- Email: [email protected]
Share Your Passion for Nephrology: Ten Tips to Invigorate Attending Rounds and Precepting Sessions
Perspective Share Your Passion for Nephrology: Ten Tips to Invigorate Attending Rounds and Precepting Sessions Melanie P. Hoenig, MD Although there have been mounting concerns over the decline in applicants to nephrology training programs, strategies to entice students and trainees to pursue a career in nephrology are lacking. Furthermore, the complex factors that contribute to career decisions and the lag between a positive interaction and a decision to pursue nephrology make such strategies difficult to assess. Nevertheless, it is still important to continue efforts to mentor and inspire. This article offers 10 strategies to help nephrologists share passion for nephrology in the clinical arena. These include the excitement of the dialysis unit, ethical dilemmas, pearls for the bedside, and questions “on the fly.” Am J Kidney Dis. -(-):---. ª 2015 by the National Kidney Foundation, Inc. INDEX WORDS: Nephrology education; mentoring; precepting; nephrology workforce; teaching strategies; medical student; resident; attending rounds; inpatient ward.
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n recent years, much has been written regarding the widening gap in the United States between individuals needed to sustain the nephrology workforce and the number of trainees interested in pursuing nephrology. In addition, declining applications for the nephrology subspecialty through the National Residency Matching Program left almost half of all programs unfilled for the academic year beginning in 2015.1,2 Despite mounting concerns, there has been little published on strategies to increase interest in careers in nephrology. Exit interviews with residents indicate that 2 major reasons for choosing alternative fields are negative perceptions regarding dialysis and anxiety related to complex electrolyte cases.3-5 In this article, I offer 10 strategies to help nephrologists share passion for nephrology in the clinical arena. My emphasis is on the inpatient ward experience, but I also include some suggestions for the outpatient clinic. The focus of this piece is to help educators inspire trainees through the use of nephrology content; an excellent review on etiquette and collegiality has been published recently.6 1. Rejoice in Successful Care of Patients With End-Stage Kidney Disease Contrary to popular belief, issues related to endstage kidney disease provide a wonderful platform for nephrologists to share their passion for nephrology. Dialysis is currently the best treatment to replace a functional organ of any type. Dialysis is also the ultimate opportunity for “show and tell.” Students and house staff may stand reluctantly outside the doors of the dialysis unit with anxiety akin to that experienced when standing outside the operating room for the first time, hoping that the scrub nurse will offer a gown and gloves. This moment is an ideal opportunity for you to welcome the trainee into the unit. A quick tour of the Am J Kidney Dis. 2015;-(-):---
blood circuit requires just a few minutes, yet shortly thereafter, the same house officer may be seen reviewing this circuit with a colleague. After you explain the magnitude of the dialysate flow rate, ask the resident or student to calculate the water requirement for 1 treatment, 1 shift, 1 day, and 1 week. No elaborate lecture on water is needed. Instead, a simple discussion of the features of community water and a tour of the water treatment area will suffice. A review of arteriovenous access is essential; many are under the impression that they cannot distinguish a fistula from a graft, but this is relatively easy with a simple examination (1 incision or 2, extra anatomic thrill, and thick rugated material). Ask the team to move through the unit and look at the panoply of arteriovenous accesses and characterize each. Alert them to the comprehensive “Atlas of Vascular Access” by Dr Vachharajani for the Fistula First initiative.7 Show students the size of the needles used for cannulation and the relatively blunt bevel of needles used for the buttonhole technique. Peritoneal dialysis is another important consideration. Take out the peritoneal dialysis training apron and have students perform a mock exchange. No nephrologist can seem intimidating while wearing the peritoneal dialysis apron. Consider the electrolytes
From the Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA. Received November 25, 2014. Accepted in revised form March 6, 2015. Address correspondence to Melanie P. Hoenig, MD, Department of Medicine-Renal Division, Beth Israel Deaconess Medical Center Clinic, Fa 8/185 Pilgrim Rd, Boston, MA 02215. E-mail: [email protected] 2015 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.03.027 1
Melanie P. Hoenig
within the dialysate and what effects an exchange may yield. Regale trainees with Nobel Laureate Joseph Murray’s story of the first successful living donor kidney transplantation after 20 failed cadaveric ones, and how Murray confirmed that the Herrick twins were identical by successful skin grafts and a stealth visit to the Boston Police Department to compare fingerprints.8 If you are based at a transplantation center, send the residents to witness the magnificence of urine flow when the surgeon removes the clamps from the transplanted renal vasculature. 2. Consider the Ethics of End-Stage Kidney Disease Care Medical ethics takes on new dimensions in the controversies in the care of patients with end-stage kidney disease. House staff are often struck by frustrations related to end-of-life care in patients with advanced kidney disease who have serious comorbid conditions. Explain the origins of dialysis therapy and the barriers to availability in the early years. Share with them the LIFE magazine exposé on the “god committee” that helped decide “who lives and who dies” when the first free-standing dialysis unit in Seattle had only 3 stations.9 Point out some of the then-used criteria for suitability for dialysis, including unique moral duties, constituency and social value.9 To drive home the gravity of such an exercise, ask residents and students to create an imaginary ranking system and consider how patients on the service or in the dialysis unit would rank. Describe how, with the advent of the US dialysis program (scripted by the Social Security Amendment, Section 299I of Public Law 92603), dialysis became available to all, and note that passage of this amendment grossly underestimated the cost and number of potential patients.10 Ask learners to debate changes that might improve this legislation. Kidney transplantation also offers many ethical challenges. These may be on a personal scale: the potential donor who is not interested but instead claims that the transplantation unit does not return telephone calls, the lover who wants to donate but keep her identity secret from the recipient’s wife, or the patient with Caroli disease (congenital hepatic fibrosis and autosomal recessive polycystic kidney disease) whose liver function is too poor to tolerate surgery for kidney transplantation but too good to merit a combined liver/kidney transplant. Then there are transplantation challenges on a broader scale, such as the logistics of a kidney donation “domino chain,”11 not to mention the complexities of organ allocation, laws against paid donation, and access to the wait list. 2
3. Go to the Bedside The bedside physical examination offers numerous unique opportunities. First and foremost, teaching at the bedside allows the clinician educator the opportunity to model the caring and intimate connections that are afforded by the patient-physician relationship. Here, the attending can listen and learn. Homer Smith award recipient Franklin Epstein exemplified this approach when he sat on his patients’ beds to hear their stories, fluffing their pillows before he left.12 As physician novelist Dr Abraham Verghese wrote in his best-seller Cutting for Stone: [the doctor-teacher] invited me to a world that wasn’t secret but it was well hidden. You needed a guide. You had to know what to look for, but also how to look. You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, if you went through that door, a strange thing happened: you left your petty trouble on the threshold. It could be addictive.13(p224)
Nephrologists should be that guide, the expert who can capitalize on knowledge of physiology to reconcile clues needed for physical diagnosis. Given our crude strategies to measure volume status compared to the human body’s elegant and redundant transistors, if review of the physical examination could at minimum help trainees assess volume status, this would be a triumph.14 To complement this practice, the team can consider the weight of edema by loading saline solution bags into their white coats and debate the difference between dehydration and volume depletion and the requisite dietary sodium intake of an anephric hemodialysis patient who gains 5 kg between each dialysis treatment. Bedside examination of patients with polycystic kidney disease provides an opportunity to review the abdominal examination; remind learners that one hand is placed behind the kidney just below and parallel to the 12th rib and the other is placed on the abdomen lateral to the rectus muscle. As the posterior hand gently pushes the kidney anteriorly, the other hand is used to feel the kidney move forward to greet the anterior hand. Next, the examination should be used to inform regarding the pathophysiology of this disorder: the potential mechanisms of hypertension, implications of bulky disease, and renal and extrarenal manifestations. 4. Pose Questions on the Fly One of the realities of modern medicine is that appropriate documentation is needed for good patient care. Though adequate notes can rob attending rounds of their momentum, returning to write notes after rounds is often not logistically possible. In this Am J Kidney Dis. 2015;-(-):---
Share Your Passion for Nephrology
instance, if trainees have no specific tasks at hand, they can be occupied with quick thought questions that they can consider on their own or as a group. It is useful to have a few such questions at the ready (Box 1).15-19 For example, question the dogma that serum urea nitrogen level is often elevated in an upper gastrointestinal bleed from absorption of blood. Then recount the story of 3 healthy physicians with normal kidney function who each had a nasogastric tube placed and were then administered 800 mL of expired citrated human blood into their stomach. In this experiment, the serum urea nitrogen level did increase—by a mean of 5 mg/dL over 5 hours—then returned to normal within 24 hours. When the same physicians ingested 180 g of protein, the mean increase was 20 mg/dL.19 5. Do Calculations and Make Predictions Together Although it may seem mundane, routine calculations or at least a review of the important formulas and their derivation, features, and limitations are important for modern learners who have an “app for that” at their fingertips. Students need to know the context in which each formula can be appropriately applied. Trainees often feel inadequately prepared to manage symptomatic hyponatremia with hypertonic saline solution, but by calculating the rate together with their mentors, trainees can learn that the rate of infusion is typically slow and that safety is ensured
through frequent measurement of the serum sodium level. Show how, if the pH is very low, problems can arise when using the “rule of thumb” (the strategy of concluding that there is simple metabolic acidosis with appropriate respiratory response if, by covering the first digit of the pH with the thumb, the last 2 digits of the pH are similar to the PCO2).20 Instead, teach students the Winters formula and how it was derived from data for real patients with simple metabolic acidoses.21 In this era of “copy and paste,”22 laboratory studies are ordered to populate lengthy admission and progress notes. Ask the team to think critically about the laboratory studies they order, make predictions, and keep track of responses. For example, in a patient who has oliguric acute kidney injury, ask the team to predict the volume of urine required before creatinine level reaches a plateau. Ask residents to estimate the serum sodium level in a hyponatremic patient the morning after intravenous fluids have been given. Question learners about the expected decrease in serum bicarbonate level in an oliguric patient who is eating protein. This exercise primes the learner to think about an expected outcome and in so doing, fosters the development of intellectual curiosity in nephrology-related content. When results fall outside of predicted outcomes, learners will then need to determine whether their hypotheses were flawed or other unforeseen factors are at play. 6. Tell a Great Story
Box 1. Sample Questions for Use on Rounding Thought questions Normal saline solution has a sodium content of 154 mEq/L, whereas the normal serum sodium level is w140 mEq/L. Why? Consider the lessons learned from a “normal saline ceremony.”15 Can the serum sodium concentration determine the volume status?16 Why is ANCA-associated vasculitis considered “pauciimmune” when the immune system is clearly activated? Kitchen nutrition: How much potassium is in a serving of a sports drink? Which beverage is most like normal saline solution? Why do the GFR estimating equations perform poorly when kidney function is close to normal? What were the hurdles to the development of hemodialysis? “Myth busters”—what is the evidence? Thiazide diuretics are often prescribed “30 minutes before” a loop diuretic. Is it necessary? Does furosemide work better as an infusion vs a bolus? Should it be mixed with albumin? 19 Why is the SUN elevated in gastrointestinal bleeding? What is the utility of the classic triad of fever, rash, and peripheral eosinophilia in interstitial nephritis? What is the utility of the test for eosinophils in the urine?17 18 Why is there edema in the nephrotic syndrome? Abbreviations: ANCA, antineutrophil cytoplasmic antibody; GFR, glomerular filtration rate; SUN, serum urea nitrogen. Am J Kidney Dis. 2015;-(-):---
Sometimes a problem can come alive with a vivid narrative. Humans frequently think in terms of stories that frame an experience and provide structure.23 Senior faculty may have a vast repository of knowledge of nephrology or personal experience that is easily retrievable, but junior faculty who have not watched the mysteries of nephrology unfold can benefit from mentorship from more senior colleagues. In JASN’s formative years, feature editor Mark Knepper ran a series called “Milestones in Nephrology,” which is a virtual treasure trove of such stories. These articles, which appeared from 1997 to 2001, had been published in other journals at least 20 years earlier and were reprinted with comments from the original author, if he or she was alive, or from a current expert in the field. Some particularly noteworthy issues include the original article by Drs Brescia and Cimino accompanied by Dr Scribner’s commentary and confession that he realized their technique would make his eponymous shunt obsolete.24 Dr Bywaters’ description of the first patients that he followed with crush injuries, the bitter criticism he received from the professor of surgery who thought that Bywaters had performed too many tests, and Bywaters’ initial failed attempts to create an 3
Melanie P. Hoenig
animal model make for a gripping narrative.25 Plus, who can resist tales from Dr Schwartz on the syndrome that “probably” resulted from inappropriate secretion of antidiuretic hormone26 or from de Wardener on his antics during his seminal experiments on water loading.27 7. Review Landmark Studies Examination of influential articles can be provocative and not just entertaining. Share the original publication on the fractional excretion of sodium and remind trainees that in this report with 17 participants, the gold standard for prerenal azotemia was improvement of kidney function after fluid resuscitation. However, the presence of muddy brown casts was not considered.28 It is also useful to review the use of “urinary anion gap” or “net urine charge” in the diagnosis of hyperchloremic metabolic acidosis from the original report that had 38 patients with distal renal tubular acidosis and 8 with diarrheal illness.29 Landmark discoveries are not restricted to the prior century. Recent triumphs include the discovery of the elusive podocyte antigen, M-type phospholipase A2 receptor (PLA2R1), which is the target for membranous nephropathy.30 The pathogenesis was long predicted to be caused by a circulating antibody to a podocyte antigen based on the experimental rat model, Heymann nephritis, but it was not until 2009 that the circulating antibody and its target on podocyte membranes was discovered. In 2010, sophisticated genetic analyses identified a gene on chromosome 22 that appears responsible for the excess risk of focal glomerulosclerosis, end-stage kidney disease, and human immunodeficiency virus (HIV)-associated nephropathy in individuals of African ancestry. The genetic variants persist, analogous to the benefit of sickle trait in preventing malaria, to confer resistance to a strain of African sleeping sickness, Trypanosoma brucei rhodesiense, the parasite spread by tsetse flies in Western Africa. When the parasite ingests this variant of APOL1, it creates a pore in the parasite lysosomes and leads to parasite death.31 The mechanism for APOL1-induced risk of kidney disease is sure to follow. 8. Go to the Microscope The advent of digital cameras on handheld devices and telephones has made sharing results of the urinalysis possible.32 This is an opportunity to view the gamut of findings from hyaline casts to crystals and to explain to trainees why urinary acanthocytes are a good indicator for the presence of glomerular bleeding. Share with them the carefully crafted study in which urine sediment findings from the full spectrum of renal parenchymal diseases were compared, demonstrating that those with glomerular bleeding 4
were most likely to have acanthocytes33 and, by way of comparison, show that urine of all types (concentrated or dilute, low or high pH) supplemented with a drop of medical student blood does not have these changes. (One caveat: use of hand-held devices with cameras must be locked and patient confidentiality must be maintained at all times.) 9. Have a Curriculum It is important to develop a curriculum for time spent with trainees rather than leaving learning to chance. Some programs have the luxury of a revised elective for residents,34 but others have residents on service sporadically when they are not pulled to cover for ill colleagues. Certainly, case-mix will dictate a portion of the experience, but at a minimum, it is essential that individuals who rotate through nephrology understand the approach to a patient with acute kidney injury and can properly weigh the value of the history, physical examination, urine indexes, and urine sediment examination. In the clinic, house staff should learn how to assess kidney function, proteinuria, and hematuria. In addition, understanding of the clinical use of diuretics and blockade of the renin-angiotensinaldosterone axis is crucial. For the tech-savvy learners, do not leave their internet exploration to chance. Instead, introduce them to the action-packed blogs from AJKD (www.ajkdblog.org) and the Renal Fellow Network (renalfellow.blogspot.com). Have technophiles tweet with NephJC, the biweekly twitter nephrology journal club (#NephJC) or complete their brackets for “NephMadness,”35 the whimsical nephrology-themed contest patterned after the US college basketball tournament. 10. Love Thy Patient The excitement of a “great case” or the tedium of a long day should never detract from the primary responsibility to the patient. First and foremost, we must strive to provide superb and compassionate care. In an early blog post for CJASN’s journal club, Dr David Goldfarb noted, “You have to love your patients; you have to care about them, their health and their problems.”36 That investment in patient care can make an impact on a trainee who should see the nephrologist as an individual who strikes an uncanny balance between the primary care provider and the intensivist. The complex factors that translate into a decision to pursue a career in nephrology are difficult to measure. The lag between a positive interaction during medical school or residency and the application for nephrology fellowship may be 2 to 6 years later. It is difficult to study inspiration, but it is not difficult to inspire. Share your passion. Am J Kidney Dis. 2015;-(-):---
Share Your Passion for Nephrology
ACKNOWLEDGEMENTS The author would like to thank Dr Gerald Hladik for review of the manuscript before submission. Support: None. Financial Disclosure: The author declares that she has no relevant financial interests.
REFERENCES 1. National Resident Matching Program. Results and Data: Specialties Matching Service 2014 Appointment Year. Washington, DC: National Resident Matching Program; 2014. 2. NRMP SMS Nephrology Match for Appointment Year 2015. Revised December 3, 2014. Brief analysis. https://www.asnonline.org/education/training/workforce/ASN_NRMP_SMS_2015_ Analysis.pdf. Accessed January 24, 2015. 3. Parker MG, Ibrahim T, Shaffer R, Rosner MH, Mollitoris BA. The future of the nephrology workforce: will there be one? Clin J Am Soc Nephrol. 2011;6(6):1501-1506. 4. Parker MG, Pivert KA, Ibrahim T, Molitoris B. Recruiting the next generation of nephrologists. Adv Chronic Kidney Dis. 2013;20(4):326-335. 5. Jhaveri JD, Sparks MA, Shah HH, et al. Why not nephrology? A survey of US internal medicine subspecialty fellows. Am J Kidney Dis. 2013;61(4):540-546. 6. Watnick S. Academic etiquette for the nephrologist. Clin J Am Soc Nephrol. 2008;3(6):1884-1886. 7. Vachharajani TJ. Atlas of dialysis vascular access. http:// esrdncc.org/wp-content/uploads/2014/07/Vascular-Access-Atlas.pdf. Accessed November 22, 2014. 8. Murray JE, Merrill JP, Harrison JH. Renal homotransplantations in identical twins. 1955 (with comments from Murray JE and Carpenter CB). J Am Soc Nephrol. 2001;12:201-204. 9. Alexander S. They decide who lives, who dies: medical miracle puts moral burden on small committee. Life. 1962;53:102-125. 10. Blagg CR. The early history of dialysis for chronic renal failure in the United States: a view from Seattle. Am J Kidney Dis. 2007;49(3):482-496. 11. Gentry SE, Montgomery RA, Segev DL. Controversies in kidney paired donation. Adv Chronic Kidney Dis. 2012;19(4): 257-261. 12. Brown RS, Karumanchi A, Sukhatme VP, Zeidel ML. Frankline H. Epstein—researcher, teacher, clinician and humanist. Clin J Am Soc Nephrol. 2009;4(8):1285-1289. 13. Verghese A. Cutting for Stone. New York, NY: Alfred A Knopf; 2009:224. 14. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999;281(11): 1022-1029. 15. Goldfarb DS. The normal saline ceremony. Am J Kidney Dis. 2010;56(2):A28-A29. 16. Edelman IS, Leibman J, O’Meara P, Birkenfeld LW. Interrelations between serum sodium concentration, serum osmolarity and total exchangeable sodium, total exchangeable potassium and total body water. J Clin Invest. 1958;37(9):1236-1256. 17. Muriithi AK, Nasr SH, Leung N. Utility of urine eosinophils in the diagnosis of acute interstitial nephritis. Clin J Am Soc Nephrol. 2013;8(11):1857-1862.
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18. Siddall EC, Radhakrishnan J. The pathophysiology of edema formation in the nephrotic syndrome. Kidney Int. 2012;82(6):635-642. 19. Cohn TD, Lane M, Zuckerman S, Messinger N, Griffith A. Induced azotemia in humans following massive protein and blood ingestion and the mechanism of azotemia in gastrointestinal hemorrhage. Am J Med Sci. 1956;231(4):394-401. 20. Fulop M. A guide to predicting arterial CO2 tension in metabolic acidosis. Am J Nephrol. 1997;17(5):421-424. 21. Albert MS, Dell RB, Winters RW. Quantitative displacement of acid-base equilibrium in metabolic acidosis. Ann Intern Med. 1967;66(2):312-322. 22. Hirschtick RE. A piece of my mind: copy-and-paste. JAMA. 2006;295(20):2335-2336. 23. Washburn KD. The Architecture of Learning: Designing Instruction for the Learning Brain. Pelham, AL: Clerestory Press; 2010:240. 24. Brescia MJ, Cimino JE, Appel K, Hurwich BJ, Scribner BH. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. 1966 (with comments from Cimino JE and Scribner B). J Am Soc Nephrol. 1999;10(1): 193-199. 25. Bywaters EG, Beall D. Crush injuries with impairment of renal function. 1941 (with comments from Bywaters EG and Knochel JP). J Am Soc Nephrol. 1998;9(2):322-332. 26. Schwartz WB, Bennett W, Curelop S, Bartter F. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. 1957 (with comments from Schwartz WB and Verbalis JG). J Am Soc Nephrol. 2001;12(12):2860-2870. 27. De Wardener HE, Herxheimer A. The effect of a high water intake on the kidney’s ability to concentrate the urine in man. 1957 (with comments from DeWardner HE and Nielson S). J Am Soc Nephrol. 2000;11(5):980-987. 28. Espinel CH. The FENa test: use in the differential diagnosis of acute renal failure. JAMA. 1976;236(6):579-581. 29. Battle DC, Hizon M, Cohen E, Gutterman C, Gupta R. The use of the urinary anion gap in the diagnosis of hyperchloremic metabolic acidosis. N Engl J Med. 1988;318(10):594-599. 30. Beck LH, Bonegio RGB, Lambeau G, et al. M-Type phospholipase receptor as target antigen in idiopathic membranous nephropathy. N Engl J Med. 2009;361(1):11-21. 31. Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science. 2010;329(5993):841-845. 32. Mutter WP, Brown RS. Point of care photomicroscopy of urine. N Engl J Med. 2011;364(19):1880-1881. 33. Kohler H, Wandel E, Brunch B. Acanthocyturia—a characteristic marker for glomerular bleeding. Kidney Int. 1991;40(1):115-120. 34. Jhaveri KD, Shah HH, Mattana J. Enhancing interest in nephrology careers during medical residency. Am J Kidney Dis. 2012;60(3):350-353. 35. Sparks MA, Lerma EV, Kupin W, Phelan PJ, Jhaveri KD, Topf J. NephMadness 2015: nephrology as a cornerstone of medicine. Am J Kidney Dis. 2015;65(3):375-377. 36. Goldfarb D. Re: Satisfaction CJASN eJournal club archives. 2012. http://ejc.cjasn.org/phpBB3/archive_item.php? topic_id5476. Accessed September 23, 2013.
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I
n recent years, much has been written regarding the widening gap in the United States between individuals needed to sustain the nephrology workforce and the number of trainees interested in pursuing nephrology. In addition, declining applications for the nephrology subspecialty through the National Residency Matching Program left almost half of all programs unfilled for the academic year beginning in 2015.1,2 Despite mounting concerns, there has been little published on strategies to increase interest in careers in nephrology. Exit interviews with residents indicate that 2 major reasons for choosing alternative fields are negative perceptions regarding dialysis and anxiety related to complex electrolyte cases.3-5 In this article, I offer 10 strategies to help nephrologists share passion for nephrology in the clinical arena. My emphasis is on the inpatient ward experience, but I also include some suggestions for the outpatient clinic. The focus of this piece is to help educators inspire trainees through the use of nephrology content; an excellent review on etiquette and collegiality has been published recently.6 1. Rejoice in Successful Care of Patients With End-Stage Kidney Disease Contrary to popular belief, issues related to endstage kidney disease provide a wonderful platform for nephrologists to share their passion for nephrology. Dialysis is currently the best treatment to replace a functional organ of any type. Dialysis is also the ultimate opportunity for “show and tell.” Students and house staff may stand reluctantly outside the doors of the dialysis unit with anxiety akin to that experienced when standing outside the operating room for the first time, hoping that the scrub nurse will offer a gown and gloves. This moment is an ideal opportunity for you to welcome the trainee into the unit. A quick tour of the Am J Kidney Dis. 2015;-(-):---
blood circuit requires just a few minutes, yet shortly thereafter, the same house officer may be seen reviewing this circuit with a colleague. After you explain the magnitude of the dialysate flow rate, ask the resident or student to calculate the water requirement for 1 treatment, 1 shift, 1 day, and 1 week. No elaborate lecture on water is needed. Instead, a simple discussion of the features of community water and a tour of the water treatment area will suffice. A review of arteriovenous access is essential; many are under the impression that they cannot distinguish a fistula from a graft, but this is relatively easy with a simple examination (1 incision or 2, extra anatomic thrill, and thick rugated material). Ask the team to move through the unit and look at the panoply of arteriovenous accesses and characterize each. Alert them to the comprehensive “Atlas of Vascular Access” by Dr Vachharajani for the Fistula First initiative.7 Show students the size of the needles used for cannulation and the relatively blunt bevel of needles used for the buttonhole technique. Peritoneal dialysis is another important consideration. Take out the peritoneal dialysis training apron and have students perform a mock exchange. No nephrologist can seem intimidating while wearing the peritoneal dialysis apron. Consider the electrolytes
From the Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA. Received November 25, 2014. Accepted in revised form March 6, 2015. Address correspondence to Melanie P. Hoenig, MD, Department of Medicine-Renal Division, Beth Israel Deaconess Medical Center Clinic, Fa 8/185 Pilgrim Rd, Boston, MA 02215. E-mail: [email protected] 2015 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.03.027 1
Melanie P. Hoenig
within the dialysate and what effects an exchange may yield. Regale trainees with Nobel Laureate Joseph Murray’s story of the first successful living donor kidney transplantation after 20 failed cadaveric ones, and how Murray confirmed that the Herrick twins were identical by successful skin grafts and a stealth visit to the Boston Police Department to compare fingerprints.8 If you are based at a transplantation center, send the residents to witness the magnificence of urine flow when the surgeon removes the clamps from the transplanted renal vasculature. 2. Consider the Ethics of End-Stage Kidney Disease Care Medical ethics takes on new dimensions in the controversies in the care of patients with end-stage kidney disease. House staff are often struck by frustrations related to end-of-life care in patients with advanced kidney disease who have serious comorbid conditions. Explain the origins of dialysis therapy and the barriers to availability in the early years. Share with them the LIFE magazine exposé on the “god committee” that helped decide “who lives and who dies” when the first free-standing dialysis unit in Seattle had only 3 stations.9 Point out some of the then-used criteria for suitability for dialysis, including unique moral duties, constituency and social value.9 To drive home the gravity of such an exercise, ask residents and students to create an imaginary ranking system and consider how patients on the service or in the dialysis unit would rank. Describe how, with the advent of the US dialysis program (scripted by the Social Security Amendment, Section 299I of Public Law 92603), dialysis became available to all, and note that passage of this amendment grossly underestimated the cost and number of potential patients.10 Ask learners to debate changes that might improve this legislation. Kidney transplantation also offers many ethical challenges. These may be on a personal scale: the potential donor who is not interested but instead claims that the transplantation unit does not return telephone calls, the lover who wants to donate but keep her identity secret from the recipient’s wife, or the patient with Caroli disease (congenital hepatic fibrosis and autosomal recessive polycystic kidney disease) whose liver function is too poor to tolerate surgery for kidney transplantation but too good to merit a combined liver/kidney transplant. Then there are transplantation challenges on a broader scale, such as the logistics of a kidney donation “domino chain,”11 not to mention the complexities of organ allocation, laws against paid donation, and access to the wait list. 2
3. Go to the Bedside The bedside physical examination offers numerous unique opportunities. First and foremost, teaching at the bedside allows the clinician educator the opportunity to model the caring and intimate connections that are afforded by the patient-physician relationship. Here, the attending can listen and learn. Homer Smith award recipient Franklin Epstein exemplified this approach when he sat on his patients’ beds to hear their stories, fluffing their pillows before he left.12 As physician novelist Dr Abraham Verghese wrote in his best-seller Cutting for Stone: [the doctor-teacher] invited me to a world that wasn’t secret but it was well hidden. You needed a guide. You had to know what to look for, but also how to look. You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, if you went through that door, a strange thing happened: you left your petty trouble on the threshold. It could be addictive.13(p224)
Nephrologists should be that guide, the expert who can capitalize on knowledge of physiology to reconcile clues needed for physical diagnosis. Given our crude strategies to measure volume status compared to the human body’s elegant and redundant transistors, if review of the physical examination could at minimum help trainees assess volume status, this would be a triumph.14 To complement this practice, the team can consider the weight of edema by loading saline solution bags into their white coats and debate the difference between dehydration and volume depletion and the requisite dietary sodium intake of an anephric hemodialysis patient who gains 5 kg between each dialysis treatment. Bedside examination of patients with polycystic kidney disease provides an opportunity to review the abdominal examination; remind learners that one hand is placed behind the kidney just below and parallel to the 12th rib and the other is placed on the abdomen lateral to the rectus muscle. As the posterior hand gently pushes the kidney anteriorly, the other hand is used to feel the kidney move forward to greet the anterior hand. Next, the examination should be used to inform regarding the pathophysiology of this disorder: the potential mechanisms of hypertension, implications of bulky disease, and renal and extrarenal manifestations. 4. Pose Questions on the Fly One of the realities of modern medicine is that appropriate documentation is needed for good patient care. Though adequate notes can rob attending rounds of their momentum, returning to write notes after rounds is often not logistically possible. In this Am J Kidney Dis. 2015;-(-):---
Share Your Passion for Nephrology
instance, if trainees have no specific tasks at hand, they can be occupied with quick thought questions that they can consider on their own or as a group. It is useful to have a few such questions at the ready (Box 1).15-19 For example, question the dogma that serum urea nitrogen level is often elevated in an upper gastrointestinal bleed from absorption of blood. Then recount the story of 3 healthy physicians with normal kidney function who each had a nasogastric tube placed and were then administered 800 mL of expired citrated human blood into their stomach. In this experiment, the serum urea nitrogen level did increase—by a mean of 5 mg/dL over 5 hours—then returned to normal within 24 hours. When the same physicians ingested 180 g of protein, the mean increase was 20 mg/dL.19 5. Do Calculations and Make Predictions Together Although it may seem mundane, routine calculations or at least a review of the important formulas and their derivation, features, and limitations are important for modern learners who have an “app for that” at their fingertips. Students need to know the context in which each formula can be appropriately applied. Trainees often feel inadequately prepared to manage symptomatic hyponatremia with hypertonic saline solution, but by calculating the rate together with their mentors, trainees can learn that the rate of infusion is typically slow and that safety is ensured
through frequent measurement of the serum sodium level. Show how, if the pH is very low, problems can arise when using the “rule of thumb” (the strategy of concluding that there is simple metabolic acidosis with appropriate respiratory response if, by covering the first digit of the pH with the thumb, the last 2 digits of the pH are similar to the PCO2).20 Instead, teach students the Winters formula and how it was derived from data for real patients with simple metabolic acidoses.21 In this era of “copy and paste,”22 laboratory studies are ordered to populate lengthy admission and progress notes. Ask the team to think critically about the laboratory studies they order, make predictions, and keep track of responses. For example, in a patient who has oliguric acute kidney injury, ask the team to predict the volume of urine required before creatinine level reaches a plateau. Ask residents to estimate the serum sodium level in a hyponatremic patient the morning after intravenous fluids have been given. Question learners about the expected decrease in serum bicarbonate level in an oliguric patient who is eating protein. This exercise primes the learner to think about an expected outcome and in so doing, fosters the development of intellectual curiosity in nephrology-related content. When results fall outside of predicted outcomes, learners will then need to determine whether their hypotheses were flawed or other unforeseen factors are at play. 6. Tell a Great Story
Box 1. Sample Questions for Use on Rounding Thought questions Normal saline solution has a sodium content of 154 mEq/L, whereas the normal serum sodium level is w140 mEq/L. Why? Consider the lessons learned from a “normal saline ceremony.”15 Can the serum sodium concentration determine the volume status?16 Why is ANCA-associated vasculitis considered “pauciimmune” when the immune system is clearly activated? Kitchen nutrition: How much potassium is in a serving of a sports drink? Which beverage is most like normal saline solution? Why do the GFR estimating equations perform poorly when kidney function is close to normal? What were the hurdles to the development of hemodialysis? “Myth busters”—what is the evidence? Thiazide diuretics are often prescribed “30 minutes before” a loop diuretic. Is it necessary? Does furosemide work better as an infusion vs a bolus? Should it be mixed with albumin? 19 Why is the SUN elevated in gastrointestinal bleeding? What is the utility of the classic triad of fever, rash, and peripheral eosinophilia in interstitial nephritis? What is the utility of the test for eosinophils in the urine?17 18 Why is there edema in the nephrotic syndrome? Abbreviations: ANCA, antineutrophil cytoplasmic antibody; GFR, glomerular filtration rate; SUN, serum urea nitrogen. Am J Kidney Dis. 2015;-(-):---
Sometimes a problem can come alive with a vivid narrative. Humans frequently think in terms of stories that frame an experience and provide structure.23 Senior faculty may have a vast repository of knowledge of nephrology or personal experience that is easily retrievable, but junior faculty who have not watched the mysteries of nephrology unfold can benefit from mentorship from more senior colleagues. In JASN’s formative years, feature editor Mark Knepper ran a series called “Milestones in Nephrology,” which is a virtual treasure trove of such stories. These articles, which appeared from 1997 to 2001, had been published in other journals at least 20 years earlier and were reprinted with comments from the original author, if he or she was alive, or from a current expert in the field. Some particularly noteworthy issues include the original article by Drs Brescia and Cimino accompanied by Dr Scribner’s commentary and confession that he realized their technique would make his eponymous shunt obsolete.24 Dr Bywaters’ description of the first patients that he followed with crush injuries, the bitter criticism he received from the professor of surgery who thought that Bywaters had performed too many tests, and Bywaters’ initial failed attempts to create an 3
Melanie P. Hoenig
animal model make for a gripping narrative.25 Plus, who can resist tales from Dr Schwartz on the syndrome that “probably” resulted from inappropriate secretion of antidiuretic hormone26 or from de Wardener on his antics during his seminal experiments on water loading.27 7. Review Landmark Studies Examination of influential articles can be provocative and not just entertaining. Share the original publication on the fractional excretion of sodium and remind trainees that in this report with 17 participants, the gold standard for prerenal azotemia was improvement of kidney function after fluid resuscitation. However, the presence of muddy brown casts was not considered.28 It is also useful to review the use of “urinary anion gap” or “net urine charge” in the diagnosis of hyperchloremic metabolic acidosis from the original report that had 38 patients with distal renal tubular acidosis and 8 with diarrheal illness.29 Landmark discoveries are not restricted to the prior century. Recent triumphs include the discovery of the elusive podocyte antigen, M-type phospholipase A2 receptor (PLA2R1), which is the target for membranous nephropathy.30 The pathogenesis was long predicted to be caused by a circulating antibody to a podocyte antigen based on the experimental rat model, Heymann nephritis, but it was not until 2009 that the circulating antibody and its target on podocyte membranes was discovered. In 2010, sophisticated genetic analyses identified a gene on chromosome 22 that appears responsible for the excess risk of focal glomerulosclerosis, end-stage kidney disease, and human immunodeficiency virus (HIV)-associated nephropathy in individuals of African ancestry. The genetic variants persist, analogous to the benefit of sickle trait in preventing malaria, to confer resistance to a strain of African sleeping sickness, Trypanosoma brucei rhodesiense, the parasite spread by tsetse flies in Western Africa. When the parasite ingests this variant of APOL1, it creates a pore in the parasite lysosomes and leads to parasite death.31 The mechanism for APOL1-induced risk of kidney disease is sure to follow. 8. Go to the Microscope The advent of digital cameras on handheld devices and telephones has made sharing results of the urinalysis possible.32 This is an opportunity to view the gamut of findings from hyaline casts to crystals and to explain to trainees why urinary acanthocytes are a good indicator for the presence of glomerular bleeding. Share with them the carefully crafted study in which urine sediment findings from the full spectrum of renal parenchymal diseases were compared, demonstrating that those with glomerular bleeding 4
were most likely to have acanthocytes33 and, by way of comparison, show that urine of all types (concentrated or dilute, low or high pH) supplemented with a drop of medical student blood does not have these changes. (One caveat: use of hand-held devices with cameras must be locked and patient confidentiality must be maintained at all times.) 9. Have a Curriculum It is important to develop a curriculum for time spent with trainees rather than leaving learning to chance. Some programs have the luxury of a revised elective for residents,34 but others have residents on service sporadically when they are not pulled to cover for ill colleagues. Certainly, case-mix will dictate a portion of the experience, but at a minimum, it is essential that individuals who rotate through nephrology understand the approach to a patient with acute kidney injury and can properly weigh the value of the history, physical examination, urine indexes, and urine sediment examination. In the clinic, house staff should learn how to assess kidney function, proteinuria, and hematuria. In addition, understanding of the clinical use of diuretics and blockade of the renin-angiotensinaldosterone axis is crucial. For the tech-savvy learners, do not leave their internet exploration to chance. Instead, introduce them to the action-packed blogs from AJKD (www.ajkdblog.org) and the Renal Fellow Network (renalfellow.blogspot.com). Have technophiles tweet with NephJC, the biweekly twitter nephrology journal club (#NephJC) or complete their brackets for “NephMadness,”35 the whimsical nephrology-themed contest patterned after the US college basketball tournament. 10. Love Thy Patient The excitement of a “great case” or the tedium of a long day should never detract from the primary responsibility to the patient. First and foremost, we must strive to provide superb and compassionate care. In an early blog post for CJASN’s journal club, Dr David Goldfarb noted, “You have to love your patients; you have to care about them, their health and their problems.”36 That investment in patient care can make an impact on a trainee who should see the nephrologist as an individual who strikes an uncanny balance between the primary care provider and the intensivist. The complex factors that translate into a decision to pursue a career in nephrology are difficult to measure. The lag between a positive interaction during medical school or residency and the application for nephrology fellowship may be 2 to 6 years later. It is difficult to study inspiration, but it is not difficult to inspire. Share your passion. Am J Kidney Dis. 2015;-(-):---
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ACKNOWLEDGEMENTS The author would like to thank Dr Gerald Hladik for review of the manuscript before submission. Support: None. Financial Disclosure: The author declares that she has no relevant financial interests.
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18. Siddall EC, Radhakrishnan J. The pathophysiology of edema formation in the nephrotic syndrome. Kidney Int. 2012;82(6):635-642. 19. Cohn TD, Lane M, Zuckerman S, Messinger N, Griffith A. Induced azotemia in humans following massive protein and blood ingestion and the mechanism of azotemia in gastrointestinal hemorrhage. Am J Med Sci. 1956;231(4):394-401. 20. Fulop M. A guide to predicting arterial CO2 tension in metabolic acidosis. Am J Nephrol. 1997;17(5):421-424. 21. Albert MS, Dell RB, Winters RW. Quantitative displacement of acid-base equilibrium in metabolic acidosis. Ann Intern Med. 1967;66(2):312-322. 22. Hirschtick RE. A piece of my mind: copy-and-paste. JAMA. 2006;295(20):2335-2336. 23. Washburn KD. The Architecture of Learning: Designing Instruction for the Learning Brain. Pelham, AL: Clerestory Press; 2010:240. 24. Brescia MJ, Cimino JE, Appel K, Hurwich BJ, Scribner BH. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. 1966 (with comments from Cimino JE and Scribner B). J Am Soc Nephrol. 1999;10(1): 193-199. 25. Bywaters EG, Beall D. Crush injuries with impairment of renal function. 1941 (with comments from Bywaters EG and Knochel JP). J Am Soc Nephrol. 1998;9(2):322-332. 26. Schwartz WB, Bennett W, Curelop S, Bartter F. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. 1957 (with comments from Schwartz WB and Verbalis JG). J Am Soc Nephrol. 2001;12(12):2860-2870. 27. De Wardener HE, Herxheimer A. The effect of a high water intake on the kidney’s ability to concentrate the urine in man. 1957 (with comments from DeWardner HE and Nielson S). J Am Soc Nephrol. 2000;11(5):980-987. 28. Espinel CH. The FENa test: use in the differential diagnosis of acute renal failure. JAMA. 1976;236(6):579-581. 29. Battle DC, Hizon M, Cohen E, Gutterman C, Gupta R. The use of the urinary anion gap in the diagnosis of hyperchloremic metabolic acidosis. N Engl J Med. 1988;318(10):594-599. 30. Beck LH, Bonegio RGB, Lambeau G, et al. M-Type phospholipase receptor as target antigen in idiopathic membranous nephropathy. N Engl J Med. 2009;361(1):11-21. 31. Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science. 2010;329(5993):841-845. 32. Mutter WP, Brown RS. Point of care photomicroscopy of urine. N Engl J Med. 2011;364(19):1880-1881. 33. Kohler H, Wandel E, Brunch B. Acanthocyturia—a characteristic marker for glomerular bleeding. Kidney Int. 1991;40(1):115-120. 34. Jhaveri KD, Shah HH, Mattana J. Enhancing interest in nephrology careers during medical residency. Am J Kidney Dis. 2012;60(3):350-353. 35. Sparks MA, Lerma EV, Kupin W, Phelan PJ, Jhaveri KD, Topf J. NephMadness 2015: nephrology as a cornerstone of medicine. Am J Kidney Dis. 2015;65(3):375-377. 36. Goldfarb D. Re: Satisfaction CJASN eJournal club archives. 2012. http://ejc.cjasn.org/phpBB3/archive_item.php? topic_id5476. Accessed September 23, 2013.
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