Rounding with observers, students, residents, or fellows is at the core of academic medicine. It is an age old tradition that has its roots in the early days of apprenticeship. However, spending quality time teaching and discussing principles of patient care is becoming increasingly more difficult. The modern hospital and clinic continue to demand more time of everyone involved. Pressure is being placed to see more patients, and write lengthy notes with more cumbersome documentation. There is an ever increasing burden of administrative tasks, duty hour constraints, didactic lecture requirements, and many other issues that conspire to hinder the wonderful teaching opportunities that occur while rounding. In a recent article in AJKD, Dr. Melanie Hoenig offers 10 tips to invigorate attending rounds and precepting sessions for the nephrologist. This comes at a perfect time. Our field is in the midst of a midlife crisis. It is time to inspire a new generation of kidney doctors. Patients depend on it.
- Rejoice in the care of patients on dialysis
- Discuss the ethics of ESKD
- Go to the bedside
- Pose questions “on the fly”
- Perform calculations and make predictions
- Tell a great story
- Review landmark studies
- Go to the microscope
- Have a curriculum
- Love and Care for your Patients
I’ll highlight some of the examples and tips that she gives. First, Hoenig implores us to go back the bedside. This sounds so obvious, yet it so vital. She gives the example of taking the team to the dialysis unit. Examining a patient as dialysis is being performed leads to a discussion on how the blood flows from the patient to the machine and back to the patient. Describe how the dialysate interacts with the blood in the dialysis membrane. Examine the access and point the learner to resources like Dr. Vachharajani’s “Atlas of Vascular Access”.
Another great tip is to develop a curriculum. As obvious as it sounds, it is often times overlooked. Don’t rely on random chance to bring up topics. Try to reinforce various aspects of the field without just focusing on inpatient nephrology. Weave in stories or a narrative: this is so powerful and what has made TED talks such a phenomenon. Use them yourself. Hoenig discusses the story of Brescia and Cimino whose seminal work on fistula creation was a game changer and ushered in the era of dialysis.
Discuss the landmark studies. Examples include the original publication on the fractional excretion of sodium. The report of Dr. Murray performing the first kidney transplant. The recent description of the 2015 NephMadness champion APOL1 risk alleles partly explaining the disparities in kidney disease but simultaneously conferring resistance to African sleeping sickness, Trypanosoma brucei rhodesiense. The description and application of measuring PLA2R antibody levels in idiopathic membranous nephropathy.
Most importantly, love thy patient. She provides quote from David Goldfarb from the CJASN e-journal club which is perfect: “You have to love your patients; you have to care about them, their health and their problems”. Show the learners that being a nephrologist is important. We help guide patients through some of life’s most difficult transitions. We provide support and guidance. This is what’s the essence of nephrology.
These are great tips, and enforce what a fantastic field nephrology is. This is why I became a nephrologist and I’m sure it is why many others did as well. Watching my mentors connect with patients and families. Making a complex problem simple and understandable. Nephrologists have the opportunity to see their patients more often than any other specialists in medicine. This is truly powerful. We get to share in the joy of a kidney transplant or successfully treating a glomerular disease. Let’s all do our part and spread the joy of nephrology.
Dr. Matthew Sparks
AJKD Blog Advisory Board member