Nephrology Competencies

2018
VERSION 1.0

Effective for residents who enter training on or after July 1, 2018.

NOTE: Throughout this document, references to the patient’s family are intended to include
all those who are personally significant to the patient and are concerned with his or her
care, including, according to the patient’s circumstances, family members, partners,
caregivers, legal guardians, and substitute decision-makers.

NOTE: Throughout this document: references to dialysis modalities include peritoneal

dialysis, hemodialysis, continuous renal replacement therapy (CRRT); references to renal
replacement therapy include the dialysis modalities and renal transplantation; and,
references to extracorporeal treatment modalities include the dialysis modalities,
plasmapheresis, immunoadsorption, and hemoperfusion.

DEFINITION

Nephrology is that branch of medicine concerned with the care of patients with kidney
disease and disorders of fluid and electrolyte metabolism.

NEPHROLOGY PRACTICE

Nephrologists provide care to patients at all stages of diseases or disorders that affect renal
function, both congenital and acquired. This includes providing primary prevention for
individuals at high risk for kidney disease, managing acute presentations of renal
dysfunction, and providing ongoing care for patients with chronic kidney disease, monitoring
for disease progression, and applying strategies for secondary prevention. The long-term
sustaining of life with renal replacement therapies is unique to Nephrology with the
availability of several treatment modalities for end stage renal disease, including peritoneal
dialysis, hemodialysis, and renal transplantation. Nephrologists also apply the use of
extracorporeal treatment modalities in the management of poisonings and metabolic
disorders.

The natural history of chronic kidney disease and its highly effective long-term treatments
result in patients transitioning through many settings, treatments, and/or goals of care
during their individual medical journey. Nephrologists provide continuity of care and
facilitate transition from the pediatric to adult care setting, from one treatment modality to
another, and from active care to end of life care.

The patient population served by Nephrology encompasses the entire lifespan, from prenatal
consultation to geriatric care. This group of patients has a high prevalence of other co-

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
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 NEPHROLOGY COMPETENCIES (2018)

morbidities and complex care needs. Providing optimal care for this population requires that
Nephrologists employ strategies for chronic disease management, and work effectively
within a team of physicians and surgeons, both primary care physicians and other
specialists, as well as other health care professionals. Nephrologists strive to provide
secondary and tertiary care close to the patient’s home by coordinating with and supporting
community physicians and using a variety of technology to reach the remote areas where
patients may live.

The combination of a population with a high burden of disease and complex, limited, and/or
costly therapies requires the Nephrologist’s involvement in ensuring high quality health care
delivery and resource stewardship at all levels of the health care system. Nephrologists
work with individual patients to promote risk reduction through primary prevention, to
advocate for access to appropriate treatments, and to surmount barriers to care. They also
play an important role as stewards of health care resources, allocating finite resources, and
addressing ethical issues in resource allocation, and as managers of end stage renal disease
programs, monitoring and improving delivery of services. Nephrologists are advocates for
the population of patients with kidney disease interacting with health services,
governments, industry, and other sectors to improve access to, and delivery of renal care.

NEPHROLOGY COMPETENCIES

Medical Expert

Definition:

As Medical Experts, Nephrologists integrate all of the CanMEDS Roles, applying medical
knowledge, clinical skills, and professional values in their provision of high-quality and safe
patient-centred care. Medical Expert is the central physician Role in the CanMEDS
Framework and defines the physician’s clinical scope of practice.

Key and Enabling Competencies: Nephrologists are able to…

1. Practise medicine within their defined scope of practice and expertise

1.1. Demonstrate a commitment to high-quality care of their patients
1.2. Integrate the CanMEDS Intrinsic Roles into their practice of Nephrology
1.3. Apply knowledge of the clinical and biomedical sciences relevant to Nephrology
1.3.1. Embryology, growth, and development of the kidney in the normal and
disordered state
1.3.2. Anatomy and histology of the kidney, including the structure and function
of the glomerular filtration barrier, tubular epithelium, interstitium and
renal vasculature
1.3.3. Physiology and pathophysiology of:
[Link]. Renal blood flow and glomerular filtration
[Link]. Regulation of acid-base, electrolyte, and water homeostasis
[Link]. Mineral metabolism and its alteration in renal disease, metabolic
bone disease, and nephrolithiasis

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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[Link]. Blood pressure regulation and hypertension

[Link]. Endocrine functions of the kidney, including regulation of
erythropoiesis
[Link]. Renal function in pregnancy and the postpartum period, including
the effects on hemodynamics, and renal blood flow and function
(adult Nephrology only)

1.3.4. Clinical pharmacology as it pertains to:

[Link]. Drug prescribing in renal disease
[Link]. Transplantation, especially in regards to immunosuppression
[Link]. Medication use in pregnancy and during breastfeeding

1.3.5. Toxicology as it relates to the use of extracorporeal therapies for

poisonings
1.3.6. Immunology as it pertains to mechanisms of renal injury, including but not
limited to glomerulonephritis, vasculitis, tubulointerstitial disease, and renal
transplant rejection, and relevant diagnostic testing
1.3.7. Microbiology as it pertains to infections of the urinary system and infectious
complications of renal transplantation
1.3.8. Mechanisms of fluid delivery, machine mechanics and membrane
physiology as they relate to all extracorporeal treatment modalities
1.3.9. Pathology of disease in the native and transplanted kidney, including but
not limited to glomerulonephritis, vasculitis, and systemic disease such as
diabetes and hypertension
1.3.10. Epidemiology of acute renal failure and chronic kidney diseases, including
those conditions commonly causing end-stage renal failure, such as
diabetes and hypertension
1.3.11. Principles of genetics as they relate to the inheritance and transmission of
diseases that affect the kidney
1.3.12. Impact of chronic illness on mental health
1.3.13. The effects of systemic diseases on the kidney as well the effect of
disordered renal function on systemic health
1.3.14. Principles of end of life care

1.4. Perform appropriately timed clinical assessments with recommendations that are
presented in an organized manner
1.4.1. Adapt the clinical assessment to the expectations and boundaries of the
consultant role

1.5. Carry out professional duties in the face of multiple, competing demands
1.6. Recognize and respond to the complexity, uncertainty, and ambiguity inherent in

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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Nephrology practice

2. Perform a patient-centred clinical assessment and establish a management

plan
2.1. Prioritize issues to be addressed in a patient encounter
2.1.1. Identify clinical emergencies and prioritize response

2.2. Elicit a history, perform a physical exam, select appropriate investigations, and
interpret their results for the purpose of diagnosis and management, disease
prevention, and health promotion
2.2.1. Perform focused patient-centred clinical assessments
2.2.2. Select investigations and interpret the results
[Link]. Measures of renal function
[Link]. Urinalysis and other urine tests, including but not limited to
measures of electrolyte, metabolite, and protein excretion
[Link]. Urine microscopy
[Link]. Serologic tests for investigation or monitoring of vasculitis or
glomerulonephritis
[Link]. Tests to monitor therapeutic drug levels, treatment effect and/or
toxicity of immune modulating therapies
[Link]. Genetic tests for investigation of hereditary disorders
[Link]. Measures of blood pressure, including automated and ambulatory
blood pressure monitoring
[Link]. Measures of dialysis adequacy and efficacy
[Link]. Renal imaging
[Link]. Renal histology

2.2.3. Synthesize clinical information to determine:

[Link]. Diagnosis and prognosis
[Link]. Response to treatment and/or treatment toxicity
[Link]. Indications, and acuity of need, for renal replacement therapy
[Link]. Suitability for transplantation
[Link]. Suitability for organ donation

2.3. Establish goals of care in collaboration with patients and their families, which may
include slowing disease progression, treating symptoms, achieving cure,
improving function, renal replacement therapy, and palliation

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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2.4. Establish a patient-centred management plan for the following presentations and
their associated complications:
2.4.1. Acute kidney injury
2.4.2. Chronic kidney disease of all stages, including transplantation
2.4.3. Proteinuria
2.4.4. Hematuria
2.4.5. Nephrolithiasis
2.4.6. Hypertension
2.4.7. Genetic renal disorders: cystic; metabolic; tubular; nephritis
2.4.8. Pyuria
2.4.9. Disorders of fluid, electrolyte, and acid-base
2.4.10. Inherited or acquired disorders of the urinary tract at all stages of fetal
development (pediatric Nephrology only)

3. Plan and perform procedures and therapies for the purpose of assessment
and/or management
3.1. Determine the most appropriate procedures or therapies
3.1.1. Renal protection, including but not limited to control of blood pressure,
minimization of proteinuria, and prevention of contrast nephrotoxicity
3.1.2. Prevent and manage complications of kidney disease, including but not
limited to bone disease, anemia, growth delay, infection, and malnutrition
3.1.3. Interventions for conservative management of renal dysfunction including
but not limited to fluids, diet, and symptomatic treatments
3.1.4. Renal biopsy
3.1.5. Immune modulating therapies
3.1.6. Plasmapheresis
3.1.7. Access for dialysis: central venous catheter, arterial venous fistula, arterial
venous graft, and peritoneal dialysis catheter
3.1.8. Timing for initiation and choice of renal replacement therapy modality
[Link]. Hemodialysis
[Link]. Peritoneal dialysis
[Link]. Renal replacement therapy in critically ill patients
[Link]. Renal transplantation

3.1.9. Renal artery revascularization

3.2. Obtain and document informed consent, explaining the risks and benefits of, and
the rationale for, a proposed procedure or therapy

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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3.3. Prioritize procedures or therapies, taking into account clinical urgency and
available resources
3.4. Perform procedures in a skilful and safe manner, adapting to unanticipated
findings or changing clinical circumstances
3.4.1. Insertion of central venous access (adult Nephrology only)
3.4.2. Prescription, monitoring, and adjustment of extracorporeal therapy for
renal replacement, as well as in the treatment of poisonings and metabolic
disorders

4. Establish plans for ongoing care and, when appropriate, timely consultation
4.1. Implement a patient-centred care plan that supports ongoing care, follow-up on
investigations, response to treatment, and further consultation
4.1.1. Anticipate, recognize and manage complications of therapy, procedures
and/or the underlying condition(s)
[Link]. Manage complications of dialysis therapies
[Link]. Manage complications of immune modulating therapies
[Link]. Manage complications of renal biopsy

4.1.2. Coordinate treatment and follow-up across care settings

4.1.3. Provide safe transitions of care
[Link]. From pediatric to adult nephrology care
[Link]. Between primary care and tertiary care
[Link]. To a renal replacement therapy modality
[Link]. Between different modalities of renal replacement therapy

5. Actively contribute, as an individual and as a member of a team providing care,

to the continuous improvement of health care quality and patient safety
5.1. Recognize and respond to harm from health care delivery, including patient safety
incidents
5.2. Adopt strategies that promote patient safety and address human and system
factors

Communicator

Definition:

As Communicators, Nephrologists form relationships with patients and their families that
facilitate the gathering and sharing of essential information for effective health care.

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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Key and Enabling Competencies: Nephrologists are able to…

1. Establish professional therapeutic relationships with patients and their families

1.1. Communicate using a patient-centred approach that encourages patient trust and
autonomy and is characterized by empathy, respect, and compassion
1.2. Optimize the physical environment for patient comfort, dignity, privacy,
engagement, and safety
1.3. Recognize when the perspectives, values, or biases of patients, physicians, or
other health care professionals may have an impact on the quality of care, and
modify the approach to the patient accordingly
1.4. Respond to a patient’s non-verbal behaviours to enhance communication
1.5. Manage disagreements and emotionally charged conversations, such as:
1.5.1. Delivering information about progression of disease, deterioration in
medical condition, and/or poor prognosis
1.5.2. Addressing anger, confusion, and misunderstanding
1.5.3. Initiating, withdrawing, or withholding dialysis
1.5.4. Appropriateness and choice of renal replacement modality

1.6. Adapt to the unique needs and preferences of each patient and to his or her
clinical condition and circumstances

2. Elicit and synthesize accurate and relevant information, incorporating the

perspectives of patients and their families
2.1. Use patient-centred interviewing skills to effectively gather relevant biomedical
and psychosocial information
2.2. Provide a clear structure for and manage the flow of an entire patient encounter
2.3. Seek and synthesize relevant information from other sources, including the
patient’s family, with the patient’s consent

3. Share health care information and plans with patients and their families
3.1. Share information and explanations that are clear, accurate, and timely while
checking for patient and family understanding
3.2. Disclose harmful patient safety incidents to patients and their families accurately
and appropriately

4. Engage patients and their families in developing plans that reflect the patient’s
health care needs and goals
4.1. Facilitate discussions with patients and their families in a way that is respectful,
non-judgmental, and culturally safe
4.2. Assist patients and their families to identify, access, and make use of information

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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and communication technologies to support their care and manage their health
4.3. Use communication skills and strategies that help patients and their families make
informed decisions regarding their health
4.3.1. Support patients and/or families in decisions regarding end of life care

5. Document and share written and electronic information about the medical
encounter to optimize clinical decision-making, patient safety, confidentiality,
and privacy
5.1. Document clinical encounters in an accurate, complete, timely, and accessible
manner, in compliance with regulatory and legal requirements
5.2. Communicate effectively using a written health record, electronic medical record,
or other digital technology
5.3. Share information with patients and others in a manner that respects patient
privacy and confidentiality and enhances understanding

Collaborator

Definition:

As Collaborators, Nephrologists work effectively with other health care professionals to

provide safe, high-quality patient-centred care.

Key and Enabling Competencies: Nephrologists are able to…

1. Work effectively with physicians and other colleagues in the health care
professions
1.1. Establish and maintain positive relationships with physicians and other colleagues
in the health care professions to support relationship-centred collaborative care
1.2. Negotiate overlapping and shared responsibilities with physicians and other
colleagues in the health care professions in episodic and ongoing care
1.3. Engage in respectful shared decision-making with physicians and other colleagues
in the health care professions

2. Work with physicians and other colleagues in the health care professions to
promote understanding, manage differences, and resolve conflicts
2.1. Show respect toward collaborators
2.2. Implement strategies to promote understanding, manage differences, and resolve
conflict in a manner that supports a collaborative culture

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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3. Hand over the care of a patient to another health care professional to facilitate
continuity of safe patient care
3.1. Determine when care should be transferred to another physician or health care
professional
3.2. Demonstrate safe handover of care, using both oral and written communication,
during a patient transition to a different health care professional, setting,
treatment modality, or stage of care

Leader

Definition:

As Leaders, Nephrologists engage with others to contribute to a vision of a high-quality

health care system and take responsibility for the delivery of excellent patient care through
their activities as clinicians, administrators, scholars, or teachers.

Key and Enabling Competencies: Nephrologists are able to…

1. Contribute to the improvement of health care delivery in teams, organizations,

and systems
1.1. Apply the science of quality improvement to contribute to improving systems of
patient care
1.1.1. Participate in the quality improvement processes of renal replacement
therapy programs

1.2. Contribute to a culture that promotes patient safety

1.3. Analyze patient safety incidents to enhance systems of care
1.4. Use health informatics to improve the quality of patient care and optimize patient
safety

2. Engage in the stewardship of health care resources

2.1. Allocate health care resources for optimal patient care
2.1.1. Demonstrate just allocation of high-cost therapies or finite societal
resources such as dialysis, deceased donor organs, or high cost
medications
2.1.2. Apply knowledge of health care resources in different settings to provide
optimal patient care

2.2. Apply evidence and management processes to achieve cost-appropriate care for
individual patients with kidney disease as well as at the level of the health care
system

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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3. Demonstrate leadership in professional practice

3.1. Demonstrate leadership skills to enhance health care
3.1.1. Demonstrate an understanding of the management of renal replacement
therapy programs

3.2. Facilitate change in health care to enhance services and outcomes

4. Manage career planning, finances, and health human resources in a practice

4.1. Set priorities and manage time to integrate practice and personal life
4.1.1. Integrate clinical, scholarly, supervisory, and other responsibilities

4.2. Manage a career and a practice

4.3. Implement processes to ensure personal practice improvement

Health Advocate

Definition:

As Health Advocates, Nephrologists contribute their expertise and influence as they work
with communities or patient populations to improve health. They work with those they serve
to determine and understand needs, speak on behalf of others when required, and support
the mobilization of resources to effect change.

Key and Enabling Competencies: Nephrologists are able to…

1. Respond to an individual patient’s health needs by advocating with the patient

within and beyond the clinical environment
1.1. Work with patients to address determinants of health that affect them and their
access to needed health services or resources
1.1.1. Identify barriers to access in the health care and social services system for
individual patients
1.1.2. Recognize and address potential barriers to patient learning

1.2. Work with patients and their families to increase opportunities to adopt healthy
behaviours
1.2.1. Work with patients to increase opportunities for self-care and independence

1.3. Incorporate disease prevention, health promotion, and health surveillance into
interactions with individual patients

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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2. Respond to the needs of the communities or populations they serve by

advocating with them for system-level change in a socially accountable manner
2.1. Work with a community or population to identify the determinants of health that
affect them
2.2. Improve clinical practice by applying a process of continuous quality improvement
to disease prevention, health promotion, and health surveillance activities
2.3. Contribute to a process to improve health in the community or population they
serve
2.3.1. Promote strategies to prevent or mitigate kidney disease
2.3.2. Promote access to dialysis therapies
2.3.3. Promote organ donation and access to renal transplantation

Scholar

Definition:

As Scholars, Nephrologists demonstrate a lifelong commitment to excellence in practice

through continuous learning, and by teaching others, evaluating evidence, and contributing
to scholarship.

Key and Enabling Competencies: Nephrologists are able to…

1. Engage in the continuous enhancement of their professional activities through

ongoing learning
1.1. Develop, implement, monitor, and revise a personal learning plan to enhance
professional practice
1.2. Identify opportunities for learning and improvement by regularly reflecting on and
assessing their performance using various internal and external data sources
1.3. Engage in collaborative learning to continuously improve personal practice and
contribute to collective improvements in practice

2. Teach students, residents, the public, and other health care professionals
2.1. Recognize the influence of role-modelling and the impact of the formal, informal,
and hidden curriculum on learners
2.2. Promote a safe and respectful learning environment
2.3. Ensure patient safety is maintained when learners are involved
2.4. Plan and deliver learning activities
2.5. Provide feedback to enhance learning and performance
2.6. Assess and evaluate learners, teachers, and programs in an educationally
appropriate and supportive manner

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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3. Integrate best available evidence into practice

3.1. Recognize practice uncertainty and knowledge gaps in clinical and other
professional encounters and generate focused questions that can address them
3.2. Identify, select, and navigate pre-appraised resources
3.3. Critically evaluate the integrity, reliability, and applicability of health-related
research and literature
3.4. Integrate evidence into decision-making in their practice

4. Contribute to the creation and dissemination of knowledge and practices

applicable to health
4.1. Demonstrate an understanding of the scientific principles of research and scholarly
inquiry and the role of research evidence in health care
4.2. Identify ethical principles for research and incorporate them into obtaining
informed consent, considering potential harms and benefits, and considering
vulnerable populations
4.3. Contribute to the work of a research program
4.4. Pose questions amenable to scholarly investigation and select appropriate
methods to address them
4.4.1. Pose a question
4.4.2. Perform a literature review
4.4.3. Develop a proposal to solve the question using appropriate methodology
4.4.4. Identify, consult, and collaborate with content-experts and others to
conduct the research
4.4.5. Collect data
4.4.6. Analyze data
4.4.7. Synthesize the literature and new information to solve the question
4.4.8. Defend and disseminate the results
4.4.9. Identify areas for further investigation

4.5. Summarize and communicate to professional and lay audiences, including patients
and their families, the findings of relevant research and scholarly inquiry

Professional

Definition:

As Professionals, Nephrologists are committed to the health and well-being of individual

patients and society through ethical practice, high personal standards of behaviour,
accountability to the profession and society, physician-led regulation, and maintenance of

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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personal health.

Key and Enabling Competencies: Nephrologists are able to…

1. Demonstrate a commitment to patients by applying best practices and adhering

to high ethical standards
1.1. Exhibit appropriate professional behaviours and relationships in all aspects of
practice, demonstrating honesty, integrity, humility, commitment, compassion,
respect, altruism, respect for diversity, and maintenance of confidentiality
1.2. Demonstrate a commitment to excellence in all aspects of practice
1.3. Recognize and respond to ethical issues encountered in practice
1.3.1. Donation and allocation of living and deceased donor organs
1.3.2. Initiation, withdrawal, and withholding of dialysis
1.3.3. Genetic counselling for individuals with hereditary renal disease

1.4. Recognize and manage conflicts of interest

1.5. Exhibit professional behaviours in the use of technology-enabled communication

2. Demonstrate a commitment to society by recognizing and responding to

societal expectations in health care
2.1. Demonstrate accountability to patients, society, and the profession by responding
to societal expectations of physicians
2.2. Demonstrate a commitment to patient safety and quality improvement

3. Demonstrate a commitment to the profession by adhering to standards and

participating in physician-led regulation
3.1. Fulfil and adhere to the professional and ethical codes, standards of practice, and
laws governing practice
3.2. Recognize and respond to unprofessional and unethical behaviours in physicians
and other colleagues in the health care professions
3.3. Participate in peer assessment and standard-setting

4. Demonstrate a commitment to physician health and well-being to foster

optimal patient care
4.1. Exhibit self-awareness and manage influences on personal well-being and
professional performance
4.1.1. Recognize the personal impact of caring for patients with organ failure and
at the end of life

4.2. Manage personal and professional demands for a sustainable practice throughout

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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the physician life cycle

4.3. Promote a culture that recognizes, supports, and responds effectively to
colleagues in need

This document is to be reviewed by the Specialty Committee in Nephrology by October

2019.

APPROVED – Specialty Standards Review Committee – October 2017

© 2017 The Royal College of Physicians and Surgeons of Canada. All rights reserved.

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