Specialist on callA census of all consultant renal physicians in 2010reported that 33% have a regular on-call commitmentfor unselected emergency medical admissions (Dr PhilMason, personal communication) – a decrease from52% in the census in 2002 and 40% in 2006. 33,34 On-callwork for renal medicine is often highly intensive,particularly because of the need to support patientswith AKI and the complexity of intercurrent illness inpeople on RRT. A frequency of no more than one infour is recommended.Other specialist activity, including activitiesbeyond the local servicesMany consultant renal physicians provide cover forsatellite dialysis units and give telephone advice oraccept referrals from neighbouring hospitals that areunable to provide 24-hour nephrology cover.Advice is increasingly given to patients, GPs and otherhealthcare professionals by phone or email, which mayobviate or replace outpatient clinic visits. Such ‘virtual’clinical practice, which is in keeping with NHScommitments to environmental sustainability, saves thepatient time and money and encourages patient‘empowerment’, must be recognised in consultant jobplans and in contractual arrangements.Clinically related administrationClinical activity in renal medicine often generatesclinically related administrative duties that can require afurther 50–100% of the time spent in direct contact withpatients, eg after a renal transplant clinic, the consultantrenal physician will need to check laboratory results forall patients, arrange admission or rearrange follow-up ifunexpected results are identified, contact patients orGPs concerning any alterations to treatment, anddictate and sign relevant correspondence. This clinicallyrelated administration should be taken into accountwhen time for direct clinical care is allotted inconsultant job plans.7 Opportunities for integrated careAs well as the obvious links with transplant surgeonsand vascular access surgeons, renal physicians now oftenprovide integrated care with other specialists: egobstetricians, diabetologists, geriatricians and palliativecare physicians. They also typically work inmultidisciplinary teams with (for example) dietitians,pharmacists, psychologists, podiatrists, vasculartechnicians, etc.8 Workforce requirements for the specialtyA census of all renal units by the RCP’s JSC establishedthat there were 525 consultants in renal medicine(106 women; 404 WTEs dedicated to renal medicine; asmany renal physicians also have other commitments,especially GIM or academia) as of February 2010(Dr Phil Mason, personal communication).More renal physicians are required. The justification forthis statement comes from the recommendations of theBRS’s National Renal Workforce Planning Group(2002), 35 which are endorsed by the RCP’s working220 C○ Royal College of Physicians 2013
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