Summary
Goals and Objectives
Inpatient Services
Ambulatory Care
Educational Program
Evaluation
Research
Policies
Application
 

SUMMARY
 

Adult Nephrology Program:  University of Arizona, Tucson, Arizona 

Fellow Positions:                    First year 1-2; Second Year 1-2, Third Year 1-2

Participating Hospitals:         University of Arizona Medical Center (365 beds + ICU)

                                                Tucson VA Medical center (200 beds + ICU)

                                                Kino community Hospital (120 beds +ICU)

FACULTY (Key Faculty noted by *):          

Professors:                             Y. Howard Lien* (Section Chief), Murray Katz*, Ulrich Michael

Associate Professors:            Joy Logan* (Fellowship Program Director), Sam James*, Eric Prosnitz, Donald A. Schon

Assistant Professors:             Arnold Silva*, David Whittman*, Napisvadee Wongchavanich*, Mehul Dixit (Pediatric Nephrologist),  Rick Mishler

Description of Training Program: Fellows are accepted for 18 months of intensive clinical training and six months of research time. 

Rotations (Approximate in Months):                                    1st year            2nd year

                        UMC consult                                                        4                      2

                        TVAMC & Kino consult/dialysis service                4                       2

                        Desert Dialysis                                                       2                       4

                        Research                                                                2                       4

Outpatient Experiences:        Fellow Continuity Clinic                                    24 months

                                                Transplant Clinic                                               12 months

                                                VA Renal Clinic                                                6 months

                                                Dialysis Clinic                                                   24 months

Research Programs:

            Diabetic nephropathy                            Katz

            Gene therapy                                        Lien

            Osmoregulation                                    Lien

            Ca/Mg metabolism                               Lien

Bone disease                                        Silva, James, Lien

Chronic kidney disease                        Whittman

Vascular access                                    Whittman

            Cocci in Transplant Patients                  Logan

            Angiotensin II in HTN                           Dixit

I. GOALS AND OBJECTIVES

The overall goal is to prepare the trainee to function as a competent nephrologist and meet the requirements for ABIM certification in Nephrology.  An optional third year is offered if desired to prepare for an academic career.  The clinical and didactic experiences are designed to meet the following specific objectives:

1.      Acquire a good working knowledge of the specific program content in clinical nephrology, renal transplantation, and dialysis as outlined by the ACGME and ABIM.

2.      Proficiency in the key technical skills in Nephrology as outlined by ACGME and ABIM.

3.      Participation in scholarly activities and a research experience that prepares the trainee for lifelong learning and scholarship.

4.      Competency in interpersonal communication, professional attitudes, humanistic qualities and practice-based learning that are defined for Internal Medicine and Nephrology diplomates.

5.      Acquire competence in system-based practice with special emphasis on out patient dialysis facility issues.

The written curriculum outlines the clinical and other educational experiences that prepare the trainee to meet these objectives.  The specific objectives, methods, expectations and evaluation for each experience are delineated.  Descriptions of facilities, resources, support services, schedules are also included.     

University of Arizona Nephrology Fellowship

Clinical Competency Requirements

PGY IV:

1. CLINICAL NEPHROLOGY

 Fellows should acquire expertise in the prevention, evaluation, and management of the following disorders:

                        a.         Disorders of mineral metabolism, including nephrolithiasis and renal osteodystrophy.

                        b.         Disorders of fluid, electrolyte, and acid-base regulation.

                        c.         Acute renal failure.

                        d.         Chronic kidney disease.

                        e.         End-stage renal disease.

                        f.          Hypertensive disorders.

                        g.         Renal disorders of pregnancy.

                        h.         Urinary tract infections.

                        i.          Tubulointerstitial renal diseases, including inherited diseases of transport, cystic disease, and other congenital disorders.

j.          Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, and atheroembolic renal disease.

                        k.         Disorders of drug metabolism and renal drug toxicity.

            2. TRANSPLANT NEPHROLOGY

            Fellows should gain competence in:

                        a.         Evaluation and selection of transplant candidates.

                        b.         Preoperative evaluation and preparation of transplant recipients.

                        c.         Immediate postoperative management of transplant recipients, including administration of immunosuppressants.

d.         Clinical diagnosis of all forms of rejection including laboratory, histopathologic, and imaging techniques.

e.         Medical management of rejection, including use of immunosuppressant drugs and other agents.

3. DIALYSIS AND EXTRACORPOREAL THERAPY

            Fellows should acquire expertise in dialysis and extracorporeal therapy:

                        a.         Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.

b.         Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options.

c.         Drug dosage modification during dialysis and other extracorporeal therapies.

d.         Evaluation and management of medical complications in patients during and between dialyses and other extracorporeal therapies, including dialysis access, and an understanding of their pathogenesis and prevention.

            e.         An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy.

            f.          The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.

            g.         An understanding of the complications of peritoneal dialysis, including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, plural effusions, and other less common complications and their management.

            4. PROCEDURES

Fellows should acquire expertise and experience in the following procedural skills.  These will include the indications, contraindications, complications, and interpretation of results.

            a.         Urinalysis

            b.         Percutaneous biopsy of both autologous and transplanted kidneys

            c.         Peritoneal dialysis

d.         Placement of temporary vascular access for hemodialysis and related procedures

            e.         Acute and chronic hemodialysis

            f.          Continuous hemofiltration, arteriovenous and/or venovenous

PGY V:

1. DIALYSIS AND EXTRACORPOREAL THERAPY

            Fellows should acquire expertise in dialysis and extracorporeal therapy:

                        a.         Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis.

            b.         An understanding of the principles and practice of peritoneal dialysis, including the establishment of peritoneal access, the principles of dialysis catheters, and how to choose appropriate catheters.

            c.         An understanding of the technology of peritoneal dialysis, including the use of cyclers.

            d.         Assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the principles of peritoneal biopsy.

            e.         The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.

            f.          An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient.

2. TRANSPLANT NEPHROLOGY

            Fellows should meet the following requirements:

                        a.         Recognition and medical management of the surgical and nonsurgical complications of transplantations.

            b.         Long-term follow-up of transplant recipients in the ambulatory setting.

            3. PROCEDURES

Renal fellows are encouraged to develop knowledge and expertise in the following procedures, including their cost-effectiveness and application to patient care:

a.                   Tunneled vascular catheter placement and removal

b.                  Renal ultrasound

c.                   Radiology of vascular access

            d.         Balloon angioplasty of vascular access

            e.         Therapeutic plasmapheresis

            f.          Bone biopsy

            g.         Placement of peritoneal catheters

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 INPATIENT CLINICAL ROTATIONS
 

There are two inpatient clinical rotations:

            1. UMC Consult and Transplant Service

            2. Tucson VA Medical Center &  Kino Hospital Consult Service         

1. UMC CONSULT AND TRANSPLANT SERVICE

A.     Specific Objectives:

1.      Build fund of knowledge in clinical nephrology, acute care of transplant patients and all inpatient dialysis modalities including continuous renal replacement therapy.

2.      Gain experience in key technical skills

3.      Develop interpersonal communication skills with referring physicians, other consulting physicians, and hospital staff.

4.      Develop professional and humanistic qualities needed for rapid pace of this clinical rotation.

5.      Acquire cultural sensitivity to diverse groups of people cared for at UMC.

6.      Develop teaching and leadership skills in working with residents and students.

B.     Methods:

1.      Providing inpatient consultation.

2.      Management of the in patient consult team (residents, students, pharmacists)

3.      Management of all dialysis patients in the acute unit.

4.      Kidney biopsy on all inpatients

5.      Urinalysis on all consults

6.      Temporary access placement of all inpatients

7.      Triaging care with emergency room physicians

8.      Triaging care of all inpatient dialysis patients on discharge

9.      Bedside and conference based teaching

            C.  Expectations:

1.      Patient Care.  Is skillful in acquiring data.  Demonstrates respect for the patient and their preferences.  Uses sound judgment and appropriately seeks guidance from the supervising physician.  Prepares a written report of the consultation for the medical record and an accurate log of all consults. 

2.      Knowledge.  Has a satisfactory fund of knowledge and is committed to continuous learning evidenced by reading, literature searches, teaching and conference participation and preparation.

3.      Technical skills:  Performs a careful urinalysis on each consult.  Places access and performs kidney biopsy with supervision as necessary and provides appropriate follow up for complications.  Records all procedures performed in the log and any complications.

4.      Communication:  Establishes good relationships with patients, staff, referring physicians and all other members of the team.  Specifically is attentive to the scheduling needs of the acute dialysis nurses and the radiology team helping with access and biopsies. 

5.      Professionalism:  Performs consults in a timely and helpful manner.  Is compassionate, honest and accepts responsibility for errors. 

            D. Evaluation

1.      Fellow evaluation form completed by the UMC attending physicians on service.

            E.  Facility, Resources and Support Services

University Medical Center (UMC) is a 365 bed tertiary care referral center located on the campus of University of Arizona College of Medicine.  It has an active renal transplant programs, in addition to cardiac, liver and bone marrow transplantation. There is a 6-station acute dialysis unit at the UMC providing all aspects of dialysis including CAVHD, CVVHD, acute hemodialysis and acute peritoneal dialysis.           The renal consultation team including one renal attending, one renal fellow, and various numbers of medical students and residents will see 10-20 new consults per week and follow 10-20 inpatients. Key support services include the Nephropathologists, Interventional Radiology, Vascular Surgery, Transplant Surgery, and Urology.

2. TUCSON VA MEDICAL CENTER/KINO HOSPITAL CONSULT SERVICE

A.      Specific Objectives:

1.      As outlined for the UMC rotation except there are no acute transplant patients.

2.      Both hospitals afford unique opportunities to learn how to care for patients from diverse cultural and socioeconomic backgrounds.

3.      The hospital-based outpatient dialysis unit at the VA also affords a unique opportunity to learn to practice in this setting as well.  The fellow will learn quality assurance methods and management issues.

4.      The electronic medical record at the VA offers the fellow a great opportunity to investigate problems with a system-based approach.

B.     Methods

1.      As outlined for the UMC inpatient consult service.

2.      Rounds on the outpatient VA dialysis patient, participation in dialysis unit conferences..

C.     Expectations

1.      As outlined for the UMC inpatient consult service.

2.      The fellow will learn and use the electronic medical record to learn new methods of tracking and solving clinical problems in individual and groups of patients.

D.    Evaluation

1.      Attending evaluation forms for the work at Kino by the UMC attending and for the VA, by the VA attending.

            E.  Facilities, resources and support services 

            Tucson VA Medical Center (TVAMC) is presently operating with 213 inpatient beds with a projected capacity of 347 beds.  The VA supports a 12 station chronic hemodialysis units, provides acute dialysis and has an active home dialysis program (CAPD, CCPD). There is also an active cardiothoracic surgery program, as well as representation of the other surgical subspecialties.  Key support services include Vascular Surgery, primary care teams, Urology and Interventional Radiology.  The renal consultation team including one renal attending, one renal fellow, and various numbers of medical students and residents will see 6-10 new consults per week and follow 5-15 inpatients.   The hospital-based dialysis programs include approximately 20 hemodialysis patients and 10 peritoneal dialysis patients.

            The Kino Community Hospital is a county hospital and the only hospital located in the southern Tucson. It is operating with about 100 beds including 8 ICU beds.  There is a 2 station acute hemodialysis unit which provides acute hemodialysis. The experience here includes exposure to patients from different cultural backgrounds, who present with a full spectrum of renal problems. The renal consultation team including one renal attending and one renal fellow at the Kino Community Hospital will see 1-5 new consults per week and follow 1-5 inpatients.

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 AMBULATORY CARE EXPERIENCE
 

1.       Specific Objectives:

a.                   Build a fund of knowledge in general nephrology and transplant medicine. 

b.                  Achieve competence in outpatient consultative nephrology.

c.                   Develop excellence in communication and coordination of care with referring and primary care physicians.

d.                  Acquire skills in dealing with multiple health care systems.  

     2.      Methods:

a.                   Outpatient consults and follow up visits.

b.                  Urinalysis and ultrasound exams.

c.                   Preparation of letters to referring physicians.

d.                  Coordination of outpatient specialty care such as biopsies and initiation of dialysis.

     3.      Expectations:

                   a.                   Patient Care:  Performs excellent interviews and exams.  Provides patient education and information in a respectful and helpful    manner.  Establishes a good working relationship with the patients and assumes responsibility for following up on all pertinent testing and monitors outside of clinic hours.

 b.                  Medical Knowledge:  Achieves a good knowledge base of common renal disease.  Reads about challenging problems encountered and formulates and implements state of the art treatment regimen. 

c.                   Practice-Based Learning:  Performs self-assessment and eagerly accepts feedback from attendings and patients.

d.                  Interpersonal and Communication Skills:  Works well with colleagues, attendings and staff.  Provides timely, concise and helpful consultative reports and follow up to referring physicians.

e.                   System-based Practice:  Effectively uses resources to accomplish diagnostic and therapeutic goals for the patient.  Reduces errors and develops systems and habit that assure proper follow up.

     4.      Evaluation

                 a.                   Fellows are supervised and given direct feedback on a case by case basis.

b.                  The chart stimulated recall oral exam is conducted biannually to review the competence in the specific objectives.

c.                   Patient survey forms    

5.      Outpatient Clinic Sites

            A. UMC Renal Clinic:

There is an ambulatory care clinic located at UMC that consists of several examining rooms, a small laboratory with a centrifuge and microscope, ultrasound equipment and a conference room.  Fellows spend one afternoon per week seeing patients throughout the two year of fellowship. A variety of renal diseases are seen at this clinic including but not limited to, acute and chronic renal failure, secondary hypertension, glomerulonephritis, vasculitis and electrolyte disorders. In addition, long term follow-up of transplant patients are performed here.

            B. UMC Transplant Clinic

The transplant clinic meets twice per week.  The dialysis and research fellows participate in acute post-transplant management, and evaluations of potential recipients and donors.  This clinic is supervised by the transplant nephrologist.

            C. TVAMC Clinics:

                         The VA renal clinic is a one half-day clinic held weekly for fellows rotating on the VA/Kino inpatient consult service.  A variety of clinical problems are addressed, including follow up of transplant and peritoneal dialysis patients.  A unique feature of this out-patient service is a Pre-Dialysis Clinic which interarticulates with this clinic.  Participation with the nurses running this clinic is a part of the day to day activity of the Renal Fellow assigned to the VA.   The Pre-Dialysis Clinic manages EPO and iron therapy, Ca-Phos-PTH problems, nutritional adequacy, and dialysis and access planning.

    6.  Dialysis Rotation

A.  Specific Objectives.

1.       Obtain the knowledge and skill necessary to manage patients on chronic dialysis therapies.

1.       Achieve the knowledge and skills necessary to function as the medical director of a dialysis unit.  This includes technical knowledge, management skills, business issues and quality assurance techniques.

2.      Become competent in assessment of system based problems and solutions specific to dialysis services.

3.      Learn self assessment based on well defined outcome monitors.

            B.   Methods:

1.      Routine rounds on all chronic hemodialysis patients while on dialysis rotation.

2.      Participation in peritoneal dialysis clinic weekly.

3.      Routine rounds on a specific shift for two years functioning as the primary nephrologist.

4.      Participation in case conferences with nursing staff, social worker and dietician and attending physicians.

5.      Participate in Quality Assurance Meetings, Risk Management Meetings while on the dialysis rotation.

6.      Monitor fellow specific patient outcome monitors.

7.      Develop and implement a QA project.

A.     Expectations:

1.      Patient Care:  The fellow will achieve desired treatment goals on dialysis patients using state of the art practice.  All patients will be treated with respect and compassion.

2.      Knowledge:  The fellow will gain all necessary knowledge and skills to care for chronic patients on hemodialysis and peritoneal dialysis as well as knowledge pertinent to functioning as a medical director.

3.      Practice-based Learning:  Learns and applies new technologies.

4.      Professionalism:  Leads the treatment team effectively and assumes responsibility for decisions.

5.      System-based Practice:  Effectively uses resources and applies sound quality assurance techniques to improve care and reduce errors.

B.     Evaluation:

1.      Attending evaluation forms.

2.      Staff Survey

C.     Facilities, Resources and Support Services

There are two Desert Dialysis Centers.  One is a 16 station dialysis unit and the second a 24 station dialysis unit each with six separate shifts.  Each unit is staffed with administrators, nurses, technicians, social workers and dieticians   The units are Medicare certified and operated as part of the Dialysis Clinics Incorporated and therefore have access to national expertise and communication management.  The equipment and dialysis practices are state of the art.

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 EDUCATIONAL PROGRAMS

 
1. WARD AND TEACHING ROUNDS

Ward rounds are conducted daily.  The attending is updated on all of the old cases and comprehensively reviews all of the new cases on a daily basis, and goes to the bedside of all patients. The attending will review renal biopsy, urine sediments, and pertinent radiology findings with fellows, and assess the fellow's clinical judgement and recommendations and discuss cases with the fellow. Ward rounds are generally last 2-3 hours at the UMC and slightly shorter at the TVAMC and Kino Hospital. Teaching rounds are often conducted separately. In general, attendings make in-depth teaching rounds on 2-3 days of the week, usually related to problems of patients on the inpatient service.

2. CONFERENCES

            A. Renal Grand Rounds:

These rounds are conducted every Monday at UMC room 6407 (Except the lecture day).  One selected case will be presented by a medical student, resident, or renal fellow. The diagnosis and management will be discussed by all attendants. The fellow will present the case or supervise medical student's or resident's presentation. Fellows will be asked questions in areas related to the case from pathophysiology to management. The presenting fellow will give a review on the related topics, including sharing of relevant publications on the area.  

            B. Renal Journal Club and Research Conference:

This conference is conducted every Wednesday at UMC room 6331 (except the lecture day).  Faculty and fellows take turns presenting a current article related to basic or clinical nephrology or transplantation. The article will be given to fellows in advance. All attendants will participate in the discussion and critiques of the article. Focus on the research methods, analysis of data, and conclusions will be included in the discussion.  A take home message will be given at the end. Faculty may choose to present his/her own research results or publications instead of reviewing others' publication.

As a presenter, fellow should select an appropriate article under faculty's guidance. Fellow will review the related topics and give background information and then present the methods and results and lead the discussion. Each fellow will present 3-4 journal clubs per year. If the fellow is not the presenter, he/she will read the article and actively participate in the discussion. 

            C. Renal Pathology Conferences:

Monthly renal pathology conferences are held the third Friday of each month in the Pathology Conference room in Life Sciences North.  The nephropathologists will conduct the conference. Fellows will present the clinical data on selected patients who underwent biopsy of the native or transplanted kidney the month prior. About 3-4 cases will be presented at each conferences. Dr. Nagle and Pathology Residents will present the results of renal biopsy including light microscopy, immunofluorescence and electron microscopy. The clinical follow-up will be given by attendings or fellows who follow the patient. A brief review of pathological findings of any interesting or rare renal diseases will be given by Dr. Nagle and clinical-pathological correlation and management will be discussed by Nephrology faculty. Fellows should prepare for the presentation of clinical data including but not limited to present illness, physical examinations, findings of urinalysis and serology and other work-ups, indications for biopsy and possible clinical diagnoses. Fellows who do not present the case frequently will be asked questions about the pathology, pathophysiology and management of specific renal diseases.

3. LECTURE SERIES

            A. Content: Areas that are included in the renal lecture series include:

            a.         Renal anatomy, physiology, and pathology

            b.         Pathogenesis, natural history, and management of congenital and acquired diseases of the kidney and urinary tract and renal disease, associated with systemic disorders such as diabetes, collagen-vascular diseases, and pregnancy.

            c.         Normal and abnormal mineral metabolism        

            d.         Normal and abnormal blood pressure regulation

            e.         Clinical pharmacology, including drug metabolism and pharmacokinetics and the effects of drugs on renal structure and function.

            f.          Nutritional aspects of renal disorders.

                        g.         Immunology, including:

                                    - Basic principles

                                    - Immunologic mechanisms of renal disease.

- Fundamental aspects of diagnostic laboratory immunology relevant to renal diseases.

            h.         Transplantation - the curriculum includes:

                                                - Biology of transplantation rejection

                                                - Indications for and contraindications to renal transplantation

                                                - Principles of transplant recipient evaluation and selection

                                                -The pathogenesis and management of urinary tract infections

                                                - The pathogenesis and management of acute renal failure

                                                - Indications for and interpretations of radiologic tests of the kidney and urinary tract

                                                - Disorders of fluids and electrolytes and acid-base balance

                        i. Dialysis and extracorporeal therapy.

                                                - The kinetic principles of hemodialysis and peritoneal dialysis

                                                - The indication for each mode of dialysis

                                                - The short-term and long-term complications of each mode of  dialysis and their management

- The principles of dialysis access (acute and chronic vascular and peritoneal) including indications, techniques, and complications

                                                - Urea kinetics and protein catabolic rate

                                                - Dialysis modes and their relation to metabolism

                                                - Nutritional management of dialysis patients

                                                - Dialysis water treatment, delivery systems, and reuse of artificial kidneys

                                                -The artificial membranes used in hemodialysis and biocompatability

                                                -The psychosocial and ethical issues of dialysis

j.         Geriatric medicine

                                                -Physiology and pathology of the aging kidney

                                                -Drug dosing and renal toxicity in elderly patients

            B. Schedule and Presenters:

Twenty four to thirty lectures are given each year. One Renal Grand Rounds and occasional Journal Club/Research Conference time slots are used for presentation of the core curriculum.  The monthly Friday Noon Core Curriculum lectures and Medicine Grand Rounds also are used for presentation in the formal learning setting.  Physicians and scientists are recruited from outside the regular faculty to provide the needed expertise to optimize the learning experience.  These include visiting professors, and professors within the University of Arizona faculty from from key related services such as Radiology, Vascular Surgery, Transplant Surgery, Pathology and Immunology, Pharmacology.  Fellows give three in-depth reviews on renal topics during the fellowship, one in the first year and two in the second.

C.     Evaluation

Immediate feedback is given to the fellows on their presentations and is reviewed at the semi-annual review of their performance by the Program Director.  An overall evaluation of the fellows success in acquiring the knowledge in the core curriculum is part of the on-going evaluation of in patient and out patient services.  A written exam is also given yearly to assess progress in learning from all the conferences given.  Questions are extracted from information presented at core lectures, journal clubs and visiting professors.  Overall competence is assessed by the fellows performance on the subspecialty boards in Nephrology.

4. SELF LEARNING

                    Fellows will acquire knowledge through self-learning process. The following materials and programs are available:

            A. Major textbooks:

                    The following Nephrology and transplantation textbooks are available at the Renal Office:

            a. Disease of the kidney. 6th Ed, Schrier and Guttschalk, 1997

            b. Pathology of the kidney. 4th Ed, Heptinstall, 1992

            c. Textbook of Nephrology. 3rd Ed, Massry and Glassock, 1995

            d. The kidney. 5th Ed, Brenner, 1996

            e. The kidney: physiology and pathophysiology. 2nd Ed,  Seldin & Giebisch, 1992

            f. Dialysis therapy.  2nd Ed, Nissenson and Fine, 1993

            g. Kidney transplantation.  4th Ed, Morris, 1993

            h. Handbook of kidney transplantation. 2nd Ed. Danovitch, 1996

            i.  Atlas of renal ultrasonography.  O’Neill.  2000.

            j.  Atlas of diseases of the kidney, Schrier, et al., 1999.  

5. SCIENTIFIC MEETINGS

Fellows will attend at least one meeting of the Southern Arizona Nephrology Conference. The meeting will provide fellows with state-of -the-art information regarding the pathogenesis and treatment of a variety of disease states.  Fellows will also be encouraged to submit abstracts for presentation at national or regional scientific meetings. If selected for presentation, they will attend meetings at the expenses of the program. Meetings which previous fellows attended include annual meeting of the Society of Nephrology, the Society of Transplant Surgeons and Physicians, and the Society of Hypertension.

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EVALUATION

1. EVALUATION OF FELLOWS

Fellows are evaluated with regards to their competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and system-based practice.  The description of each of the clinical rotations and didactic educational programs included specific outlines of the evaluation tools.  The following table outlines the tools and the educational experience they are used to assess.