Today's guest is @kidney_boy, Dr. Joel Topf, a nephrologist with unique experiences through his medical training. He gives us his insights into the path of a physician and how it doesn't necessarily have to be a straight line.
He talks about his experiences during his medical training, his roles in medical education with residents and medical students, and what kind of medical students stand out to him.
Here are the highlights of the conversation with Joel:
Joel's cool Twitter handle @kidney_boy experience:
- Joel's Twitter interaction with a patient, Dr. Snit, talking about Margaret Atwood's book
- Margaret joining the conversation and drawing superheroes based on them
- Weeks later, she published drawings of @DrSnit and @kidney_boy
Joel's road to being a physician:
- Did undergrad in 4 years and went to University of Michigan taking Bachelor of General Studies
- Applied to several medical schools
- Matriculated at Wayne State University School of Medicine
- Did most of his rotations at the downtown hospitals
His experience at downtown hospitals:
- Graduated in 1995 at the peak of the HIV epidemic where 1/3 of hospital admissions were HIV positive
- Seeing the worst of the worst cases (age-related complications, opportunistic infections)
- Their first patients were all dying of HIV
Joel's advice to pre-medical students to those who complain about taking organic chem lab, physics, or calculus and question their purpose:
- You're learning how to learn.
- You need to not just get a basic understanding of it, you need to master it.
On adapting to the changes:
- You're going to be encountering new stuff that you haven't encountered before
- There's going to be new drugs, new fields, and new physiology to learn throughout your career.
- Shift from text books to more rapidly produced materials:
Different paths Joel took through medical education:
Being a traditional student and taking a detour after medical school
On writing a microbiology book, The Microbiology Companion:
- Joel and his friend, Sarah Faubel, took the next two months after medical school and wrote a 200-page microbiology book
- The book was a total success!
On writing a Fluid Electrolyte and Acid-Base book:
- It was poorly taught in their 3rd year so they solved the problem and wrote the definitive fluid and electrolyte book for medical students
- They arranged for a year after medical school before residency while doing a light, transitional internship
- Aimed at finishing the book in 6 months but it took them four years to write
Dealing with burnout:
Not looking at the destination but just enjoying the road as best as you can
Joel's biggest obstacles:
Difficulty expressing his vision as an educator of communicating other people's discoveries which is not well-recognized in medicine
What Joel is currently working on:
- Working at different hospitals with medical students (DO & MD) and teaches 3rd medical students a renal curriculum every 3 months
- Teaching residents in a year-long curriculum with monthly lectures
- Does interview for residencies (med students applying for residency)
- Nephrology fellowship and does interviews for residents seeking to be nephrology fellows
What students are struggling with:
- The most memorable students are those who are not shy
- The importance of feeling empowered and be part of the team
- The importance of engaging in teams and not being intimidated
- Medical students are the ultimate excuse for not knowing things – not ignorant, but just a beginner
Surrounding yourself with mentors:
- Mentors come in all shapes and sizes.
- Seek them out in any opportunity
- Burton Rose's book as Joel's biggest mentor
- Have an open mind.
- Taking the flavor of the experience is good but more importantly feeling empowered to talk
What Joel should have known or done from the get go:
More shadowing and real medical experience when he was an undergrad (a part of his application that was lacking)
Why you should stick to your path amidst the circulating negativity:
- A phenomenal career with exciting challenges all the time
- New things to learn
- It delivers a lot of what it promises
- Meeting people from all walks of life and getting a broader worldview
- The greatest career possible!
Links and Other Resources
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Burton Rose's UpToDate
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Dr. Ryan Gray: The Medical School Headquarters Podcast, session number 132.
Hello and welcome to the Medical School Headquarters Podcast; where we believe that collaboration, not competition, is key to your premed success. I am your host, Dr. Ryan Gray, and in this podcast we share with you stories, encouragement and information that you need to know to help guide you on your path to becoming a physician.
If you're struggling on the MCAT and need a little bit more personal help, go to www.NextStepTestPrep.com and let them know that you heard about them from the Medical School Headquarters Podcast. Next Step Test Prep offers one-on-one tutoring, that's what they specialize in. They're not a company that gives group or classroom sessions for MCAT test prep, they will find an instructor for you and work one-on-one finding out what your weaknesses are, what your strengths are, and developing a curriculum around you, not them. So go to www.NextStepTestPrep.com, let them know you heard about them here at the Medical School Headquarters Podcast, and they will give you a deal.
Alright today's podcast we're going to be talking to Dr. Joel Topf, he's a physician- a nephrologist who has some unique experiences through his medical training that I think will give you a lot of insight into the path of a physician. How it doesn't necessarily have to be such a straight line. We're going to talk about what was going on in the world as he was going through his medical training, some big things that were happening. We're going to talk to him about some of his experiences or his roles in medical education with residents and medical students. And we're going to talk about what medical students really stand out to him, and how you can learn from that and how you can stand out yourself. So let's get started with that.
Joel, welcome to the show, thanks for joining us.
Dr. Joel Topf: Yeah, excited to be here, thanks a lot.
Dr. Ryan Gray: I want to know about your Twitter handle. Why do you have such a cool Twitter handle?
Dr. Joel Topf: It started when I was a fellow, and there were a couple of different rotations that you did as a fellow. I was at University of Chicago doing a nephrology fellowship, and one of the rotations was you were on the consult service and your beeper went off quite a bit. But the one that was really crazy was when you were on the dialysis service and essentially you were the one guy that all the dialysis patients that were in the hospital had to go through. And it was- I felt more like a traffic cop directing all these people, making sure that they all got to their dialysis on their scheduled days during the time and around their surgeries and everything. And the pager literally just constantly went off, and I recorded an intro on my pager that was, ‘da-da da-da-da- Kidney Boy,' just because I wanted the nurses just to laugh every time they called me. And so that was where Kidney Boy came from, and then years later when I was signed up for Twitter I was like, “Yeah, I think I'll pick up Kidney Boy, I'll just use that as my Twitter Handle.” And this was a time like kind of early in medicine and Twitter when people were kind of picking strange Twitter names to go by. I think that's kind of fallen by the wayside, but I'm not giving it up. One of the things that made me- that really locked it in was that I was tweeting to another person named-
Dr. Ryan Gray: Drawing a blank.
Dr. Joel Topf: I'm drawing a blank, oh my God I can't believe I'm drawing a blank on her name. Oh and it's so important for the story, can you give me just one second to look this up? I feel awful.
Dr. Ryan Gray: So while you're looking that up, obviously Kidney Boy, you are a kidney doctor, a nephrologist.
Dr. Joel Topf: Yes.
Dr. Ryan Gray: That's awesome.
Dr. Joel Topf: Yes. Yeah, it's a pretty cool field. It's one that's fallen by the wayside to a large extent, it's not getting nearly the excitement that it should get. And it's a shame because there's a lot of great opportunities. Yeah so I was talking with a woman named Dr. Snit and she's actually not a doctor, she's a patient. And we were kind of just bantering back and forth about science fiction books and I had asked if she had read Oryx and Crake by Margaret Atwood. And all of a sudden Margaret Atwood butts into our conversation and says, “Oh I'm so glad that you're talking about my book.” And we were both like stunned, we were like, “Oh my God, it's Margaret Atwood.” And then it got even weirder, she said, “Kidney Boy and Dr. Snit, you guys sound like superheroes, I think I'm going to draw your costumes.” And literally weeks later, she published these drawings of Dr. Snit, it was a great costume, and then her sidekick Kidney Boy.
Dr. Ryan Gray: Oh you were the sidekick?
Dr. Joel Topf: I was the sidekick.
Dr. Ryan Gray: Oh, you're boy, yeah.
Dr. Joel Topf: Of course you're the sidekick, and that just nailed it for me. Okay, well I'm Kidney Boy from now on.
Dr. Ryan Gray: That's amazing. Do you have that picture somewhere in your digital file?
Dr. Joel Topf: Yes I do. So it's pretty funny what your blog looks like, because it actually got some press when this happened and it got linked to by the Guardian and a couple of other magazines.
Dr. Ryan Gray: Oh wow.
Dr. Joel Topf: And so my blog kind of bounces around- it bounces a log and it's kind of low level and all of a sudden on one day it skyrockets this tremendous amount of traffic because I talked all about the whole interaction. I'll send you a link because if you guys do show notes, it's a pretty fun element. And it kind of just shows what can happen when you're on Twitter, you just- you never know how these conversations will bounce around and who's listening.
Dr. Ryan Gray: Yeah, and we've had these conversations about almost the necessity now being on Twitter. We talked to Dr. Vartabedian about kind of social media as a physician, we talked to Kevin MD- Kevin Pho about it. So it's hugely important I think to not only reach patients, but other physicians as well. So- and that's how you reached out- you actually reached out to me on Twitter and said, “Hey, I listen to your podcast and it's great.” So I said, “Hey, let's have you on the show.” So, it's awesome. So Twitter's amazing.
Dr. Joel Topf: Yeah, I'm a big fan.
Traditional Path into Medicine
Dr. Ryan Gray: So I want to do a rewind and we kind of talked a little bit about what you're doing now as a nephrologist and we'll get a little bit more into that. But I want to go back and kind of tell your story on how you got to where you are now. Were you a traditional premed student going through undergrad and knowing you wanted to be a physician the whole time?
Dr. Joel Topf: Yeah. Yeah I was about as straight arrow as you can get. I did undergrad in four years, I went to the University of Michigan. I did a Bachelor of General Studies which was the only way I could get through undergrad without doing a foreign language which was just my Achilles Heel. And then- but I spent most of my time doing biology classes and literature classes. And so I graduated in four and then applied to a whole bunch of medical schools and got into a couple of them, and matriculated at Wayne State. And you know after I got in, you know I was- I grew up in suburban Detroit and Wayne State is right downtown. And you know the thing about suburban Detroit is usually if you grow up in the suburbs you never go downtown, it's kind of- Detroit kind of has a rough reputation and it's deserved. And you know being a suburban kid, I was really intimidated by that and I was you know, hearing he stories of how hands on it was in medical school and I was really nervous about that. And I think if I had gone into another medical school, maybe any other one, I would have gone somewhere else just out of fear. But in the end I got to Wayne State and I got into Medical College of Virginia which was just so expensive, it ended up being no contest. Wayne State was a great deal. And so I went to Wayne State and it ended up being great, and I ended up living downtown kind of like go and conquer your fears, don't just run away from them, and did most of my rotations at the downtown hospital, and ended up having a great experience there.
HIV Epidemic of the ‘90s
Dr. Ryan Gray: What was that experience like looking back at it now, being in a downtown hospital in Detroit, obviously not the best and it's gone downhill since you've been there. The patient populations what you could have seen at the other school you got into, and then being at a downtown hospital seeing kind of the worst of the worst?
Dr. Joel Topf: Yeah, I mean you know Ryan the thing that my cohort of medical students went through that really was unique and no one is going to go through it again, was that I started medical school in 1991 the same month that Magic Johnson came out as being HIV positive. And you know, in many ways like that was the moment where HIV kind of exploded. You know there was a Rock Hudson about four years earlier when he died, but Magic Johnson is someone who was so clearly heterosexual in many ways the very symbol of heterosexuality, came out as being HIV positive it became clear that this was everybody's disease. And I graduated in 1995, which is the peak of the epidemic. And so you know in 1995, 50,000 Americans died of HIV and a third of hospital admissions were HIV positive. And you know once I started residency, Haart Therapy came out that same year and every year there were fewer and fewer deaths. And now HIV is like this- it's like diabetes, it's like this serious disease but it's kind of chronic and debilitating and take your medicines and we only really see complications when people have a social or psychiatric issues where they can't take their medications.
Dr. Ryan Gray: Yeah.
Dr. Joel Topf: But when I was at medical school, it absolutely dominated our experience, and kind of in funny ways. Like in a way- like when you bought a textbook, if it wasn't the latest edition, there was nothing on HIV. Patients that you're seeing, and you're seeing the worst of the worst, right? Because the hospitalized patients all have Aids-related complications, opportunistic infections. Like I said we went to our twentieth anniversary- or reunion, and we were talking to people. I said, “You know how many of you had your first patient die of HIV?” And everybody raised their hand, like that was our experience. The first people that we met- our first patients that died, were all dying of HIV. And we were seeing people dying way younger than medical students had been exposed to before. And you know we came of age as doctors in the middle of this epidemic. And then all those skills that we learned, all those HIV-specific skills, just evaporated in importance because we just don't see that [Inaudible 00:11:01] and the PCP pneumonia, and the parasitic meningitis; none of that stuff is an important skill for an internist anymore. It was just kind of a crazy moment to be born into medicine.
Keeping Motivation in Ever-Changing Medicine World
Dr. Ryan Gray: That's interesting that you bring that up, because something that we don't talk a lot about on this show because it's not really premed or medical school specific, is the kind of constant need to adapt and change to new medications, and new protocols, and everything that changes about diseases like HIV. And obviously you've been practicing now for awhile, how do you explain that to a student that is suffering through their undergraduate, is going to suffer through medical school, is going to survive residency, and then they're going to come out and go, “Okay, I'm done, I'm finally done.” But in reality they're just still beginning. How do you explain that to them to keep that motivation?
Dr. Joel Topf: I guess what I would say is the most common complaint I hear about premeds, is they're taking Organic Chemistry Lab, or they're taking a second semester of Physics, or Calculus, and they're like, “I talked to all these doctors, I shadow doctors, and they don't use any of these skills. What is the purpose of this?” And you know the standard argument is that, “Well it's the rigor and you're learning basic science.” But I think one of the other skills is that you're learning how to learn. They're giving you a very challenging subject to take care of, and you need to not just get a basic understanding of it, you need to master it, right? Because if you're going to get to medical school, you need to be getting an A or close to an A, and then you're going to need to know that information again when you take the MCATs and you're going to need to be able to apply it. And like that's what your career is like, you're going to be encountering new stuff that you hadn't encountered before, and you're not going to just be able to have kind of a cursory understanding, like your patients’ lives depend on it and you're going to have to master it, right? And there's going to be new drugs, and new fields, and new physiology to learn throughout your career. Like that was the craziest thing that realization, you know when I was halfway done with my fellowship. So I had already been a doctor for eight or nine years, and I was learning about a new hormone FGF23 that controlled phosphorus metabolism. And I was like, “I learned about phosphorus metabolism eight years ago, that was wrong? Are you trying to tell me that we actually missed an entire hormone?” Yeah, we had missed an entire hormone, right? And you know and that's happened over and over again. Like things that I've memorized as facts have like later then been turned out to be- actually that was just the explanation that we used to explain the phenomenon but it wasn't correct. And this is what's now correct. And so what you're learning in those premed classes is how to learn.
Dr. Ryan Gray: Yeah, I agree.
Dr. Joel Topf: And I don't think it's- You know one of the other things that I think the HIV epidemic accelerated, and probably would have happened anyways, was the shift from textbooks to more rapidly produced materials that we were all faced with, the fact that all of our routine textbooks were almost completely out of date if it was not the latest edition. And if the latest edition hadn't been published in the last two or three years, it was useless. And so you know we did not- you know generations before us would read and memorize [Inaudible 00:14:24]. And reading and memorizing [Inaudible 00:14:26] would be completely inapplicable for most of your patients. And it made- so we were always looking for additional sources, and this is before Wikipedia, and this is before PHO-med, and the web. But I think it really- we were very primed to look for alternative sources of information and study guides. And you know when- first day for the boards came out when I was a medical student.
Dr. Ryan Gray: Okay.
Dr. Joel Topf: I think that was part of that era. You know and there was other parts that were important like desktop publishing was maturing, computer technology was making that type of publication- publishing available to more people, democratizing that process.
Detour After Medical School to Write a Book
Dr. Ryan Gray: Interesting. So you got to live and grow through that, so that's good to know. So you kind of talked about- in your communications with me, some of the kind of different paths that you took through medical education. So you were a traditional medical student, by going from undergrad to medical school. But then you kind of took a detour, why did you take a detour after you were at medical school?
Dr. Joel Topf: So when I was studying for part one of the USMLE- the first part of boards after your first two years of medical school. There was rumors of a study guide for microbiology where they took all the microbiology books and they put them into tables. And I just- and when I heard about it I was like, “Oh, that's exactly what I need to study micro, to review micro for this test. I wish I could get my hands on it.” And- but you know it was ephemeral, I couldn't find it anywhere and you know, there was rumors that people had photocopied it from another medical school. And as I was looking for this I was like, “You know, I'm sure I'm not the only one who wants this.” And so a friend and I, right after boards, we said, “We're going to write this book. This is a great idea, everybody wants this. The people that wrote this are being economically irresponsible by not selling it, so we're going to write this and sell it.” And so we took the next two months right after medical school, we arranged our third year to give a lot of vacation time right up front, and we spent eight weeks and we wrote this book. And it was about 200 pages all done in Microsoft Word, and like it was ridiculously successful. Like you know, to the way that it really seduced me into- I was so enchanted by the success. We ended up selling it across the country, about 10% of all medical students were using it for the few years after we came out, we did two other editions, and actually we then hired some other medical students to use the same concept for Pharmacology which fit perfectly, right? Same idea, put all the drugs into tables. And they were just as successful- even more successful than we were with their book. And that writing team and myself and my friend, we became- we were so excited about this, it was like, “I want to do this again, I want to write another book.” And so we decided- and so my friend, her name is Sarah Faubel and I, we decided to write a fluid and electrolyte and acid base book. We said that was a subject that was most poorly taught in our third year and we were going to solve this problem. We were going to write the definitive fluid and electrolyte book for medical students. And so to do this we arranged for a year off after medical school before residency. And it wasn't entirely a year off, we ended up doing a transitional internship, but the internship was very light, I think we had like four months of in-patient service, a couple of months of out-patient service, and then six months off to write. I said, “No problem, we wrote the first book in two months, we'll be able to knock this one off in six months no problem.” The book ended up taking four years to write. We had no idea what we were getting into. But we took that first year off, kind of, and then we both matched the following year, a year behind our class. I did Med Peds at Indiana, and she did Intro Medicine at University of Colorado. And then- and after four years the book actually finally did get done, and it was a- I call it an artistic success, and a commercial failure. The micro book was like so- like hotcakes, and this one we could barely move any copies, but it was a really good book.
Dr. Ryan Gray: That's awesome.
Dr. Joel Topf: But yeah, it was a really fun project. And it's funny, when I chose that topic I really, I chose a topic that I thought was poorly taught in medical school, not thinking that that would be my career, but it totally became my career then, and for Sarah also it became her career and we're both nephrologists now.
Dr. Ryan Gray: Interesting. Very interesting.
Dr. Joel Topf: Yeah.
Dr. Ryan Gray: What did that- taking that time off and kind of stepping away from traditional medical education, and kind of working on medical education. What did that do to you psyche and your drive to continue- obviously burnout is a huge issue with medical students and physicians. Did that help at all?
Dr. Joel Topf: No, you know it's funny. I have never been someone who looked at the ultimate destination. Like I wasn't a guy who thought about being an attending on day one of medical school. I just thought about day two of medical school on day one of medical school- like what do I have to do next and how can I enjoy the road as best I can? Like I always- I knew I was going to be a doctor, I had the right MCAT scores and the right grades in undergrad, I knew I was going to get into medical school. It was harder than I thought, but I did get in. And I knew I was going to be a doctor, and I was like, “Well what can I do on this road to make it as interesting as possible?” And you know I mean- and again things were different right then. There was not this situation where there's not enough residency spots for medical students which is absolutely insane to me, and needs to be solved. But- and so I knew I would be able to get into residency, and internal medicine is not- I wasn't going for a surgical specialty, you know I knew it wasn't going to be such a difficult match. And so I was like, “Okay, let's do what will be interesting. And I think writing a book will be something that I'll be proud of doing years from now, yeah I think that's something I want to do.” And you know the other interesting thing about that- and something that was completely unanticipated, was it had that- it gave me that intoxicating flavor of what it meant to be a specialist. Like after I- even though I hadn't finished the book and it was not even a quarter done after a year, like I knew more about fluids and electrolytes than anybody else that I bumped into outside of the nephrology or critical care circles. And I absolutely loved that. Like I loved when we got a complex electrolyte case and I could teach the attending about what was going on. Like that was so cool. And it took me a while to realize how much I liked that, but I knew that I liked it a lot, and it would have been an easy assumption from there to understand that what I really wanted to be was a specialist. Because you know I did Med Peds because I thought I was going to be a generalist, like that's where- you know when you choose Med Peds it's kind of the road you're headed down. But changed course.
Dr. Ryan Gray: Yeah, and that's okay. We talk about course correction all the time.
Dr. Joel Topf: Absolutely, find what you like. Find what you like and pursue it. And it's funny how- like sometimes it's difficult to actually- you know even though you like doing it, to say, “Hey wait a minute, that's kind of what I really want to do for the rest of my life.” And again, it's been great for me, I love being the specialist and I love being the teacher, and so I've adopted both those to my career. I do a lot of teaching, and I'm a kidney specialist; an esoteric little specialty.
Dr. Ryan Gray: What on your journey to where you are now, it couldn't have been all smooth sailing. What were some of the- maybe one or two of the biggest obstacles that you've had to overcome? Or maybe it was all a piece of cake.
Dr. Joel Topf: No I mean it wasn't. You know there were always disappointments. You know I think- I think that I had a difficult time kind of expressing my vision that what my career has ended up being has been really kind of a third way. Is that there are people that are researchers, and there are people that are clinicians, and then people that really dedicate their lives not to discovering things, but communicating other people's discoveries; which is what I do as an educator. This third way that is not well-recognized in medicine, and sometimes it's a difficult thing to communicate because you know, what you put on your CV, they're expecting long lists of original articles. And you know you take- I think, you know my personal hero and I think one of the most important physicians in all of America is Burton Rose. Burton Rose is the guy who created UpToDate, right? This is a guy who created the definitive medical reference for internal medicine, and useful for every field of medicine from surgery to pediatrics to OB. And you know completely toppled the existing textbook paradigm with online and searchable content. And- but if you look him up in PubMed, he has twelve publications. And if you talk to people that are his contemporaries that were at Harvard, he was hated. Well maybe I'm being a little strong like that. He was not well-liked or well-accepted by the traditional authorities in the nephrology department; he was a nephrologist also. Because he didn't fit in the round hole, he wasn't the round peg in the round hole. He was a little bit different, he had a different mission, he was phenomenally successful and like I said I think he's one of the most important doctors in the world. I mean this creation is just- is absolutely genius.
Dr. Ryan Gray: Yeah, something that I think every physician uses a lot. I love UpToDate. I explain UpToDate to patients as my ‘doctor Google.'
Dr. Joel Topf: Right, right. But it's so good that you're willing to pay- you know it's a textbook that's an online resource that it's $400.00 a year, and it's absolutely worth it. I never hesitate to write that check. I tried to hesitate one time, and I very quickly went, “No, no, no, I definitely don't want to practice medicine without this.” It is an amazing resource.
Dr. Ryan Gray: Yeah. So what do you do now with medical students and residency?
Dr. Joel Topf: Yeah so I work at a couple of different hospitals, and they have medical students, DO students and MD students from a few different medical schools. They have the international medical students come and rotate there, and I teach third year medical students a renal curriculum. I repeat it every three months because they get a new shipment of medical students in. And then I teach the residents on a year-long curriculum where I give a monthly lecture on some element of nephrology and that repeats on a yearly basis. And then I'm part of the- I do interviews for medical school- for residencies. So medical students applying for residency, and then we have a nephrology fellowship where I'm also on the faculty there, and I do interviews for residents seeking to be nephrology fellows.
Dr. Ryan Gray: Awesome.
Dr. Joel Topf: Is that a good summary? Is that what you were looking for?
Dr. Ryan Gray: Yeah, that's great. So you kind of have your hands in medical education, and are seeing these medical students on their journey. As you're interviewing the medical students for residency, as you're dealing with medical students on their rotations, what are some of the things that you see students struggling with that you hope that they would have learned by now, or something that they can learn now to help them in the future?
Biggest Mistake of Medical Students
Dr. Joel Topf: Well you know clearly the medical students that are most memorable are the ones that are not shy, that are willing to like get in there and participate in the discussions. And even- it's not the level of knowledge that's important, it's the fact that they feel empowered and to be part of the team, and are able to- you know mix it up. And that- and I'll always- I'll find the questions and the level and the questions that fit their level of education and their personal knowledge level. But what is so difficult, and I find so- a bit frustrating for me is when they're just very reserved and they don't want to engage. And it feels like they're just kind of passing time with the team rather than being part of the team. And so you know, I really encourage medical students to engage your attendings and engage your residents, and don't be intimidated, that's the kind of the thing that we're looking for.
Dr. Ryan Gray: Do you think that's a symptom of not wanting to be ridiculed by attendings, or fellow medical students or residents that may be around?
Dr. Joel Topf: Yeah, I mean I think there's- that's the eternal fear of people that are smart, is being found out to be not as smart as they try to project, right? And that you never want that to happen. But nobody knows everything, and as a medical student you have the ultimate excuse for not knowing things. You're not ignorant, you're just a beginner, right? And so it really- it's the time when you really do have that free pass to not know the answer, and yeah but I think you've absolutely hit it. I think there's a lot of intimidation and a lot of nervousness about being humiliated and not feeling good about that.
Dr. Ryan Gray: One thing we talk a lot about here is the collaboration in the premed path and medical school, and how medicine nowadays is a team sport. Can you talk about it from your point of view as an attending, as an educator, how you see being a team player contributes to your day?
Dr. Joel Topf: Yeah, well I mean you know it's funny. So much of it now is a team game. Is that when I come in in the morning to see the patients that came overnight that there was a team that admitted the patient, and they needed to do their job of admitting the patient and there's that huge communication issue, the handoff from the nighttime to the daytime team. And then the daytime team, right they never have enough time to have fully worked up the patient on their own. And so you have a resident that usually has gone over a lot of the computerized stuff, and then you have the intern who's spoken with the patient and examined the patient, and they have to work together when we kind of try to put together, “Well what was the plan last night? Does that make sense?” And there's a lot of collaboration there between the intern who has the first responsibility for the patient, the resident who has the responsibility for the whole team, and then myself as the attending, integrating those two and try to tease out what are the problems, why was the patient admitted, what exactly do we need to do to get this patient to be doing better, and do we have the right diagnosis? God, so much that first morning after was all the assumptions that were made last night. What are the assumptions that were made last night? What was the presumed diagnosis, and were those assumptions and presumptions- were they correct? And that's all teamwork. Because nobody has- you know it's like a bunch of blind men feeling an elephant; nobody has the full story.
Dr. Ryan Gray: What a great visual. Especially because I was at the zoo yesterday and saw how big elephants are about five foot in front of me. A blind man feeling- I like that. I can't get that out of my head, thanks a lot. For a lot of our listeners, they're nontraditional students. Students- premed students, students that are looking to make a change and come back into medicine as a second career or maybe just got a slow start from undergrad. And they don't have that same structure of being in an undergrad and having the advisors and everybody around them. How do you suggest- or do you have any ideas for them to surround themselves with mentors or other people to help them on their path?
Different Sources for Mentors
Dr. Joel Topf: You know I guess what I would say is that mentors come in all shapes and sizes, and seek them out at any opportunity. Gosh you know this is going to sound completely nerdy, but the biggest mentor on my journey was a book. There was this phenomenal on fluids and electrolytes, and I remember-
Dr. Ryan Gray: Not the one that you wrote, right?
Dr. Joel Topf: Not the one that I wrote.
Dr. Ryan Gray: Okay, good.
Dr. Joel Topf: I was a third year medical student, rotated at the VA and I was completely baffled by the fluids and electrolytes and why this patient got D5 half normal saline, and this one got normal saline, and that one got lactated ringer's- none of it made any sense to me, it all seemed arbitrary. And there was a really intelligent resident- I said, “Well what should I read? I've got to get a book to understand this, I have no idea what I'm doing.” He told me to get this book by Burton Rose. And so I dutifully went to the medical bookstore and got this book, and it was a 1,200 page book; I'm on a one month internal medicine rotation, he gives me a 1,200 page book on one element of this. I bought the book, put it on the shelf, never- didn't think I would ever look at it again because you know, it was the act of buying it. Trying to- as if that would help me get the information. But a year later when we started working on thinking about doing this book I pulled that book off the shelf and started reading it, and it was absolutely- it crystallized everything. Made all of a sudden what seemed to be arbitrary, it's this logical model of how fluids works in the body. And I was like, “Oh my God, this is exactly what I want to do. I want to take care of patients in such a logical and informative matter,” and it absolutely kind of transformed me and like I said, that book by Burton Rose- same guy that started UpToDate, personal hero of mine, modelled my career after what he has done. And so you know, mentors come in a lot of different shapes and sizes. And so kind of have an open mind, and don't hesitate to kind of model and follow your- follow the patterns that may not be typical, but are still viable models for a career.
Dr. Ryan Gray: So one of the typical mentors that premed students think about, and even medical students, is our physicians to shadow. And it seems to be a hot topic for premed students, I get lots of emails discussing how premeds should go about finding a physician to shadow. How- obviously again, you're in the hospital, you're at ground zero, do you have students approaching you to shadow? Or how do you think these premed students should do that?
Dr. Joel Topf: Yeah I've had a couple of premeds shadow me. It's usually been children of friends of mine that have- you know so they have kind of a personal connection. And some of them have been just great experiences. I remember one student who actually has just graduated medical school just a month ago. And when he- he was a premed, and he shadowed with me and we were on the wards and we were talking about creatinine which is the basic toxic metabolite that marks kidney function. And you know- and like I said he was willing to mix it up. He said, “You know, I go to the gym and I take creatine. Is that the same thing?” I was like, “Well, there's only an I and an N difference, like they're very similar. And in fact they're biochemically related, not only do they sound the same, they actually are biochemically rated that creatine is metabolized into creatinine.” And then he's like, “Well is that going to affect my creatinine,” and I was like, “Oh absolutely. If you increase the creatine intake it will bump your creatinine, but it doesn't indicate a decrease in kidney function which the traditional interpretation of it increasing creatinine that this ends up being a false positive.” And then he's like- and then he kept talking about it, I was like, “You know what? Why don't you go do some research on it, let's go take a look at this.” And then he presented it- the next day he came back and he had all this information and we kind of helped him pound it into a presentation, it was kind of his first on the fly, you know, five minute presentation, kind of the traditional clinical workshop assignment, you know, give me a five minute talk on this. And it took him a couple of days to get it right, put this together, and he did a great job. And I think he saw- because he was modeling the same behavior that the third year medical students and the residents were also doing, they were doing these five minute presentations. And he was able to take one of his interests and relate it to something he saw in the hospital, and do the same kind of process. It was a very cool experience for both me and for him. And you know he ended up pursuing medicine, getting into medical school, and just graduated.
Dr. Ryan Gray: Yeah, so it's a great experience.
Dr. Joel Topf: Yeah, and- but I've seen- I've had other people that come and they shadow, and that's all they are. They're just like a shadow, and they don't mix it up, and they don't feel like they can- they don't feel empowered to talk. I don't know if that's I'm not doing a good job, but I can't imagine they're getting useful- much that is useful out of it besides a checkbox.
Dr. Ryan Gray: Yeah, unfortunately that's what a lot of them are using it for. Or maybe they were told that that's exactly what they should do is just stand there and be quiet.
Dr. Joel Topf: Yeah, you know it's funny in the end sometimes that's not bad advice, it's that part of it is- you know for some people just taking in the flavor of the experience is there's something there, and that's probably worthwhile for lots of people. But if you feel empowered to talk, man I think you have an attending or team that's willing to listen to you. And that doesn't find you annoying and willing to actually, you know bring you in and make that a real fertile ground for discussion. That's just- it was- I think it was a really good experience for everybody.
Dr. Ryan Gray: Yeah. That's awesome. So looking back over you whole journey to where you are now, what do you wish you would have known from the get-go to help your path easier?
Dr. Joel Topf: You know I wish I had done some more shadowing and some real medical experience when I had been an undergrad. That this was the part of my application that was lacking, and it was an obvious hole as I was interviewing that it just was always like, “So, tell us about your hospital experience,” and I had not done a lot of- or any hospital experiences that you know, my dad had been a doctor, I'd been kind of around it my whole life, I had gone on rounds with him as a kid, and just none of that stuck as a compelling story when I went and did the interview. They seemed to brush right past it, and to me it was a really important part- like I was like- I felt like I was not getting into medicine with my eyes closed. I was not- I did not have a television view of what medicine was like, right? Like I knew what it was really like in terms of a job and as a lifestyle. But I couldn't communicate that, and my CV and transcript certainly didn't back that up. And I think- I don't think that would have been a difficult thing for me to fix, and I think it would have been valuable, right? I would have come in with a lot more kind of background knowledge of medicine. Like I said I'm more of a- don't tell me what's going to happen in a month, I just want to know what's going to happen tomorrow, and that's probably not the best way to go through medical school.
Dr. Ryan Gray: Yeah. Last week's podcast we talked a lot about the negativity around medicine and kind of the joy that an acceptance letter brings a premed student, and hearing from a physician like, “Run now, don't do it.” What do you tell that premed, or the medical student that's struggling on their path, and kind of wanting to quit? What do you tell them now as you're a physician, why they should stick with it?
Advice to the Struggling Premed
Dr. Joel Topf: To me it's been a phenomenal career that's had exciting challenges all the time, new things to learn, like I think it delivers a lot of what it promises. Like people want a job where they're going to get to help people, or they're going to get to meet people. And they're going to get to meet people from all walks of life, from CEOs to bums, and I love seeing that. And I get such a broader world view because of this experience. I think it is the greatest career possible. And in the end a lot- I think a lot of the changes that medicine is going through that we spend a lot of time focusing on whether it's maintenance of certification, or whether it's changes in reimbursement, end up being- those are important, they're kind of superficial and they're not changing the focus of the job, and the focus of the job has stayed the same, and it's a great job. And you know I share all those medical students' enthusiasm for getting into medical school, I can totally understand that. Like you are starting on just a phenomenal journey, and it's a journey that doesn't end when you finish residency or finish fellowship. Like the journey continues, there's still new things to be learning, new techniques, new therapies that are coming about, and so always changing.
Dr. Ryan Gray: Alright, again that was Kidney Boy, Dr. Joel Topf. I did Google Kidney Boy as we were talking, and it's a pretty great image. And it looks like it's even been updated since the original Kidney Boy was drawn. And so it looks pretty awesome, we'll have those in the show notes so you can find that at www.MedicalSchoolHQ.net/132 as always, that's episode 132, you can find all of our show notes if you do that slash episode number trick.
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If you have any questions or suggestions on future topics, or future guests, feel free to email me, I am Ryan@medicalschoolhq.net. And as always I love when you come say ‘Hi' to me on Twitter. I am @MedicalSchoolHQ.
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