But the pill, and other hormonal methods of birth control, have been fraught with issues for women, some ignored by their gynaecologists. From bleeding to depression to fertility issues, women have been through it, and below they share some horror stories.

What's been your experience with hormonal birth control? For these women, though the benefits were good in terms of preventing pregnancy, their lives were changed for the worse for the time they utilised birth control.

Emily, 40:

I tried two hormonal methods, and finally settled on the pill after Depo made me bleed for months. I tried several pills, and for one particular brand which promised to help with acne, that was the worst experience. I became suicidal and homicidal, no cap. I thought of ways to harm my partner. I had very, very dark thoughts, and though my acne cleared, the depression had me in a dark place. It was when I googled it that I saw other women's experiences — mind you, my female gynaecologist said what I felt couldn't have been linked to the pill. But why would my symptoms have started when I started it, and ended when I stopped? I switched to a pill with a totally different formulation, and the side effects were non-existent.

Ruth-Ann, 28:

Every single month on the pill I got a yeast infection or bacterial vaginosis (BV). Every single month I was at the doctor for treatment, and at one point the inserts wouldn't even work anymore. I didn't even make the link at first, and my doctor never told me. Ironically, the antibiotics for the BV made the pill less effective, and I had to use another barrier method of birth control. Just imagine not being able to live your life because there's always some outbreak down there. When I came off the pill everything stopped. Today, I just stick to condoms.

Vanessa, 30:

Zero sex drive; it was like I was a zombie. I was supposed to be more relaxed and less worried about pregnancy on the pill so that I could enjoy my husband, but instead I had no desire for him and was just very dry. All I wanted to do was sleep. It was a magazine article that I read which made me realise that low libido was a symptom. I switched brands and then everything balanced out.

Nordia, 44:

My experience was with the injection; I was on it for about three years. When I stopped I expected things to regulate like in a few months. This wasn't the case. I was bleeding consistently for several weeks; and when that stopped I didn't have my menses for several other months so I had no way to track my ovulation, and this was while trying to get pregnant. It was a very unsettling experience because the hormones were in my body so long. It was literally two years after stopping that things got regular, and I was ovulating and got pregnant.

Indoor ventilation relates to the movement and distribution of air into and throughout a building. As more buildings are designed to increase energy efficiency, inadequate ventilation is increasingly becoming an important public health concern due to its correlation with the incidence of upper and lower respiratory tract infections, especially in vulnerable populations such as children and the elderly. When an individual sneezes, the plume can travel as far as eight metres, at 35 metres per second. This therefore means that when someone with a respiratory infection such as the seasonal flu sneezes, small particles containing viruses and bacteria are released. Aided by poor ventilation in a building, the concentration of contaminants in the air increases the risk for transmission of a respiratory illness to individuals occupying the said space.

Economic and social effects associated with poor ventilation in buildings

Adequate ventilation is determined based on the size and occupancy of a space. Where inadequate ventilation exists in buildings it has a direct impact on human capital and results in productivity loss, increased absenteeism, and creates a burden on the health-care system. Annually, in some countries approximately $2.9 billion is spent on over-the-counter drugs and another $400 million on prescription medicines for the relief of symptoms related to illnesses such as the common cold. Seventy-five per cent of those who get a respiratory illness also take a minimum of two to three days off to recuperate.

Signs of poor ventilation in a building

• Sick Building Syndrome in which symptoms of illnesses such as nausea, fatigue, shortness of breath, runny nose and itchy skin are triggered due to spending time in a particular building

• Windows and glass in a building appear frosted due to condensation

• Signs of mould growth can be seen on structural surfaces like walls and ceilings

• Strong odours in a building that do not dispel

• Heat build-up and high humidity in a space for prolonged periods that do not dissipate.

Ways to improve ventilation in buildings, hence minimising the spread and impact of infectious respiratory illnesses

Increase the introduction of outdoor air by:

• Opening windows and doors when weather and other conditions permit

• Using fans to increase the effectiveness of open windows

• Installing fans in a manner so that they do not blow air from one person to another.

When designing buildings, ensure that windows and doors are positioned correctly and are sized to equal a minimum of ten per cent of the floor area of a given space.

Avoid placing fans or designing air conditioning systems in a way that could potentially cause air to flow directly from a contaminated area to a clean area.

Ensure that ventilation systems such as hoods and other units work efficiently by providing and maintaining indoor air quality based on the occupancy level and the nature of the activity done within the space.

Develop and maintain preventive maintenance schedules for ventilation systems to ensure that units are cleaned, and that air filters and other parts are within their recommended service life.

Ensure that restrooms are vented in such a manner that exhaust fans and windows located within the space pull contaminated air outside of the building.

Reduce overcrowding in buildings such as classrooms so that air change per hour (ACH) is maintained at a minimum level of 4 ACH. Note that the more persons in a space, the more rapid the air exchange required.

Consider removing particles from the air through the installation of air purifying machines.

In non-residential settings, run ventilation and air conditioning systems at maximum outside airflow for two hours before and after the building is occupied. This allows for the air in the space to be refreshed before arrival of the occupants, and ensures as well the removal of contaminants from the air that might still remain after the use of the space.

Benefits of having adequate ventilation in buildings

During the months of October to March respiratory illnesses such as the common cold and influenza continue to have a tremendous negative impact on the populace of many countries. In 2019 published data associated with the incidence of respiratory illnesses in Jamaica demonstrated that six deaths were attributable to influenza; and while not categorically stating there was a direct link between indoor ventilation and the occurrence of these deaths, it is a known fact that where poor ventilation exist in indoor spaces, illnesses such as influenza and others of similar nature spread easily.

The flu virus, in particular, is considered to be highly contagious and survives for up to 24 hours in some environments. Rhinoviruses such as those which cause the common cold behave in a similar manner, lasting up to nine hours in the air after been released — especially in improperly ventilated spaces. Allergic asthma and other sick building illnesses are of no less importance in relation to the need for proper ventilation in buildings. Improving ventilation in buildings will therefore result in a decrease in the associated mortality and morbidity rates, decreased absenteeism due to sick days, decreased health-care costs, and increased human productivity..

Karlene Atkinson is a public health specialist and lecturer at the School of Public Health, University of Technology, Jamaica.

Since 1900 the global mean temperature has risen by 1.1°C, with most of the change happening in the last 50 years. Regions with extreme climates, such as highlands and polar regions, have been affected the most, while temperatures in tropical regions are approaching the thermal limits of many organisms. Based on current national policies and actions, it is expected that the temperature will rise by 2.5°C to 2.9°C or more by the end of the century.

Climate change and its manifestations, including changes in precipitation and flooding in some areas and drought in others, have significant implications for vector-borne diseases. The effects on pathogens, vectors, and hosts can make it challenging to attribute changes in the distribution and frequency of diseases to climate change, as other factors such as changes in land use, the abundance of reservoir hosts, and control measures also play a role. However, it is clear that the components of vector-borne diseases, including pathogens, vectors, and reservoir hosts, are highly sensitive to changes in the environment. The behaviour, physiologic characteristics, and life history of vectors and pathogens, as well as the abundance and behaviour of reservoir and definitive hosts, can all be impacted by rising temperatures. Interactions between temperature, vectors, and pathogens can increase the risk of disease spreading and spilling over to humans. Thermal performance curves can be used to predict the effects of rising temperatures on vector-borne diseases by illustrating the ways in which temperature impacts the physiological traits of pathogens, vectors, and reservoir hosts.

The Intergovernmental Panel on Climate Change has high confidence that the prevalence of vector-borne diseases has increased in recent decades, and that malaria, dengue, Lyme disease, and West Nile virus infections in particular are expected to continue rising if action is not taken to adapt and strengthen control strategies.

In this first part of a two-part series we will examine climate-sensitive vector-borne diseases, including malaria, dengue, Lyme disease, and West Nile virus.

CLIMATE-SENSITIVE VECTOR BORNE DISEASES

Malaria

Malaria, caused by the plasmodium species and transmitted through infected female Anopheles mosquitoes, remains the deadliest and most studied, climate-sensitive, vector-borne disease. Despite control efforts, over 600,000 deaths were attributed to malaria in 2020, primarily among pregnant women and young children in Africa. In many regions malaria is seasonal or epidemic, responding to short-term changes in rainfall, humidity, and temperature. Rising temperatures have been linked to the spread of malaria to higher elevations in Colombia and Ethiopia while droughts are increasing, potentially reducing the prevalence of malaria in certain regions. However, broader effects of climate change on local livelihoods, food security, and migration may increase population vulnerability to the disease and undermine control efforts.

Dengue

Dengue, the most common mosquito-borne viral disease worldwide, has seen a substantial expansion of its geographic range in recent decades, driven by declining vector control programmes and increasing global trade and travel. With an estimated 390 million cases occurring each year in over 100 countries, the four serotypes of dengue virus are transmitted between humans through infected female mosquitoes, most commonly Aedes aegypti and Aedes albopictus. Water storage containers, which are commonly used in regions without piped water, can become mosquito breeding sites, driving epidemics. By 2030 the dominant cause of expansion of these vectors is predicted to be climate change. The differential ability of Aedes aegypti and Aedes albopictus to survive normally lethal temperatures may influence their roles in future outbreaks.

Lyme disease

Lyme disease is the most common tick-borne illness worldwide, with an estimated seroprevalence of 14.5 per cent; the reported prevalence is highest in the temperate regions of central and western Europe and East Asia. Without early treatment, infection can cause debilitating, multi-systemic chronic disease. Worldwide, Lyme disease involves four dominant tick species, although generally only one tick species is cause for concern in any given region. Wide-ranging reservoir hosts — including mammals (eg, mice and squirrels), lizards, and birds — are part of the ecologic complexities of this disease; however, humans play no role in ongoing transmission. The life cycle and prevalence of tick vectors are strongly influenced by the abundance of reservoir hosts and the ambient air temperature.

Insurance records indicate that 470,000 cases of Lyme disease were diagnosed and treated in the United States during the period from 2010 to 2018, as compared with 329,000 cases during the period from 2005 to 2010. Lyme disease is most common in the Northeast and rare in the Southeast. Although tick vectors are found in both regions, variations in the host preferences of the ticks (e.g., lizards or mice), in the host-seeking behaviour of the ticks, and in the tick density, help to explain this geographic pattern. The increases in Lyme disease cases in the Northeast are largely attributed to the recovery of white-tailed deer populations, which are critical hosts for adult stages of the tick vector; however, increased human–tick interaction owing to the extended summer season resulting from climate change also contributes to the increases in cases. Warming temperatures have been associated with the expansion of Ixodes ticks into Canada and Norway, with a corresponding increase in cases of Lyme disease.

West Nile virus infection

West Nile virus causes potentially fatal neuroinvasive disease in humans and animals worldwide. The virus is part of a complex ecosystem that is centred around a bird–mosquito transmission cycle involving more than 300 bird species and at least 65 mosquito vectors. Mammals, including humans and horses, can be incidentally infected. Human infections are mostly asymptomatic but can cause life-threatening illness in rare cases, predominantly in older adults, and in immunocompromised persons.

West Nile virus, which was first identified in the United States (in New York City) in 1999, is the leading cause of mosquito-borne disease in the continental United States. During the period from 1999 to 2016 nearly 7 million persons were infected. The observed air temperature that results in a peak incidence of the virus among humans across the country was found to be 24°C, which closely matches the temperatures (which ranged from 24°C to 25°C) that were predicted by mechanistic models that were based on vector and pathogen thermal performance curves. Warming temperatures are expected to shift transmission of this disease northward, as is already occurring in Europe; local transmission was recently discovered in Germany after unusually warm weather.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Send correspondence to info@caribbeanheart.com or call 876-906-2107

DM Nephrology or Doctorate of Medicine in Nephrology also known as DM in
Nephrology is a super specialty level course for doctors in India that is done
by them after completion of their postgraduate medical degree course. The
duration of this super speciality course is 3 years, and it focuses on the
diagnosis, treatment and management of diseases affecting kidney and
urinary tract.

The course is a full-time course pursued at various recognized medical
colleges across the country. Some of the top medical colleges offering this
course include All India Institute of Medical Sciences, New Delhi, Jawaharlal
Institute of Postgraduate Medical Education & Research, Puducherry (JIPMER),
Postgraduate Institute of Medical Education & Research, Chandigarh and
more.

Admission to this course is done through the NEET-SS Entrance exam
conducted by the National Board of Examinations, followed by counselling based
on the scores of the exam that is conducted by DGHS/MCC/State Authorities.

The fee for pursuing DM (Nephrology) varies from college to college and
may range from Rs. 5000 to Rs. 20 lakhs per year.

After completion of their respective course, doctors can either join the
job market or can pursue certificate courses and Fellowship programmes
recognised by NMC and NBE. Candidates can take reputed jobs at positions as
Senior residents, Consultants etc. with an approximate salary range of Rs.5 lakhs to Rs. 96 lakhs per year depending upon their expertise.

What is DM in Nephrology?

Doctorate of Medicine in Nephrology, also known as DM (Nephrology) or DM
in (Nephrology) is a three-year super speciality programme that candidates can
pursue after completing a postgraduate degree.

Nephrology is the branch of medical science dealing with the diagnosis,
treatment and management of diseases affecting kidney and urinary tract.

The postgraduate students must gain ample knowledge and experience in
the diagnosis, and treatment of patients with acute, serious, and life-threatening
medical and surgical diseases.

PG education intends to create specialists who can contribute to
high-quality health care and advances in science through research and training.

The required training done by a postgraduate specialist in the field of
Nephrology would help the specialist to recognize the health needs of the
community. The student should be competent to handle medical problems
effectively and should be aware of the recent advances in their speciality.

The candidate is also expected to know the principles of research methodology
and modes of the consulting library. The candidate should regularly attend
conferences, workshops and CMEs to upgrade her/ his knowledge.

Course Highlights

Here are some of the course highlights of DM in Nephrology

Name of Course

DM in Nephrology

Level

Doctorate

Duration of Course

Three years

Course Mode

Full Time

Minimum Academic
Requirement

Candidates must have a postgraduate medical Degree in MD/DNB
(General Medicine) or MD/DNB (Paediatrics) obtained from any
college/university recognized by the Medical Council of India (Now NMC)/NBE,
this feeder qualification mentioned here is as of 2022. For any further
changes to the prerequisite requirement please refer to the NBE website.

Admission Process /
Entrance Process / Entrance Modalities

Entrance Exam
(NEET-SS)

INI CET for various
AIIMS, PGIMER Chandigarh, JIPMER Puducherry, NIMHANS Bengaluru

Counselling by
DGHS/MCC/State Authorities

Course Fees

Rs.5000 to
Rs. 20 lakhs per year

Average Salary

Rs.5 lakhs to Rs. 96
lakhs per year

Eligibility Criteria

The eligibility criteria for DM in Nephrology are defined as the set of
rules or minimum prerequisites that aspirants must meet to be eligible
for admission, which includes:

Name of DM course

Course Type

Prior Eligibility Requirement

Nephrology

DM

MD/DNB (General Medicine)

MD/DNB (Paediatrics)

Note:

· The feeder qualification for DM in Nephrology is
defined by the NBE and is subject to changes by the NBE.

· The feeder qualification mentioned here is as of
2022.

· For any changes, please refer to the NBE website.

· The candidate must have obtained permanent
registration with any State Medical Council to be eligible for admission.

· The medical college's recognition cut-off dates for
the Postgraduate Degree courses shall be as prescribed by the Medical Council
of India (now NMC).

Admission Process

• The admission process
  contains a few steps to be followed in order by the candidates for
  admission to DM in Nephrology. Candidates can view the complete admission
  process for DM in Nephrology mentioned below:

• The NEET-SS or National
  Eligibility Entrance Test for Super speciality courses is a national-level
  master's level examination conducted by the NBE for admission to DM/MCh/DrNB
  Courses.

• Qualifying
  Criteria-Candidates placed at the 50th percentile or above shall be
  declared as qualified in the NEET-SS in their respective speciality.

• The following Medical
  institutions are not covered under centralized admissions for DM/ MCh
  courses through NEET-SS:

1. AIIMS,
   New Delhi and other AIIMS
2. PGIMER,
   Chandigarh
3. JIPMER,
   Puducherry
4. NIMHANS,
   Bengaluru

• Candidates from all eligible
  feeder speciality subjects shall be required to appear in the question
  paper of the respective group if they are willing to opt for a super
  speciality course in any of the super speciality courses covered in that
  group.

• A candidate can opt for
  appearing in the question papers of as many groups for which his/her
  Postgraduate speciality qualification is an eligible feeder qualification.

• By appearing in the question
  paper of a group and on qualifying for the examination, a candidate shall be
  eligible to exercise his/her choices in the counselling only for those super speciality subjects covered in the said group for which his/ her broad
  speciality is an eligible feeder qualification.

Fees Structure

The fee structure for DM in Nephrology varies from college to college.
The fee is generally less for Government Institutes and more for private
institutes. The average fee structure for DM in Nephrology is around Rs.5000 to Rs. 20 lakhs per year.

Colleges offering DM in Nephrology

Various medical colleges across India offer courses for
pursuing DM in (Nephrology).

As per National Medical Commission (NMC) website, the following medical
colleges are offering DM in (Nephrology) courses for the academic year 2022-23.

Sl.No.

Course Name

State

Name and Address of
Medical College / Medical Institution

Management of College

1

DM - Nephrology

Andhra Pradesh

Andhra Medical College, Visakhapatnam

Govt.

2

DM - Nephrology

Andhra Pradesh

Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati

Govt.

3

DM - Nephrology

Andhra Pradesh

NRI Medical College, Guntur

Trust

4

DM - Nephrology

Andhra Pradesh

Kurnool Medical College, Kurnool

Govt.

5

DM - Nephrology

Andhra Pradesh

Narayana Medical College, Nellore

Trust

6

DM - Nephrology

Assam

Gauhati Medical College, Guwahati

Govt.

7

DM - Nephrology

Bihar

Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna

Govt.

8

DM - Nephrology

Chandigarh

Postgraduate Institute of Medical Education & Research, Chandigarh

Govt.

9

DM - Nephrology

Chattisgarh

All India Institute of Medical Sciences, Raipur

Govt.

10

DM - Nephrology

Delhi

Atal Bihari Vajpayee Institute of Medical Sciences and Dr RML
Hospital, New Delhi

Govt.

11

DM - Nephrology

Delhi

All India Institute of Medical Sciences, New Delhi

Govt.

12

DM - Nephrology

Goa

Goa Medical College, Panaji

Govt.

13

DM - Nephrology

Gujarat

Smt. G.R. Doshi and Smt. K.M. Mehta Institute of Kidney Diseases and
Research Centre, Dr H.L. Trivedi Institute of Transplantation Sciences,
Ahmedabad, Gujarat

Govt.

14

DM - Nephrology

Jammu & Kashmir

Sher-I-Kashmir Instt. Of Medical Sciences, Srinagar

Govt.

15

DM - Nephrology

Karnataka

Rajarajeswari Medical College & Hospital, Bangalore

Trust

16

DM - Nephrology

Karnataka

Karnataka Institute of Medical Sciences, Hubballi

Govt.

17

DM - Nephrology

Karnataka

Jawaharlal Nehru Medical College, Belgaum

Trust

18

DM - Nephrology

Karnataka

Father Mullers Medical College, Mangalore

Trust

19

DM - Nephrology

Karnataka

JSS Medical College, Mysore

Trust

20

DM - Nephrology

Karnataka

Kasturba Medical College, Manipal

Trust

21

DM - Nephrology

Karnataka

M S Ramaiah Medical College, Bangalore

Trust

22

DM - Nephrology

Karnataka

St. Johns Medical College, Bangalore

Trust

23

DM - Nephrology

Karnataka

Institute of Nephro-Urology, Bangalore

Govt.

24

DM - Nephrology

Kerala

Medical College, Thiruvananthapuram

Govt.

25

DM - Nephrology

Kerala

Government Medical College, Kozhikode, Calicut

Govt.

26

DM - Nephrology

Kerala

Government Medical College, Kottayam

Govt.

27

DM - Nephrology

Kerala

Pushpagiri Institute Of Medical Sciences and Research Centre,
Tiruvalla

Trust

28

DM - Nephrology

Kerala

T D Medical College, Alleppey (Allappuzha)

Govt.

29

DM - Nephrology

Kerala

Amrita School of Medicine, Elamkara, Kochi

Trust

30

DM - Nephrology

Madhya Pradesh

All India Institute of Medical Sciences, Bhopal

Govt.

31

DM - Nephrology

Madhya Pradesh

Sri Aurobindo Medical College and Post Graduate Institute, Indore

Trust

32

DM - Nephrology

Maharashtra

Mahatma Gandhi Missions Medical College, Aurangabad

Trust

33

DM - Nephrology

Maharashtra

Seth GS Medical College, and KEM Hospital, Mumbai

Govt.

34

DM - Nephrology

Maharashtra

Bombay Hospital Institute of Medical Sciences, Mumbai

Govt.

35

DM - Nephrology

Maharashtra

Padmashree Dr D.Y.Patil Medical College, Navi Mumbai

Trust

36

DM - Nephrology

Maharashtra

Grant Medical College, Mumbai

Govt.

37

DM - Nephrology

Maharashtra

Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha

Trust

38

DM - Nephrology

Maharashtra

Topiwala National Medical College, Mumbai

Govt.

39

DM - Nephrology

Maharashtra

Dr D Y Patil Medical College, Hospital and Research Centre, Pimpri,
Pune

Trust

40

DM - Nephrology

Manipur

Regional Institute of Medical Sciences, Imphal

Govt.

41

DM - Nephrology

Orissa

SCB Medical College, Cuttack

Govt.

42

DM - Nephrology

Orissa

Kalinga Institute of Medical Sciences, Bhubaneswar

Trust

43

DM - Nephrology

Orissa

Instt. Of Medical Sciences & SUM Hospital, Bhubaneswar

Trust

44

DM - Nephrology

Pondicherry

Jawaharlal Institute of Postgraduate Medical Education & Research,
Puducherry

Govt.

45

DM - Nephrology

Punjab

Dayanand Medical College & Hospital, Ludhiana

Trust

46

DM - Nephrology

Punjab

Christian Medical College, Ludhiana

Trust

47

DM - Nephrology

Rajasthan

All India Institute of Medical Sciences, Jodhpur

Govt.

48

DM - Nephrology

Rajasthan

SMS Medical College, Jaipur

Govt.

49

DM - Nephrology

Rajasthan

Government Medical College, Kota

Govt.

50

DM - Nephrology

Rajasthan

Geetanjali Medical College & Hospital, Udaipur

Trust

51

DM - Nephrology

Rajasthan

National Institute of Medical Science & Research, Jaipur

Trust

52

DM - Nephrology

Rajasthan

Mahatma Gandhi Medical College and Hospital, Sitapur, Jaipur

Trust

53

DM - Nephrology

Tamil Nadu

Kilpauk Medical College, Chennai

Govt.

54

DM - Nephrology

Tamil Nadu

Saveetha Medical College and Hospital, Kanchipuram

Trust

55

DM - Nephrology

Tamil Nadu

Sri Ramachandra Medical College & Research Institute, Chennai

Trust

56

DM - Nephrology

Tamil Nadu

Christian Medical College, Vellore

Trust

57

DM - Nephrology

Tamil Nadu

Madras Medical College, Chennai

Govt.

58

DM - Nephrology

Tamil Nadu

SRM Medical College Hospital & Research Centre, Chengalpattu

Trust

59

DM - Nephrology

Tamil Nadu

Stanley Medical College, Chennai

Govt.

60

DM - Nephrology

Tamil Nadu

Madurai Medical College, Madurai

Govt.

61

DM - Nephrology

Tamil Nadu

Govt. Mohan Kumaramangalam Medical College, Salem- 30

Govt.

62

DM - Nephrology

Tamil Nadu

Tirunelveli Medical College,Tirunelveli

Govt.

63

DM - Nephrology

Tamil Nadu

PSG Institute of Medical Sciences, Coimbatore

Trust

64

DM - Nephrology

Telangana

Osmania Medical College, Hyderabad

Govt.

65

DM - Nephrology

Telangana

Gandhi Medical College, Secunderabad

Govt.

66

DM - Nephrology

Telangana

Nizams Institute of Medical Sciences, Hyderabad

Govt.

67

DM - Nephrology

Uttarakhand

All India Institute of Medical Sciences, Rishikesh

Govt.

68

DM - Nephrology

Uttar Pradesh

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow

Govt.

69

DM - Nephrology

Uttar Pradesh

Institute of Medical Sciences, BHU, Varanasi

Govt.

70

DM - Nephrology

Uttar Pradesh

Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow

Govt.

71

DM - Nephrology

West Bengal

Institute of Postgraduate Medical Education & Research, Kolkata

Govt.

72

DM - Nephrology

West Bengal

Nilratan Sircar Medical College, Kolkata

Govt.

Syllabus

A DM in Nephrology is a three years specialization course that provides
training in the stream of Nephrology.

NMC as of 8/02/23 has not defined a Competency-based curriculum
for DM Nephrology. The syllabus of AIIMS below provides a basic outline on what
a DM Nephrology candidate has to undergo while training:

.1 SUBJECT-SPECIFIC THEORETICAL COMPETENCIES

3.1.1 Cognitive domain (Knowledge domain)

3.1.2 Affective domain (Attitudes including Communication and
Professionalism)

3.2 SUBJECT SPECIFIC PRACTICE-BASED OR PRACTICAL COMPETENCIES

The curriculum outlines competencies that trainees must reach by the end
of the programme (combining 3.1 and 3.2)

A. Investigation of the kidney

1. Renal Anatomy and Physiology

Knowledge

• To understand the
  embryology and development of the genito-urinary system
• To understand the development
  of renal function and physiology for the assessment of:

a. GFR from height
and plasma creatinine

1. Calcium, phosphate &
   bone mineral metabolism

c. Urinary
concentrating and diluting ability

d. Tubular handling
of fluid and electrolytes

e. Acid-base
balance

• To explain the
  practicalities, limitations and special precautions of measurement of:

a. Creatinine
clearance

b. Protein and
calcium excretion

c. Tubular handling

d. Tests for
urinary acidification

Skills

To appropriately
request and interpret the above investigations

Multidisciplinary

aspects

Laboratory Medicine
Department

Resources

Clinical Physiology
of Acid-Base and Electrolyte Disorders – Burton David Rose

Principles of Renal
Physiology – Chris Lote

Pediatric Renal
Investigations – Chapman & Taylor

1. Imaging

Knowledge

• To understand the role,
  limitations and interpretation of commonly used imaging modalities
• To know the practicalities
  and safety precautions associated with each test

· To understand the
role of arteriography and percutaneous

nephrostomy tube
placement

Skills

· To appropriately
request the different radiological investigations

· To be able to
interpret scan images

Multidisciplinary
aspects

• Liaison with radiologists
  in deciding the most appropriate investigations

Resources

• Nephro-urology radiology
  meetings/Posting in nuclear medicine unit

· Bank of typical
case images

2. Renal Biopsy and nephropathology

Knowledge

· To describe the
anatomy of both native and transplant kidneys

· To know the
indications for renal biopsy

· To describe the
procedure of renal biopsy and its complications

• To know the type of
  solutions used for light (LM), immunofluorescence (IF), and electron
  microscopy (EM) specimens immediately post-biopsy
• To have a basic knowledge
  of handling and processing of renal biopsy tissue and utility of various
  stains (hematoxylin and eosin, periodic acid Schiff, Trichrome (Masson),
  silver-stains, and Congo

red
/immuno-fluroscence used in the diagnosis of renal disease.

Skills

• To counsel families in
  preparation for renal biopsy, thus allowing informed consent

· To perform a
native (and transplant) biopsy safely

• To recognize the
  histopathologic characteristics of normal kidney on LM, IF, and EM
• To recognize common
  histological appearances and consequences for diagnosis, prognosis and
  treatment
• Able to interpret slides,
  including all the components: LM, IF and EM.

· Obtain adequate
clinical background and information from the

appropriate
nephrologist submitting the specimen to allow optimal

interpretation of
the biopsy.

Multidisciplinary

aspects

Radiologist and
pathologist

Resources

Nephropathology
meetings Bank of typical case histology

Training day for
processing, staining and interpreting of renal biopsy

samples

(B) Urinary Tract Infection (UTI) and Vesicoureteric Reflux

Knowledge

· To know the
epidemiology of UTI

· To understand
current theories about renal scarring

· To be aware of
issues in the diagnosis of UTI

• To describe the role of
  ultrasound scans, MCU, DMSA and other investigations for UTI
• To know the medical and
  surgical options in the management of UTI
• To describe the mechanisms
  of action of antimicrobials and their adverse effects

· To understand the
secondary progression of renal damage and its

prevention

Skills

• To appropriately manage
  urinary tract infections in different age groups

· To show the ability
to counsel parents about relevant investigations of

UTI, and possible
management of siblings of children with reflux

Multidisciplinary
aspects

· To know the
appropriate follow-up into adult life

· To recognize the
role of microbiologists, urologists and radiologists

• To be able to contribute
  to the development of strategies for management of UTI at local and
  regional level

Resources

· Microbiology
department

· Nephro-pediatric
surgery-radiology meeting

• Structural
  Malformations

Knowledge

· To understand
renal embryology and developmental anatomy

• To describe the anatomy of
  the urinary tract and the sites and causes of urinary obstruction
• To know the presentations
  of developmental variants and abnormalities, including obstruction
• To describe the fluid and
  electrolyte disturbances occurring following the relief of obstruction
• To be aware of the
  different reconstructive procedures performed, and their implications
  for future management
• To be aware of other
  urological diagnoses, including genital anomalies

· To know the
importance of ambiguous genitalia and intersex in

renal disease:
structural as well as neoplastic

Skills

· To be able to
provide medical support to urological services, especially
following the relief of obstruction

Multidisciplinary
aspects

• Liaison with radiologists,
  obstetricians and surgeons in management decisions and antenatal
  counselling

· To show the ability
to communicate and work together with other health professionals

Resources

· Department of
Pediatric Surgery

· Radiology meeting

·
Department/Division of Neonatology

(D) Disorders of Micturition

Knowledge

• To know the common renal
  and non-renal diagnoses associated with enuresis

· To know the
appropriate use of urodynamic studies

• To explain the rationale
  for various management strategies in enuresis using behavioural and
  pharmacological therapies

Skills

• To be able to interpret urodynamic
  studies, and instigate appropriate management

· To know the
practicalities involved in enuretic alarms

Multidisciplinary
aspects

· Liaison with
urodynamic staff

· Role of the
psychologist

Resources

Pediatric
urologists/surgeons

Bank of images

(E) Neurogenic bladder

Knowledge

· To know the
pathophysiology of neurogenic bladder

· To know the role
of basic urodynamic investigations

• To know the appropriate
  surgical management of different types of bladder dysfunction

· To understand the
treatments available to regularize bowel and

bladder habit

Skills

• To be able to
  appropriately assess the whole child with neurogenic bladder

· To show the ability
to investigate and manage the upper and lower urinary tract

Multidisciplinary

aspects

· To know the
importance of shared care with surgeons and urologists

Resources

· Pediatric urology
services

(F) Hematuria

Knowledge

• To know the
  pathophysiology of macroscopic and microscopic hematuria
• To describe the methods of
  investigation in microscopic hematuria, including the role of renal
  biopsy
• To understand the various
  findings of phase contrast microscopy and their meaning
• To know the underlying
  causes of hematuria
• To know the long-term outcome
  of the underlying causes

Skills

• To be able to perform a urinalysis
• To demonstrate appropriate
  investigation and management of the child with hematuria, including role
  of imaging,

urological
assessment, and genetic and molecular studies

Multidisciplinary
aspects

• To explain the mode of
  inheritance of hereditary nephritis, and implications for other family
  members
• To appreciate the role of
  the pediatric surgeon
• To understand the need for
  long-term follow up

Resources

• Nephropathology meeting
• Pathology laboratory
  (microscopy of urine)

(G) Proteinuria

Knowledge

• To know the
  pathophysiology of proteinuria
• To know the physiological
  and pathological causes of asymptomatic proteinuria
• To describe the methods of
  investigation of asymptomatic proteinuria
• To list the indications
  for renal biopsy
• To know the long-term
  prognosis of the various conditions causing proteinuria

Skills

• To be able to
  differentiate between pathological and physiological proteinuria
• To show the ability to manage
  the child with proteinuria

Multidisciplinary
aspects

• To understand the
  requirement for long-term follow-up

(H) Glomerular disease

Knowledge

• To describe the aetiology,
  pathophysiology and immunological basis of glomerulonephritis
• To know the different
  forms of presentation
• To understand the clinical
  course and prognosis of acute and chronic glomerulonephritis
• To know the indications
  for immunosuppressive agents,

cytotoxic drugs,
plasmapheresis and dialysis

Skills

• To appropriately
  investigate and manage the acute nephritic syndrome,
  and new presentation of chronic glomerulonephritis

• To demonstrate the
  appropriate use of general and specific measures to treat
  glomerulonephritis

Resources

• Pathology laboratory

(I) Nephrotic syndrome

Knowledge

• To know the causes of
  nephrotic syndrome
• To be aware of the
  pathophysiology of nephrotic syndrome, including the latest research
• To understand the
  investigation of nephrotic syndrome including indications for renal
  biopsy
• To understand the complications
  of the nephrotic state
• To know the pharmacology
  and side effects of steroids, other immunosuppressive agents and other
  treatment modalities

Skills

• To appropriately
  investigate and manage the initial episode of nephrotic syndrome and
  relapses and the complications
• To appropriately
  investigate and manage steroid-resistant nephrotic syndrome and the
  complications
• To manage the adverse effects
  of immunosuppressive medications
• To demonstrate the
  appropriate use of general and specific

measures to treat
secondary causes of nephrotic syndrome

Multidisciplinary
aspects

Liaison with local
paediatricians in long-term management

Resources

Pediatrics,
Pathology

(J) Systemic lupus erythematosus (SLE)

Knowledge

• To describe the
  pathogenesis of SLE and underlying immunological mechanisms
• To list the histological
  classification of lupus nephritis
• To describe the clinical
  course of lupus nephritis
• To describe the different
  treatment options

Skills

• To perform a relevant
  clinical examination to diagnose and assess a patient with SLE
• To plan and interpret
  investigations, including renal histology and immunology
• To appropriately manage
  acute renal failure due to SLE, including the use of plasmapheresis
• To show the ability to
  undertake long-term management of the

patient with lupus
nephritis

Multidisciplinary
aspects

• To appreciate the role of
  other specialists, especially rheumatologists
• To counsel the patient
  about the long-term implications of SLE, including problems with renal
  transplantation and

impact on
reproductive potential

Resources

Adult nephrology,
rheumatology services

(K) Other Vasculitis

Knowledge

• To understand the
  pathophysiology and immunology of vasculitis
• To know the different
  causes of vasculitis
• To know the presentation
  of vasculitis, patterns of multisystem involvement and spectrum of
  disease
• To describe the
  investigation and monitoring of the patient with vasculitis
• To list the different
  therapeutic options available, including

adverse effects

Skills

• To perform a relevant
  multisystem clinical examination
• To be able to
  appropriately investigate and treat vasculitis, including the use of
  immunosuppression, in the short and long- term

Multidisciplinary
aspects

To work with other
specialists including rheumatologists

Resources

Pediatric and adult
rheumatology clinics

(L) Hemolytic uremic syndrome (HUS)

Knowledge

• To understand the
  pathophysiology of microangiopathic hemolytic anaemia
• To know the epidemiology
  of VTEC, S. dysenteriae
• To know the presentation
  and clinical course of diarrhoea-positive and atypical HUS
• To be aware of non-renal
  manifestations of HUS
• To understand the
  long-term consequences and prognosis of D+ HUS
• To understand principles
  of treatment, including conservative, and the role of plasma exchange
  and dialysis
• To understand the
  investigation of atypical HUS
• To be aware of the
  long-term management of atypical HUS including implications for
  transplantation

Skills

• To be able to investigate,
  diagnose and manage the initial presentation of HUS
• To appropriately initiate
  dialysis and plasma exchange
• Interstitial nephritis

Knowledge

To list the causes
of interstitial nephritis and tubulo- interstitial
disease, and their relationship to systemic conditions

Skills

To appropriately
investigate and manage the child with interstitial
nephritis, including the use of corticosteroids

(N) Hypertension

Knowledge

• To define and understand
  how to diagnose hypertension
• To know the common renal
  and non-renal diagnoses implicated in hypertension in different age
  groups
• To describe the possible mechanisms
  causing primary (essential) and secondary hypertension
• To describe the
  investigation of hypertension including the use of arteriography and
  renal vein sampling; nuclear imaging
• To describe the mechanism
  of action and side effects of anti-hypertensive agents

  To understand vascular interventions in renal artery stenosis

Skills

• To show the ability to
  appropriately investigate the child with hypertension
• To be competent in the
  management of hypertensive emergencies
• To be competent in the management
  of chronic hypertension, and in using the different classes of drugs
• To be able to perform and
  interpret ABPM read-out and modify prescription

Multidisciplinary
aspects

• Liaison with local
  paediatricians; the interventional radiologist

Resources

• Intensive care unit;
  Radiology services

(O) Nephrolithiasis

Knowledge

• To know the aetiology of
  renal stone formation, including underlying tubular abnormalities
• To know the biochemical
  and radiological investigation of renal stones
• To understand the acute
  and chronic medical (including prevention of the development of renal
  stones) and surgical management of renal
  stones (including lithotripsy)

Skills

• To demonstrate the ability to
  appropriately investigate the child with renal stones
• To show the ability to manage
  a child with renal stones

Multidisciplinary
aspects

• To involve pediatric
  urologists where indicated
• To show an understanding of
  the significance of the family history and genetic implications in some
  cases

Resources

Departments of
Laboratory Medicine, Pediatric Surgery, Urology and
Radiology

(P) Tubular disorders

Knowledge

• To understand the
  different presentations of primary and secondary tubular disorders
• To know the different
  causes
• To understand the investigation
  of tubulopathies

Skills

• To be competent in the
  investigation and management of

tubular disorders

Multidisciplinary
aspects

• To understand the role of
  other specialists (hepatologists, neurologists, biochemists,
  geneticists) in the diagnosis, management and treatment of these
  disorders
• To be able to provide
  dialysis support to other specialists

Resources

Metabolic clinics,
Endocrine Clinic

Biochemistry
department

• Cystic
  disease

Knowledge

• To list the different
  causes of renal cystic disease in different age groups
• To describe the mode of
  inheritance and methods of screening
• To know the clinical
  course and associated features of autosomal recessive and autosomal
  dominant polycystic kidney disease

Skills

• To appropriately examine
  and investigate the child with renal cysts in different age groups
• To appropriately manage
  a child with polycystic kidney disease

Multidisciplinary
aspects

• To appreciate the
  implications of a diagnosis of autosomal dominant polycystic kidney
  disease on other family members
• To recognize the
  importance of genetic counselling

Resources

• Radiology services

(R) Genetic disorders (Inherited diseases of the kidneys)

Knowledge

• To know the presentation
  and management of commonly encountered inherited renal disease including
  renal involvement in syndromes, familial nephritis and polycystic kidney
  disease
• To understand basic
  genetic principles

Skills

• To be able to advise
  parents of the risks of recurrences and the need for family screening in
  commonly inherited

diseases

Multidisciplinary
aspects

To understand the
role of the geneticist in diagnosis and counselling,
including antenatal diagnosis

Resources

Geneticist

(S) Fluid and electrolyte disturbances

Knowledge

• To understand the
  physiology underlying fluid and electrolyte imbalance in a child
  without primary renal disease
• To know the principles of
  treatment of fluid and electrolyte imbalance
• To know the endocrine
  diseases associated with electrolyte imbalance and their
  management

Skills

To be able to
manage fluid and electrolyte imbalances in non-renal disease
including overdose

Resources

• Intensive care unit
• Endocrine clinics

(T) Acute Kidney Injury (AKI)

Knowledge

• To know the differential
  diagnosis of AKI
• To know the investigation
  including the role of renal biopsy
• To describe the methods to
  correct fluid and biochemical abnormalities and to know the indications
  for dialysis
• To describe the principles
  of dialysis and filtration
• To know the treatment of
  reversible causes of AKI

Skills

• To perform a reliable and
  accurate clinical assessment of the patient's fluid status

• To be able to
  appropriately manage the complications of AKI – conservative and
  dialysis
• To be able to select and
  practically manage the different dialysis modalities including
  peritoneal dialysis, hemodialysis and hemofiltration
• To be able to commence the correct treatment of the underlying cause
• To manage the patient with
  multiorgan failure or systemic disease requiring
  acute renal replacement therapy

Multidisciplinary
aspects

• To recognize the role of
  nurses in the management of AKI
• Liaison and share care
  with the intensive care unit

Resources

Intensive care and
neonatal intensive care units

(U) Chronic Kidney Disease (CKD)

Knowledge

• To know the epidemiology
  of CKD
• To list the causes of CKD
• To know the investigations
  required in a child with a new presentation of CKD, including assessment
  of the degree of renal failure and reversibility of the condition
• To understand the natural
  history and prognosis of common diseases causing CKD, and treatment
  strategies that may ameliorate the condition
• To understand the factors
  involved in the failure to thrive in CKD
• To describe the
  pathophysiology, investigation and indications for treatment in the
  management of renal bone disease
• To describe the
  pathophysiology of renal anaemia, and its investigation and management,
  including the use of erythropoietin and
  iron therapy

Skills

• To identify and
  appropriately manage the underlying cause

• To manage the child with
  CKD including biochemical disturbance, bone disease and anaemia
• To appropriately counsel
  the family to facilitate the selection of dialysis modality before
  referral for renal transplantation
• To make an accurate
  clinical assessment of nutritional status and to use appropriate dietary
  advice with the assistance of dietitians
• To prescribe and monitor
  treatment for hyperlipidemia
• To show the ability to
  prevent, diagnose and manage the renal bone disease
• To diagnose and
  appropriately treat renal anaemia

Multidisciplinary
aspects

• To appreciate the role of
  the multi-professional team including a dietitian, psychologist, social
  worker
• To understand the role of
  the dialysis nurses and transplant coordinator
• To audit biochemical and
  haematological results against national guidelines
• To appreciate the impact
  of CKD on cardiovascular disease in adult life

Resources

• Chronic kidney disease
  clinics
• Multidisciplinary team
  meeting

(V) Transplantation

Knowledge

Pre-Transplantation

• To understand the ethical
  issues surrounding organ donation/ transplant
• To know the principles of recipient
  selection, indications and contraindications
• To describe the
  theoretical and practical application of blood grouping, HLA
  matching and donor-recipient cross-matching

• To know what is involved
  in a transplant work-up
• To know the advantages and
  disadvantages of deceased versus live-related donor transplantation
• To know the acceptability
  criteria for deceased organ donation
• To describe the advantages
  and disadvantages of preemptive transplantation

Transplantation

• To understand the unique
  needs of children undergoing organ transplantation
• To know the basic surgical
  procedures involved
• To know the medications
  used, including side effects and recent advances and trials
• To know the approach
  towards handling deceased organ transplantation

Post-Transplantation

• To know the indications
  for and knowledge of the procedure of renal transplant biopsy
• To understand the immune
  mechanisms of rejection
• To know the recurrence
  rate of the original disease, and other complications about the original
  diagnosis and their management

Skills

Pre-transplantation

• To assess the suitability
  of a patient for a renal transplant
• To discuss the issues of
  transplantation

Transplantation

• To be able to manage the
  peri-operative transplant period
• To assess renal transplant
  function
• To plan and modify
  immunosuppressive therapy

Post-transplantation

• To be competent in the
  diagnosis and management of acute rejection episodes
• To understand the role of
  fine needle cytology and histopathology in diagnosing rejection
• To be able to manage the
  stable transplant patient
• To be able to advise the
  child, family and school
• To be able to diagnose and
  manage chronic rejection
• To be aware of the
  diagnosis and management of the short and long-term complications of
  transplantation
• To counsel patients with a
  failing graft and discuss future management of renal
  replacement therapy

Multidisciplinary
aspects

To understand the
role of the transplant coordinator

To appreciate the
role of the multidisciplinary team

Resources

• Transplant clinics
• Tissue typing laboratory
• Transplant surgeon

(W) DIALYSIS

1. Hemodialysis

Knowledge

• To describe the principles
  of hemodialysis and compare and contrast them with other methods of dialysis
• To describe the anatomy of
  the neck veins and their assessment
• To describe the methods of
  vascular access and arteriovenous fistulas and their complications
• To understand the
  principles of water treatment and maintaining water quality
• To define the methods to
  assess the adequacy of hemodialysis
• To list the complications
  occurring during dialysis
• To list the particular
  infections which may occur in patients on dialysis, and to define strategies
  to prevent blood-borne viral
  infections in patients on hemodialysis

Skills

• To be able to plan the
  initiation of hemodialysis

• To manage different forms
  of vascular access and their difficulties
• To assess the functional
  status of AV fistula and cannulate
• To operate hemodialysis
  machine and respond to alarms; disinfect machines and circuits
• To be able to handle
  dialyzers and the dialyzer tubings appropriately
• To adjust the prescription
  of hemodialysis based on adequacy and monitor the change
• To manage the
  complications of hemodialysis
• To diagnose, investigate
  and treat infection

Multidisciplinary
aspects

• To understand the role of
  the nurses in preparing the patient physically and psychologically for
  hemodialysis, and in the long-term management
• To counsel patients about
  blood-borne infection
• To work closely with the
  microbiologist in developing protocols and in audit and management of
  infection

Resources

Hemodialysis
technicians and nurses

Departments of
Nephrology, Microbiology and Surgery

2. Peritoneal Dialysis

Knowledge

• To describe the principles
  of acute and peritoneal dialysis, and know the advantages and
  disadvantages compared to hemodialysis
• To describe methods to
  assess the adequacy of peritoneal dialysis and ultrafiltration
• To describe the anatomy
  and outline the surgical procedure of insertion of peritoneal dialysis
  catheters
• To know the complications
  of peritoneal dialysis, both

infective and
mechanical

Skills

• To be able to prescribe
  peritoneal dialysis and monitor change and measure adequacy
• To perform a peritoneal
  equilibration test (PET)

• To operate and troubleshoot PD cyclers

  To manage the complications of peritoneal dialysis

Multidisciplinary
aspects

Pediatric surgeon

(X) Pharmacology

Knowledge

• To define the principles
  of pharmacokinetics and drug handling in renal impairment
• To list ways in which
  different classes of drugs act on the nephron
• To describe how drugs may
  affect renal function
• To list the effects of
  hemodialysis, hemofiltration and peritoneal dialysis on drug prescribing
• To describe the principles
  of drug interactions especially immunosuppressive
  agents

Skills

• To prescribe safely to
  patients with renal disease

Multidisciplinary
aspects

• To educate patients
  regarding the importance of compliance and reporting problems with medication

Resources

Pharmacologists

• Psychosocial
  and Ethical issues

Knowledge

• To understand the impact
  of chronic illness on the child, adolescent, parents, siblings and
  extended family
• To understand the ethics
  of research in children
• To know the process of
  informed consent in different ages
• To know the procedures for
  clinical trials

Skills

• To demonstrate competence
  in communication skills at initial diagnosis and thereafter
• Liaison with paediatricians
  and other health professionals
• To show interest in
  ethical discussions within the department
• To show the ability to take
  informed consent

Multidisciplinary
aspects

• To understand the role of
  the psychologist, psychiatrist, social worker, teacher and religious leaders

• To understand the care of
  the dying child

Resources

Multidisciplinary
team meeting

(Z) Teaching skills

Knowledge

• To understand the
  principles of adult learning and different teaching techniques
• To understand the role of
  clinical audit and research

Skills

• To demonstrate formal and
  informal teaching skills at undergraduate and postgraduate levels, and to
  other professionals within the multidisciplinary team
• To demonstrate continuing
  self-education and self-reflection
• To show support or active
  involvement in research
• To show the ability to
  critically evaluate literature reviews, audits and research papers
• To demonstrate ability in
  oral presentation skills and manuscript
  preparation

(A1) Nutrition

Knowledge

• To develop basic knowledge
  of the nutritional requirements of children with acute kidney injury and
  chronic kidney disease including
  those on dialysis and transplantation

Skills

• To be able to counsel and
  provide nutritional advice for children with
  chronic kidney disease

Multidisciplinary
aspects

• Nutritionist

Competency in Procedural /Practical Skills:

The postgraduate student should be able to perform independently the
following procedures

• Renal biopsy

Satisfactory performance of percutaneous biopsy of native and transplant
kidneys entails:

• knowledge of indications for
  the procedure,
• obtaining informed consent,
• performance of the procedure
  itself including minimizing patient discomfort, and
• interpretation of results of
  the biopsy.

• Central venous access insertion for hemodialysis

Satisfactory placement of vascular access entails:

• knowledge of informed
  consent,
• proper Seldinger
  technique,
• knowledge of vascular
  anatomy,
• minimizing patient
  discomfort, as well as
• functional catheter
  placement and recognize/manage complications

• Acute peritoneal dialysis catheter insertion

Satisfactory placement of peritoneal catheter placement entails:

• knowledge of informed
  consent,
• proper technique,
• minimizing patient
  discomfort, as well as
• functional catheter
  placement.

In addition, they should be able to perform independently the following:

To be able to write a prescription, conduct and supervise acute and
chronic intermittent hemodialysis

• Entails knowledge of proper
  indications for hemodialysis,
• knowledge of first dialysis
  precautions,
• writing of dialysis orders
  which includes choosing dialysis filters,
• estimating dry weight and
  modification during special circumstances (critically ill child, inborn
  errors of metabolism),
• choosing dialysate
  composition,
• understanding and treatment
  of complications, and
• modifying dialysis
  prescription for inadequate clearance in chronic hemodialysis patients.

To be able to write a prescription and conduct and supervise acute and
chronic peritoneal dialysis:

• Entails knowledge of proper
  indications of peritoneal dialysis,
• writing orders for
  peritoneal dialysis which includes dialysis prescription (volume of
  dialysate, frequency of exchanges, and use of different hypertonic
  solutions),
• understanding and treatment
  of complications, and
• modifying dialysis
  prescription in special situations (lactic acidosis, metabolic disorders)
  and inadequate clearance in chronic peritoneal dialysis patients

To be able to write a prescription, conduct and supervise continuous
renal replacement therapy (CRRT)

• Entails knowledge of proper
  indications of CRRT,
• writing orders for
  continuous renal replacement therapy (flow rate of dialysate, choosing
  ultrafiltration rate,
• choosing dialysate
  composition including the use of bicarbonate-based solutions),
• understanding and treatment
  of complications, and
• modifying dialysis prescriptions
  for inadequate clearance in patients undergoing continuous renal
  replacement therapy

To be able to write a prescription, conduct and supervise slow low
efficient daily dialysis (SLED)

• Entails knowledge of proper
  indications of SLED,
• writing orders (flow rate of
  dialysate,
• choosing ultrafiltration
  rate,
• choosing dialysate
  composition,
• understanding and treatment
  of complications, and
• modifying dialysis
  prescriptions for inadequate clearance in patients undergoing SLED

To be able to write a prescription, conduct and supervise plasmapheresis

• Entails knowledge of proper
  indications of plasmapheresis,
• writing orders (volume of
  plasma replacement,
• choosing the rate of
  plasmapheresis, monitoring,
• understanding and treatment
  of complications, and modifying plasmapheresis prescription based on the
  goal of plasmapheresis.

To be able to perform urine analysis at the bedside

• To perform correctly
  urinalysis and interpret findings and to know the limitations of
  interpretation as applied to patient care

Procedure

O

A

P

SJ

Renal biopsy

Hemodialysis
catheter access

Acute peritoneal
catheter insertion

Urine analysis

O- Observed; A- Assisted; P- Performed independently; SJ- Supervised
junior colleague

Career Options

After completing a DM in Nephrology, candidates will get employment
opportunities in Government as well as in the Private sector.

In the Government sector, candidates have various options to choose from
which include Registrar, Senior Resident, Demonstrator, Tutor, etc.

While in the Private sector, the options include Resident Doctor,
Consultant, Visiting Consultant (Nephrology), Junior Consultant, Senior
Consultant (Nephrology), and Nephrology Specialist.

Courses After DM in Nephrology Course

DM in Nephrology is a specialisation course which can be pursued after
finishing a Postgraduate medical course. After pursuing a specialisation in DM in
Nephrology, a candidate could also pursue certificate courses and Fellowship
programmes recognised by NMC and NBE, where DM in Nephrology is a feeder
qualification.

Frequently Asked Questions (FAQs) –DM in Nephrology Course

•  Question: What is the
  full form of DM?

             Answer: The full form
of DM is a Doctorate of Medicine.

• Question: What is a DM
  in Nephrology?

            Answer: DM Nephrology
or Doctorate of Medicine in Nephrology also known as DM in Nephrology is a
super speciality level course for doctors in India that is done by them after
completion of their postgraduate
medical degree course.

•  Question: What is the
  duration of a DM in Nephrology?

            Answer: DM in
Nephrology is a super speciality programme of three years.

• Question: What is the
  eligibility of a DM in Nephrology?

            Answer: The
candidate must have a postgraduate medical Degree in MD/DNB (General Medicine) or MD/DNB
(Paediatrics) obtained from any college/university recognized by the Medical Council of India (Now NMC)/NBE, this feeder
qualification mentioned here is as of 2022. For any further changes to the
prerequisite requirement please refer to the NBE website.

•  Question: What is the
  scope of a DM in Nephrology?

             Answer: DM in
Nephrology offers candidates various employment opportunities and career
prospects.

• Question: What is the
  average salary for a DM in Nephrology candidate?

            Answer: The DM in
Nephrology candidate's average salary is between Rs. 5 lakhs to Rs. 96 lakhs per
year depending on the experience.

• Question: Can you
  teach after completing DM Course?

           Answer: Yes, the candidate
can teach in a medical college/hospital after completing the DM course.

Patients who get sepsis while hospitalized are 43% more likely to return to the hospital for a stroke or any cardiac event, according to a new study published in the Journal of the American Heart Association. 

The risk rises to 51% for heart failure alone.

The study included more than 2.2 million patients who spent at least two nights in the hospital during a 10-year span — 800,000 of them were diagnosed with sepsis. 

SEPSIS, THE 'HIDDEN KILLER,' MAY BE RESPONSIBLE FOR 1 IN 5 DEATHS WORLDWIDE, STUDY SHOWS

The patients ranged in age from 19 to 87 years old, with an average age of 64.

Sepsis is "the body’s extreme response to an infection" and is considered a "life-threatening medical emergency," according to the CDC.

The condition occurs when an existing infection spreads throughout the body. 

If it’s not caught and treated early, sepsis can damage tissues and cause organs to shut down. 

Of the 1.7 million adults who develop sepsis in America each year, more than 20% will die in the hospital or go into hospice care, per CDC data.

Dr. Jacob C. Jentzer, director of the cardiac intensive care research unit at the Mayo Clinic in Rochester, Minnesota, led the new study. He explained that all participants had prior cardiac disease or cardiovascular risk factors, such as high blood pressure, high cholesterol, obesity, kidney disease or diabetes. 

5 SIMPLE WAYS TO HELP PREVENT HEART DISEASE THIS YEAR

They knew the risk level was already fairly consistent before considering the added effect of sepsis.

"Patients who survive sepsis are at a substantially higher risk of death and hospitalization for all outcomes, but the risk for cardiovascular events is particularly high," Dr. Jentzer told Fox News Digital. 

Given that cardiovascular disease is still one of the biggest causes of potentially preventable deaths in Americans, he said he sees the sepsis diagnosis as a helpful warning sign.

The doctor expected to find a higher risk among sepsis patients, but one finding did surprise him. 

CARE ABOUT YOUR HEART? TRY GETTING BETTER SLEEP, NEW STUDY SUGGESTS

"It was a bit unexpected that some of the lower-risk groups were the ones that had the strongest effect from sepsis," he said.

"If you have patients who are fairly high-risk already and the risk goes up a little bit, that's obviously bad — but not quite as bad as having someone who otherwise might do well, and then seeing that they have a much higher risk," Dr. Jentzer said.

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The key takeaway, he said, is awareness and prevention. 

Even after full recovery, someone who survived sepsis should take steps to minimize other risk factors for cardiovascular disease. 

"The fact that these patients survived sepsis makes it at least as important, if not more important, to monitor those factors," Dr. Jentzer noted. 

"It's key that they have all the essential medicines and make sure all the different components of cardiovascular risk — like blood pressure and lipids and other things — are very well-controlled," he said. 

The Host

Julie Rovner
KHN

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Health care was a recurring theme throughout President Joe Biden’s 2023 State of the Union address on Capitol Hill this week. He took a victory lap on recent accomplishments like capping prescription drug costs for seniors on Medicare. He urged Congress to do more, including making permanent the boosted insurance premium subsidies added to the Affordable Care Act during the pandemic. And he sparred with Republicans in the audience — who jeered and called him a liar — over GOP proposals that would cut Medicare and Social Security.

Meanwhile, abortion rights advocates and opponents are anxiously awaiting a federal court decision out of Texas that could result in a nationwide ban on mifepristone, one of two drugs used in medication abortion.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Among the takeaways from this week’s episode:

• President Joe Biden’s State of the Union address emphasized recent victories against high health care costs, like Medicare coverage caps on insulin and out-of-pocket caps on prescription drug spending. Biden’s lively, informal exchange with lawmakers over potential cuts to Medicare and Social Security seemed to steal the show, though the political fight over cutting costs in those entitlement programs is rooted in a key question: What constitutes a “cut”?
• Biden’s calls for bipartisanship to extend health programs like pandemic-era subsidies for Affordable Care Act health plans are expected to clash with conservative demands to slash federal government spending. And last year’s Senate fights demonstrate that sometimes the opposition comes from within the Democratic Party.
• While some abortion advocates praised Biden for vowing to veto a federal abortion ban, others felt he did not talk enough about the looming challenges to abortion access in the courts. A decision is expected soon in a Texas court case challenging the future use of mifepristone. The Trump-appointed judge’s decision could ban the drug nationwide, meaning it would be barred even in states where abortion continues to be legal.
• The FDA is at the center of the abortion pill case, which challenges its approval of the drug decades ago and could set a precedent for legal challenges to the approval of other drugs. In other FDA news, the agency recently changed policy to allow gay men to donate blood; announced new food safety leadership in response to the baby formula crisis; and kicked back to Congress a question of how to regulate CBD, or cannabidiol, products.
• In drug pricing, the top-selling pharmaceutical, Humira, will soon reach the end of its patent, which will offer a telling look at how competition influences the price of biosimilars — and the problems that remain for lawmakers to resolve.

Also this week, Rovner interviews Kate Baicker of the University of Chicago about a new paper providing a possible middle ground in the effort to establish universal health insurance coverage in the U.S.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: The New York Times’ “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters,” by Stephen I. Vladeck

Alice Miranda Ollstein: Politico’s “Mpox Is Simmering South of the Border, Threatening a Resurgence,” by Carmen Paun

Sarah Karlin-Smith: KHN’s “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen

Rachel Cohrs: ProPublica’s “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” by David Armstrong, Patrick Rucker, and Maya Miller

Also mentioned in this week’s podcast:

• The Associated Press’ “20 Attorneys General Warn Walgreens, CVS Over Abortion Pills,” by Jim Salter
• NPR’s “A Trump-Appointed Texas Judge Could Force a Major Abortion Pill off the Market,” by Sarah McCammon
• Politico’s “Federal Judge Says Constitutional Right to Abortion May Still Exist, Despite Dobbs,” by Kyle Cheney and Josh Gerstein
• The Becker Friedman Institute’s “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?” by Katherine Baicker, Amitabh Chandra, and Mark Shepard

click to open the transcript

Transcript: A Health-Heavy State of the Union

KHN’s ‘What the Health?’Episode Title: A Health-Heavy State of the UnionEpisode Number: 284Published: Feb. 9, 2023

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 9, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: And Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: Later in this episode, we’ll play my interview with Kate Baicker of the University of Chicago. She’s one of the authors of a new paper outlining a new proposal for the U.S. to achieve universal health insurance coverage, something every other developing nation already has, but we have not yet been able to achieve. But first, this week’s health news. We’re going to start, of course, with the State of the Union, which was livelier than usual, with way more back and forth than I’ve ever seen at one of these, and also more health-heavy than usual. I’m going to start with entitlements, notably the president threatening Republican proposals to hold the debt ceiling hostage for cuts in Social Security and Medicare. I’m still trying to decide whether this was intended or not, but Biden nevertheless ended up getting Republicans to vow not to demand cuts in Social Security and Medicare in exchange for raising the debt ceiling later this year. Here is the tape.

President Joe Biden: So, folks, as we all apparently agree, Social Security and Medicare is off the books now, right? And they’re not going to strike … [prolonged applause] All right. We got unanimity!

Rovner: So was this very clever or very lucky or both?

Ollstein: Well, it’s a little not quite what it seems. Republicans have been swearing up and down more recently that they never intended to cut Medicare and Social Security. But when they say “We want to reform it, we want to shore it up,” they’re talking about things that could limit benefits for beneficiaries. So it’s a semantics game, in part. I also want to point out that neither Republicans nor Biden have yet said that they consider Medicaid in that same untouchable category. So that really jumped out at me in the speech as well.

Rovner: Yeah, I mean, if you don’t touch Social Security or Medicare — and the Republicans are trying to say that because this has been used as a weapon for so many years — then basically that leaves Medicaid. And as we discovered in 2017, when they were trying to repeal the Affordable Care Act, Medicaid is actually pretty popular, too, because it takes care of a lot of people’s grandparents in nursing homes. I’m wondering when somebody is going to bring that up. Obviously, over the years, many, quote-unquote, “cuts” have been made to both Social Security and Medicare, mainly to slow the growth of the programs so that we can continue to afford them. Many more, quote-unquote, “cuts” will have to be made going forward. Every time you reduce payment to a drugmaker or a hospital or any other health care provider, that’s a cut, but it helps beneficiaries. So, you know, you say “cuts,” [and] beneficiaries say “they’re going to cut our benefits.” Not necessarily. They may just be making the program more affordable, including for the beneficiaries. I mean, this is just the continuous back and forth of each side, weaponizing Medicare in particular, right?

Ollstein: Well, and until we see actual proposals on paper, like you’re indicating, it is a semantics game — what some people consider a cut might not be what other people consider a cut. And there’s going to be all sorts of rhetorical games over the next several months along these lines. So, I’m waiting till we see an actual black-and-white proposal that we can all pick at and analyze together.

Rovner: Well, as we have seen, there’s danger in putting things on paper, as Rick Scott discovered this week. For those who don’t remember, it was his rather infamous proposal — was it last summer, I think? It was before the election — suggesting that all federal programs be sunsetted every five years and then have to be reauthorized, which would include Social Security and Medicare and Medicaid. And that’s not playing well at this point, as I think was predicted at the time, including by us. So moving on, I was also impressed at how the speechwriters managed to combine the, quote, “victory lap” stuff, record Affordable Care [Act] enrollment, Medicare drug price changes, limits on insulin, and surprise bills with the agenda ahead: expanding insulin price caps to the non-Medicare population, Medicaid expansion in the states that haven’t done it, making the Affordable Care Act subsidies expansions permanent. But none of these things — popular, though they may be — are likely to happen in this Congress, are they? … These are the things that fell out of the bill that passed last year.

Cohrs: Right. A lot of those cost money, which is going to cause even more problems this Congress than it did in the last one. And I thought it was pretty informative that the chair of the Energy and Commerce Committee in the House threw cold water on the insulin price-cap idea because it did gain some Republican support in the Senate when it came up for a vote. That was complicated. We won’t go into it. But yeah, it wasn’t a straight up-and-down vote on that policy, really. So I think there was some hope that maybe Republicans could get on board with it. But I think, because it applies to private market insurers, [it was called] a socialist policy, like, they just don’t want government in private plans, even though it’s a wildly popular policy. So, yeah, I think that doesn’t seem like a good signal for that policy in particular and for Medicaid expansion and a lot of these things. Democrats couldn’t even do it when they all agreed or had power in both the House and the Senate. So it’s definitely not a good indication for a lot of these things.

Ollstein: Let’s not forget that [Sen. Joe] Manchin [D-W.Va.] was the one who put the kibosh on the federal Medicaid expansion. He thought it wasn’t fair to states like his that expanded a long time ago and have been paying in a little bit. He thought it wasn’t right that states that were holdouts get a free ride. And the other Democrats argued back that it’s not fair for the residents in those states to be left out in the cold uninsured either. So this will continue. But like Rachel said, not going anywhere soon.

Rovner: So the things that in theory could happen, and these didn’t mostly come up in the speech or didn’t come up very much. But earlier in the day, Biden officials were floating a quote-unquote, “unity agenda” that included a long list of potentially bipartisan health issues, starting with the “cancer moonshot,” mental health and opioid treatment, strengthening the mental health parity rules. Some of these things actually could happen, right?

Cohrs: Yeah, I think especially on the mental health package, I think there was some unfinished business from last Congress, from the Senate Finance Committee. I think that all of these are issues that have been talked about this Congress already. And the leaders have signaled that they might be interested in. But I think there is some daylight here, and we’re still in very much the agenda-setting, throwing ideas out there that are a very vague part of this Congress. And I think actually getting things down on paper and going through hearings and that kind of thing will signal which areas there might actually be some agreement on. But again, spending is going to be a big challenge and there’s just not going to be time to get to everything.

Rovner: I think one of my frustrations is that normally the State of the Union comes right before the president’s budget comes out, usually within a week or two. And this year, the president’s budget isn’t coming out until March 9. So we have this, you know, talk about agenda-setting. We’re going to have a lot of time for people to just yap at each other without any specifics. But speaking of things that didn’t and aren’t likely to happen, the president didn’t talk very much about abortion. And what he did say — like threatening to veto any abortion ban Congress might pass, which won’t happen either with Democrats in charge of the Senate — that disappointed abortion rights supporters. They’re not happy, right, Alice?

Ollstein: Some were not. To be fair, some praised the speech, praised the president for saying the word “abortion.” This was a big thing over much of his career, including the beginning of his presidency. He would talk around it and not actually say the word “abortion,” which the groups felt contributed to stigma around it. And so the big mainstream groups, Planned Parenthood, NARAL, put out statements praising the speech, praising him for saying he would veto a ban, although, again, like you said, that’s a hypothetical. It’s not going to happen. But some other groups were critical that, one, he didn’t talk about some of the very looming direct threats to abortion access in the courts that we’re probably going to get to later.

Rovner: In a minute.

Ollstein: Just in a minute! But they were frustrated that he didn’t lay out more specifics that his administration will actually do to respond to the current loss of access in a lot of the country. They felt that we’re in a crisis moment and he spent less of the speech on abortion than he did on resort fees. That was a sore point for some advocates who I talked to.

Rovner: There was a lot of emphasis on junk fees. And I get why: These are the things that drive people crazy, and, particularly, in times of high inflation. But yes, abortion came very late in the speech — almost after a lot of people had tuned out and stopped paying attention, which I think also made some people unhappy. Well, speaking of abortion, here we are waiting for another make-or-break court decision out of Texas. Alice, this time it’s the future of the “abortion pill,” not just in Texas, but around the nation that’s at stake. How did we get here? And could we really see the abortion pill banned nationwide?

Ollstein: We really could. People have really been sleeping on this case, including some elected officials who were slow to realize the impact it could have. And mainly what people don’t understand is a bunch of states already ban all methods of abortion, including the pill, and then some additional states besides that have restrictions just on the pill. So this will mainly hit blue states and states where abortion access still exists. And so it could really have a huge impact because those states are now serving more than just their own populations. And in a lot of places, losing access to medication abortion means losing access to all abortion because there aren’t clinical services available. And so my colleague and I did some reporting on how the Biden administration is preparing or not for this ruling. They rebuffed calls from activists to declare a public health emergency for abortion. They said they don’t think that would help. While they do plan to appeal the ruling should the FDA lose, the upheaval that could happen in the meantime can’t really be overstated. And not to mention that an appeal would go to the 5th Circuit, which is very conservative, and then to the Supreme Court, which just overturned Roe v. Wade. And so while most experts we’ve talked to don’t think the legal arguments are that sound, you just can’t really …

Rovner: And remind us, this is the lawsuit that’s challenging the 22-year-old approval of the drug in the first place.

Ollstein: Exactly. And so health care legal experts also say that besides the absolute upheaval in the abortion space that this could cause, this would just completely destroy any certainty around drug approvals for the FDA. If anybody could come back decades later and challenge the approval of a drug, how can drugmakers feel comfortable developing and submitting things for approval and making their plans around that? It’s very chaotic.

Rovner: Sarah, is the FDA worried about this case? Has it not been on their radar either?

Karlin-Smith: I mean, they’re involved in the defense.

Rovner: They’re being sued.

Karlin-Smith: Right. I think it is a concern if this is used, right? If the folks who want this drug pulled would win, does it become precedent-setting in a way that you can get other products pulled? Perhaps. Again, the sentiments would not be there for a lot of other products in the way to use it. But it is a bit concerning when you think about judges having this power to overrule the scientific decisions we’ve left to civil servants, not politicians or judges, because they have expertise in science and medicine and clinical trial design and all these things we just would not expect judges to be able to rule on.

Rovner: Well, speaking of more politics, this week — actually, last week — a group of 20 state attorneys general from states with abortion restrictions wrote to CVS and Walgreens, which had already announced that they would apply to become providers of the abortion pill, warning them not to rely on the Justice Department’s interpretation of a 19th-century law that banned the use of the U.S. mail to send abortifacients. The letter doesn’t outright threaten the companies. It merely says that, quote, “We offer you these thoughts on the current legal landscape.” Has anybody sued over this yet? And what do we expect to happen here? I mean, are CVS and Walgreens going to back off their plans to become providers?

Ollstein: Well, the anti-abortion elected officials and advocacy groups are hoping that’s the case. But I think this could play out in so many ways. I mean, one, we have this national ruling that could come down, but we also have a few state rulings that could flip things the other way and force states that have put restrictions on the abortion pill to lift those restrictions and allow it. So now we have cases pending in North Carolina and West Virginia. One of them is by the manufacturer of the abortion pill, saying that states don’t have the right to put the FDA’s hat on their own heads and make those decisions. And the other is by an abortion provider, a doctor who says that these state restrictions hurt her ability to practice and hurt her patients. And so it’s just wild that we can swing anywhere from a national ban to forcing states with bans to lift those bans. I mean, it’s just all up in the air right now. I wanted to quickly point out two other things. A lot of activist groups say they are not counting on the Biden administration to adequately respond to this crisis. And so they’re doing a couple things. One, they’re encouraging people to do something known as “advance provision,” which is order abortion pills before they’re pregnant, before you need them, and just have them on hand just in case. And so they’re advising people do that in advance of the ruling. Interestingly, the FDA does not support that practice, but activist groups are encouraging it anyways. And then the other thing is the abortion pill regimen is actually two pills. And the big FDA lawsuit only goes after the first one. And so people are saying, you know, you can terminate a pregnancy just by taking a few of the second pill, even though that has a higher rate of not working and needing a follow-up procedure. And so …

Rovner: Although it’s still like, 95%, right?

Ollstein: It’s still very effective, but not quite as effective as using the two pills together.

Rovner: And I think it used to be when people would go to Mexico, that’s what they would get. They would get misoprostol, not mifepristone, which is what we think of as “the abortion pill” — and also methotrexate, which we talked about in the context of people with diseases for which methotrexate is indicated not being able to get it because it can cause abortions. But that’s another option there, right? And … it would be hard for FDA to pull those drugs because those drugs do have a lot of uses for other diseases.

Karlin-Smith: Or FDA could, I guess, be forced to take off the formal indication for use for abortion, but the drug would be out there and then could be subject to off-label prescribing, which then could potentially, I guess, impact insurance coverage if you’re using it for abortion. Pivot to if you had to go back to this one-drug regimen while, yes, it would still exist and be possible, I think a lot of providers are worried about the added burden that would create on folks that help people obtain abortion. And this system is just not set up to have enough workers to deal with that more complicated regimen. And it seems like it could end up leading to more need for surgical abortions, depending on how well it works and so forth. So I think logistically it creates a lot more challenges.

Rovner: Yeah, it’s a mess. Well, meanwhile, last issue here, we have a curious story out of a lawsuit in federal district court here in Washington, D.C., in which a judge proffered the notion that while the Supreme Court may have found no right to abortion in the 14th Amendment, that doesn’t mean there isn’t a federal right under the 13th Amendment. That’s the one barring slavery, specifically the restriction on the pregnant person’s personal liberty. As the judge correctly pointed out, the majority in last year’s Dobbs [v. Jackson Women’s Health Organization] ruling may well believe there’s no right to abortion anywhere in the Constitution. But that’s not the question that they litigated. Is this potentially an avenue that abortion rights advocates are going to explore?

Ollstein: I am not hearing a lot of hope being placed on this. If it goes anywhere, it would go back to the same Supreme Court that just ruled last year. And so abortion rights advocates are not optimistic about this strategy, but I think it’s a good indication of really both sides right now just trying to get as creative as possible and explore every legal avenue in the U.S. Constitution, in state constitutions, things where it never says the word abortion, but you could interpret it a certain way. I think that’s what we’re seeing right now. And so it’s really interesting to see where it goes.

Rovner: We are literally at the point where everybody is throwing whatever they can against the wall and seeing what sticks. All right. Well, let us turn to the federal research establishment. Late last month, a panel of advisers recommended a set of policies to strengthen oversight of so-called gain-of-function research that could inadvertently cause new pandemics. This was also one of the subjects of the first House hearing that called leading federal public health officials up on the carpet. What do we learn from the hearing? And has the federal government actually been funding gain-of-function research, or do we even know for sure?

Cohrs: So there has been a moratorium on this sort of research. And the interim director of the NIH [National Institutes of Health] quibbled over the term “gain-of-function research.” And he said we’re talking about a very select part of all of the research that could technically fall under that umbrella term. But he did say that there is a moratorium on funding that right now; there’s not current funding because they are reviewing their practices. And an advisory board did pass proposals and he laid out the process forward for that. So once those are finalized, he’ll write a memo to [Department of Health and Human Services] HHS Secretary Xavier Becerra, then it will get to the White House. So there is this bureaucratic progression that these new guidelines are going to go under, and it’s been pretty transparent and public so far. But we’ll see how things ultimately turn out. But I think they are very sensitive to this politically and they are trying to create guidelines that offer some lessons learned from some of the criticism they’ve gotten recently.

Rovner: And I think, I mean, this has become one of the major lines of argument about Republicans trying to figure out where covid came from. Perhaps it came from U.S.-funded gain-of-function research in China, which we don’t know, I don’t think. But there’s been a lot of “Yes, you did”-“No, you didn’t” going on. I mean, Sarah, does this go back to the, you know, politicians playing scientists?

Karlin-Smith: A little bit. And I think at the hearing, a lot of the Republicans who are pressuring NIH in particular on this are not super interested in listening to the subtleties and nuance of the argument. They just really want to make the point and bring up in people’s minds the possibility of, you know, covid being a lab leak, which I think … which hasn’t 100% been ruled out, but it’s kind of on the 98%, probably 99% ruled out by a lot of scientists. And so it was very hard for NIH and those lawmakers to have a reasonable discussion about the nuances and where this research might possibly benefit us in future pandemic prep. What type of precautions do need to be put in place? And I think NIH was trying to strive to communicate that actually a lot of what was recommended in this oversight report is things they’ve been working on and have put in place. But the hearing was designed by Republicans more to land those political punches and sound bites and not really delve into “Are there policy improvements that could be made here?”

Rovner: Well, speaking of civil servants trying to do their science policy jobs, the FDA’s been busy the last couple of weeks, including lifting a ban on men who have sex with other men donating blood. That’s a ban that’s been in effect in one way or another since the 1980s, when AIDS was first discovered. And in the wake of baby formula shortages, there’s now going to be a new deputy commissioner for food. And finally, the agency is asking Congress for new authority to regulate CBD [cannabidiol] products, particularly as more states legalize marijuana in all forms for recreational use. Sarah, this is an awful lot of stuff at once. Big policy changes where they try to hide some of them, or did they just all show up at once because that’s when they got finished?

Karlin-Smith: The food changes were sort of driven by events not quite within their control, and the blood policy, the CBD stuff were things in the works for some number of years now. So FDA is busy, and these are different divisions operating under it. I think the CBD stuff is drawing a lot of frustration because FDA had been working on considering how to regulate this aspect of hemp for a while now. And instead of coming up with a policy and taking action, they’ve rewound the circle; we’re back to square one and putting it on Congress’ issues. So that’s like one area where there’s a lot of frustration versus, I think, people are generally happier that the blood donation process was finally gone through and changed.

Rovner: Yes, the wheels of the federal regulatory process move slowly, as we know. All right. Finally this week, drug prices. Humira — which is a biological that treats rheumatoid arthritis and many other serious ailments, and for which you have undoubtedly seen TV commercials if you have ever turned on your television, because it’s the top-selling pharmaceutical in the world — is reaching the end of its patent life. That will soon provide the first real test of where the Affordable Care Act’s pathway to allow biosimilar competitors — effectively biologics version of generic drugs — whether that will actually bring down prices. Because there’s a chance here that there’s going to be a bunch of competitors to Humira and the price isn’t going to come down, right?

Karlin-Smith: Yeah, I mean, that’s a major concern for a number of reasons that get us back to the broader U.S. drug pricing debate and — including the role of pharmacy benefit managers in figuring out how people get coverage of their drugs. So Humira is one of the first biologics to lose patent protection, where patients actually fill the prescriptions themselves and give themselves the medicine, which is a very different payment system than if you’re getting a biologic medicine at a doctor’s office or a hospital. And so the way that most of the insurers are covering the drug for this year, they’re actually going to charge patients the same out-of-pocket cost in most instances, as if you’ve got the brand drug or the biosimilar. And because, unlike traditional generic medicines, a lot of these, at least initially, they’re not what is called auto-substitutable. So if your doctor writes you Humira, the pharmacist doesn’t automatically give you that generic. So you’d actually have to request a new prescription from your doctor, and they’d have to write it. And if you’re not going to pay less, why are you motivated to do that?

Rovner: When you’re not even positive how much whether the drug works the same way, whether the biosimilar works the same way.

Karlin-Smith: Right. And they think people are a little bit more hesitant. They don’t understand how biosimilars work compared to generic drugs, where it took — again, when the generic drug industry first started, it took people a while to get comfortable. So there are those issues. So, basically, what has happened is AbbVie has given insurance plans and payers’ discounts on their brand drug to keep it in a good place on their formularies. So there will be savings to the broader health system, for sure. The problem is if that doesn’t get passed on to the patients, and AbbVie can continue their market monopoly, my worry is, down the line, what happens to this biosimilar industry overall? Humira is not the only top-selling, big-selling biologic medicine where we want to bring down the cost. So if these biosimilar competitors don’t eventually gain market share and make money off of doing this, why are they going to go back and develop a biosimilar and try and lower the cost of the next big drug? And that’s what people are watching. I think there’s cautious optimism that, as more biosimilars for Humira launch, there will be some pressure for insurance companies to cut deals and lower prices and not just rely on making money off high rebates. But we don’t really know how it’s going to play out. And AbbVie was pretty creative over the years. In some ways that helped patients and others questionable — how much of … like, you know, there’s high concentration of the drug, low concentration. There is citrate-free, non-citrate-free. And that means that not all the competitors are going to be exactly the same in a way that creates as much competition as it seems at first. So yeah, it’s going to be messy.

Rovner: This is the famous evergreening that we saw with drugs. I mean, where they would change something small and get a whole new patent life.

Karlin-Smith: Right. So usually with generic research, you need three direct competitors to help bring the price down a lot. But in the case of Humira, while there’s going to be, probably at least six competitors this summer, maybe more, they’re not all direct competitors for the same version of Humira. So it sort of bifurcates the space a bit more and makes it harder to, you know, figure out the economics of all of that.

Rovner: Well, if you thought that drug pricing was confusing, now we’re adding a whole new level to it. So, I’m sure we will be talking about this more as we go forward. OK. That’s the news for this week. Now, we will play my interview with Kate Baicker of the University of Chicago. Then we will come back and do our extra credits.

I am excited to welcome to the podcast Katherine Baicker, currently the dean of the University of Chicago Harris School of Public Policy and soon to be provost of the university. Congratulations.

Katherine Baicker: Thank you so much.

Rovner: So, Kate is a health economist who is well known to health policy students for a lot of things, but most notably as the co-lead author of the Oregon Medicaid health experiment, which was able to follow a randomized population of people who got Medicaid coverage and a population that didn’t to help determine the actual impact of having Medicaid health insurance. Today, she’s here as lead author of a paper with a new way to possibly provide health coverage to all Americans. Kate, thank you so much for joining us.

Baicker: It’s a pleasure.

Rovner: So your new paper is called “Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Safety Net.” And in that single sentence, you’ve pretty much summed up the entire health insurance debate for, like, the last half-century. For those who don’t know, why is it that the U.S. doesn’t have universal insurance when literally all of our economic competitors do?

Baicker: Well, like so many things about our health care system, it goes back to the history of how it evolved, as well as some things that are different about the U.S. from other countries. If you look at how big the U.S. is geographically, how diverse our country is, how heterogeneous the health needs are. A lot of the solutions you see in other countries might not work so well in the U.S.

Rovner: So … and we’ve basically just not ever gotten over the hump here.

Baicker: Well, I also think we haven’t been asking the right questions necessarily. There is a real debate about whether health care is a “right” or not. And, of course, your listeners can’t see my “air quotes,” but I put that in air quotes because I think that’s the wrong question. Health care is not just one thing. Health care is a continuum of things. And if we just boil it down to should people have access to care or not, that doesn’t let us engage with the hard question of how much care we want to provide to everyone and how we’re going to pay for it.

Rovner: So I know a lot of people assume that the Affordable Care Act would — I’ll use my air quotes — “fix” the U.S. health insurance problem. And it has gone a long way to cover a lot of previously uninsured people. But who are the rest of the uninsured and why don’t they have coverage? It’s not necessarily who you think, right?

Baicker: That’s right. And, you know, the ACA, or Obamacare, actually made a lot of headway in covering big swaths of the uninsured population. There was a lot of discussion about health insurance exchanges, but actually more people were covered by Medicaid expansions than by health insurance exchanges. But both of those, as well as letting young people up to age 26 get on their parents’ policies. All of this chipped away at the ranks of the uninsured, but it left, for example, undocumented immigrants uninsured and also the vast majority of the uninsured people in the U.S. are already eligible for either a public program or heavily subsidized private insurance. And we have a problem of takeup and availability, not just affordability.

Rovner: So let’s get to your proposal. It’s not really that different from things that either we’ve tried in some parts of our health insurance ecosystem or what other countries do. What would it actually look like if we were to do it?

Baicker: Well, if you go back to what I think is the right question of how much health care do we want to make sure that everyone has access to and how are we going to get them enrolled in those programs? I think one key feature is having that coverage be as low-hassle as possible, automatic if possible, because we know that nonfinancial barriers to insurance are responsible for a lot of the uninsured population we still see today.

Rovner: We’ve seen that with pension plans, right? That automatically enrolling people get more people to actually put money away?

Baicker: That’s right. That’s one of the takeaways from behavioral economics is that defaults matter. Meaning what the baseline is and letting you opt in and out makes a big difference because people tend to stick with where they are. There’s a lot of inertia in saving for retirement, in enrolling in health insurance, in lots of different things. And being sophisticated in how we design the mechanics of those programs is important, as well as making sure that they’re financially affordable to people. So one step is making sure that whatever is available to people is as easy as possible for them to take advantage of. But the other is having a much harder discussion about what we want that basic package to be. And when you say “I want everybody to have all of the care that might possibly be available, no matter what price and no matter how much it impacts their health,” that’s more than 100% of GDP. We just can’t do that and still have any money for anything like food and housing and education and roads and all of the things that we also care about. So if we had that tough discussion as a nation, as a body politic, to say, here is the care that we think is really high-value that we think is a right for everyone and that we want to make sure is available to everyone, then people could be automatically enrolled in that default package and have the option to get more care that is more expensive and maybe a little less effective, but still worth it to them that they purchase on their own. And that opens up a whole host of other questions and ethical dilemmas that I’m sure you’re going to want to ask about.

Rovner: But it also — as a lot of people are concerned, that something like “Medicare for All” would eliminate the incentive to innovate new kinds of care. I mean, obviously, there’s this race to figure out, you know, a drug to treat Alzheimer’s and that if the federal government were to basically set prices for everything, that there would be no more innovation incentive. You actually address that here, right?

Baicker: Yes. And I’m so glad you raised that concern, because there are many challenges to having a monolithic one-size-fits-all Medicare for All type plan. One of them is, you know, affordability for the system and accessibility. But another is the dulled incentive for innovation and the dulled drive towards having new medicines and new treatments available. Medicare is very slow to innovate. It took 40-plus years for Medicare to include prescription drugs at all. And that was because when Medicare was formed in the Sixties, prescription medicine wasn’t a very important part of health care. It wasn’t a very expensive part of health care, there just weren’t that many drugs to treat people. Well, now those medicines are crucial to health and well-being. And Medicare finally added a prescription drug benefit in 2005. But that was a long lag, and that’s just one example. So I think having some fundamental access to care that we know is of high value for everyone could be coupled with having the option to purchase more generous insurance that covers more things. And that private insurance layered on top would really provide the financial incentives for continued innovation. It acknowledges the reality that in a world of scarce resources, higher-income people are going to have more health care than lower-income people. And that is an ugly reality and one that we ought to grapple with ethically, and as a matter of public policy priorities. I would argue we’re already rationing care. It is not possible for public programs to pay for all care for all people, no matter what the price, no matter what the health benefit, and being intentional about defining what it is we’re going to cover with public dollars and then letting people buy more care with private dollars is a way perhaps to make a financially sustainable system that also promotes innovation.

Rovner: And this isn’t really new. I mean, lots of other countries do this. I was in Switzerland a decade ago, and I remember that they … their extra-benefit package includes things like single rooms in hospitals and homeopathic medicine and things that I’m not sure we would end up putting into our top-up plans, but it’s something that’s important to them.

Baicker: Yes. And when people point to our European counterparts and say, look, they all have single-payer. In fact, a lot of them have a hybrid system like the one that we’re describing. And it’s important to differentiate: We’re talking about a basic plan that’s available for everyone. That doesn’t mean that it only covers cheap things. It should only cover high-value things. But some cheap things are incredibly ineffective and low-value, and some expensive things are really important for health and very high-value. So it’s about the value of the dollar spent in terms of producing health, not whether it’s expensive or cheap. And so when you think about having a top-up plan, it shouldn’t be about billing cost sharing that, you know, lower-income people are exposed to in the basic plan. It should be about adding services that are of less health importance but still valuable to the people purchasing them.

Rovner: Obviously, the biggest issue here is going to be who’s going to make that determination? I’m old enough to remember fights over the ACA, death panels, and the independent Medicare advisory board that never happened. In fact, there were a lot of these, you know, we’re going to appoint experts. And it never happened because none of the experts ever wanted to be on these panels. How do you overcome that hurdle of actually grappling with the decision of what should be covered?

Baicker: Yes, the devil is always in the details for these things, and you put your finger on a really important one where we haven’t provided a robust answer, and our analysis is meant to highlight the importance of making these hard decisions and the value of this framework. But we don’t have a magic bullet for this. I would argue that having Congress make this decision every year is a recipe for lobbying and decision-making that doesn’t actually line up with value. There’s an opportunity perhaps to have a panel of experts who, as you note, is just a hop, skip and a jump from being called a “death panel.” But I think we can rely on some clinical guidelines as guardrails on this. And we do have some examples of experimentation in this direction in the U.S. In fact, more than experimentation — if you look at Medicare Advantage, this used to be a small part of the Medicare program. These are private plans for Medicare beneficiaries that are now, I think, pretty soon going to be the majority of plans that people have. And it’s a mechanism for people to choose among plans that have some things that have to be covered, but can then add additional benefits for enrollees, and it can be a little more tailored to what people value in their plans. So I don’t think that’s the answer either. But it’s a proof of concept that we can do something like this in the U.S.

Rovner: So in some ways this would bridge the gap between Republican marketplace ideas and Democratic Medicare for All ideas. But it feels like, since the fight over the Affordable Care Act, Republicans have moved more to the right on health care and Democrats have moved more to the left on health care. You are no stranger to partisan politics nor the ways of Washington, D.C. How could everybody be brought back to what I daresay looks like a political compromise?

Baicker: Well, I’m an economist, as you noted, and that’s notoriously bad at understanding actual human beings. I don’t have any idea for the path forward through the political thicket that we’re in. In some ways, it is a little disheartening to see how difficult it is to do some basic commonsense things. In any complicated system like the U.S. health care system, there are always small technical fixes that need to be made that are just commonsense, that ought not to be political. And it’s hard to do those.

Rovner: We’re lacking in common sense right now in Washington.

Baicker: Yeah. So I can’t say that I’m hugely optimistic about a big change happening right away. On the other hand, I think covid really highlighted to people across the political spectrum how important it is to have continuity of coverage, how disparate our current system is in terms of access to care, how problematic it is to have your main avenue of health insurance be through your employer when a pandemic is coupled with a recession. So I think the challenges and the vast inequities of our health care system were laid bare during covid. So it is perhaps salient enough that people might be willing to consider alternative structures. But I can’t say I’m holding my breath.

Rovner: Well, Kate Baicker, thank you very much for, if anything, a great thought experiment. It’s really wonderful to look your way through … it’s like, oh, we could get there, maybe in another half a century.

Baicker: I hope sooner than that.

Rovner: I do, too. Thank you so much.

Baicker: My pleasure.

Rovner: OK, we’re back. And it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?

Cohrs: My extra credit is headlined “UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings,” in ProPublica by David Armstrong, Patrick Rucker, and Maya Miller. And I thought this story was just such a good illustration of the jargon that we use in D.C., of, like, utilization management and prior authorization. And sometimes these terms just feel so impersonal. But I feel like this story did such a good job walking through one patient’s struggle to find something that worked and then just the arbitrary choices that insurers were making, looking at their bottom line to try to prevent him from getting a very expensive treatment that actually did increase his quality of life significantly. So I would definitely recommend, as we’re thinking about insurers’ role in this whole health care cost debate as well.

Rovner: Yeah, it does bring home how the patient is always in the middle of this. Alice.

Ollstein: I chose a piece by my colleague Carmen Paun called “Mpox Is Simmering South of the Border, Threatening a Resurgence,” and it’s about how the U.S. was extremely successful in vaccinating high-risk people against mpox, which for folks who still remember the artist formerly known as monkeypox, the name was changed to reduce stigma and be more accurate. The U.S. vaccination campaign and messaging campaign to the most high-risk populations was really successful and did the trick. But as we learned from covid and every other infectious disease, if you don’t take care of other parts of the world, it could eventually come back. We’re not an island, and even islands aren’t safe. But, you know, this is about a bunch of countries, including Mexico, that really have made no mass vaccination effort at all. You know, some civil society groups are trying on their own, but they just don’t have official government backing. And that’s really dangerous. And it meant that cases are surging in parts of Latin America and parts of Africa. And as we saw from covid, that leads to the development of new variants and things traveling back to the U.S. and other places around the world. So, certainly, something to pay attention to.

Rovner: Public health is important. World public health is important. Sarah.

Karlin-Smith: I looked at a piece called “Decisions by CVS and Optum Panicked Thousands of Their Sickest Patients,” by Arthur Allen for Kaiser Health News. It’s a deep dive into CVS and Optum moving out of, to some degree, business places where they provide home infusion services of perinatal nutrition to people that essentially cannot eat or drink in most cases. And they basically decided that it’s not a great business opportunity for them in many cases. But these are people that really depend on these services to live and survive, and they’re very complex medicines and essential nutrition to get and deliver. And at the same time, I think what really fascinated me about this story is it talks about this dynamic of while companies are getting out of the space where you’re providing this service to people that need these IV treatments to survive and live, there also has been development of these medical spas, as they’re called, where people that actually do not need IV hydration or IV nutrition are essentially being given it for nonmedical purposes. And there’s a lot of money being made there. And it just shows you how some of the profit incentives in our system don’t necessarily align with treating the people that actually need the health care first.

Rovner: Yeah, it’s like the people with diabetes not being able to get their drugs because people in Hollywood want to lose 10 pounds fast. But this obviously is, you know, another life-or-death issue. Well, I chose an op-ed this week in The New York Times by the University of Texas law professor Steven I. Vladeck called “Don’t Let Republican ‘Judge Shoppers’ Thwart the Will of Voters.” And it answered a lot of questions for me. First, how is it that so many suits end up in front of the same judges who the plaintiffs know are likely to rule in their favor, and all in Texas? So it turns out that Texas has distributed its federal judges in a way that in nine districts there is only one judge. And in 10 more, there are only two judges. Obviously, there’s no random draw in those districts where there’s only one judge. That’s what you’re going to get. So we keep seeing some of the same Texas judges, first Judge Reed O’Connor in Fort Worth, and now Matthew Kacsmaryk, a former advocate for a conservative think tank and the only federal judge in Amarillo. Judge O’Connor had the big ACA case, now has a big preventive care case. Judge Kacsmaryk has the abortion pill case that we’ve been talking about. It’s a really interesting piece about how that could really twist justice. But it also includes several ways to fix it. We’ll have to see if any of them actually get taken up.

OK. That is our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me as long as Twitter is still up. I’m @jrovner. Alice?

Ollstein: @AliceOllstein

Rovner: Rachel

Cohrs: @rachelcohrs

Rovner: Sarah.

Karlin-Smith: @SarahKarlin

Rovner: We will be back in your feed next week. Until then, be healthy.

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