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A Private-Practice Nephrologist Who Also is in Academics

Session 16

This week’s guest is Dr. Joel Topf, a private practice and academic Nephrologist who loves teaching and the small details. Back in Episode 06 of the Specialty Stories Podcast, we first covered Nephrology where I talked with Dr. Jean Robey, a private-practice Nephrologist.

As you get to listen to both episodes, you will hear some differences in both of those settings. My goal for this podcast is to not just give you insights into what a certain specialty does, but also, for you to see the differences between an academic specialty and a community specialty, or a private-practice physician and be able to compare those different settings.

As you go through your medical training, most of the exposure you get is the academic side of medicine and that is not the majority of medicine practiced. Hence, I wanted to give you insights into all of the different aspects of it and be able to compare a private-practice Nephrologist (back in Episode 06) and this episode which is more of an academic Nephrologist.

[03:00] Choosing Nephrology

Having finished his fellowship in 2003, Dr. Topf is in a hybrid setting where he works for private practice but hired by the hospital to run their fellowship program. He teaches medical students (second to fourth years and the residency program), although it’s not a pure academic role since he doesn’t do a lot of research.

Coming out of medical school, Dr. Topf wanted to do a specialty that allowed him to subspecialize so he chose Med-Peds. It was on the third year of his four-year residency that he decided to do a fellowship and specialize in Nephrology. What led him to this decision is finding how interesting medicine gets and as you study it more, it gets even more interesting. Then before you know it, you can’t escape. Dr. Topf was so delighted with Nephrology. However, he was also working on another project, writing a textbook on fluids and electrolytes. So while he was learning a lot of Nephrology, he was also learning a lot of Renal Physiology and fell in love with it.

By the time he was choosing his specialty, he felt like Nephrology had picked him more than he picked the specialty and there was nothing else he would ever consider doing. Had he had a more open mind, Critical Care would have been something he considered but he’s happy with Nephrology since a lot of the very interesting cases that he likes in Nephrology are shared with Critical Care.

[05:35] Traits of a Good Nephrologist

Dr. Topf says that the most important trait that leads to being a good nephrologist is being detail-oriented and fastidious since it involves a lot of numbers and balls to keep in the air when you take care of these patients who have a number of problems especially when it comes to dialysis or transplant cases.

Most other primary care doctors and specialists want to take their hands off and leave it all up to the Nephrologist to take care of that so you end up being a generalist for a wide span of patients. So even though much time is spent focused on Nephrology, at least in training, Dr. Topf emphasized that you still need to keep your Internal Medicine skills sharp (reason that he re-certified in Internal Medicine).

[06:40] A Typical Day Being a Nephrologist

Dr. Topf would usually start his day at an outpatient dialysis clinic or two. They see all of their hemodialysis patients once a week and they have around 50 hemodialysis patients. So he goes to a couple of dialysis units in the morning and see a few of his first shift dialysis patients. Next stop is the hospital to see patients through the rest of the morning then have clinic patients in the afternoon. Sometimes in the middle of the day, he would also see dialysis patients on the second shift and at the end of the day, he often stops at the dialysis unit to see patients on a third shift.

Hemodialysis patients need to get dialysis three days a week so people are either on a Mon-Wed-Fri schedule or Tues-Thurs-Sat schedule. Each dialysis typically runs about four hours starting somewhere between 5-6 am and the first shift will go from 5-9 am or 6-10 am. Then at 10-11 am, the second shift will go on and then at 2-3 pm, the third shift will go on. Dr. Topf has patients at multiple units on all those different shifts so he has to find a way to see them once a week.

[8:20] Types of Patients and Other Procedures

In the U.S., 45% of people that are on dialysis get there via diabetes while about 30% get there from hypertension. Essentially, somewhere between two-thirds and three-quarters will be diabetes and hypertension. The rest is everything else that causes kidney disease such as glomerulonephritis, severe kidney injury that never recovers, polycystic kidney disease, cancer, myeloma, etc.

Dr. Topf doesn’t do procedures that Interventional Nephrologists normally perform. Although during his Fellowship, he did a lot of kidney biopsies and put in a lot of temporary dialysis access. He also has partners that are more interventional who still do kidney biopsies and others put in peritoneal dialysis catheters and hemolysis catheters, but it’s not something Dr. Topf likes doing.

[10:10] The Academic Aspect of Being a Nephrologist

Dr. Topf gives standard lectures every month where he gives a morning report to the residents at their hospital who are in the internal medicine program as well as lectures to their five Nephrology Fellows. He participates in the Fellowship in terms of interviewing and selecting the next year’s fellows as well as in evaluating the current fellows.

Additionally, he runs one of his outpatient clinics as a fellow clinic so he staffs that fellow in a clinic. He also has a standard role of teaching third year medical students three lecture series as a new group of internal medicine third year students rotate through the hospital for basic nephrology concepts.

Another one of his responsibilities in the Fellowship Program is helping coordinate the Fellow Research Projects so these get into fruition.

[11:53] Seeing the Two Sides of Nephrology

What attracted Dr. Topf to the job was the opportunity to teach as this is something that he really wanted to do. He just didn’t want to be locked into the bureaucracy of a traditional academic program with lots of pressure to publish and get grants. So he found this hybrid model that fits the kind of practice that he wanted to do. Basically, it was his practice that became the driving force to bring both of these things to the hospital.

[13:00] Work-Life Balance

Dr. Topf describes his Nephrology practice as enjoyable. It’s more of a traditional physician model where he doesn’t have set hours and has a call generally once a month with certain exceptions such as when a partner gets sick or death in a family so he would have to get calls twice or thrice a month, which happens rarely.

But nephrology in general is more of a traditional internist model. It’s not a hospitalist nor an E.R, doc so you’re not punching in or out. Dr. Topf describes himself as a business owner so he works harder because he owns it and the work he puts in is delivered back to him in monetary rewards.

When he gets a call, he covers all the patients in the hospital so he typically sees somewhere between 20 and 30 patients in the hospital each day that he is on call, which would be a full day.

[14:55] The Path to Residency and Fellowship

If you want to be a pediatric nephrologist, you need to do three years of internal medicine and then you need to get a Nephrology Fellowship, which is traditionally three years long (Commonly today, there are two years now.) In the old model, it consists of one year clinical and two years of research. For most fellowships now, it’s two years of clinical experience with some clinical research in the second year.

During his adult fellowship, he spent a lot of time doing Pediatric Nephrology where he did special rotations at the children’s hospital and got a lot of experience. What he found out from that experience is that it really is a different specialty. There is a crossover but there isn’t all that much because the diseases they see are quite a bit different.

If he lived in an area that didn’t have a pediatric nephrologist, he would absolutely see children but he lives in Detroit where there is a children’s hospital two to four miles away from his hospital so it would be absurd for parents to take their kid to see an adult nephrologist when there is a pediatric nephrologist right next door. He did think about doing it early on in their training but as he began to appreciate what being a specialist really meant, it made less and less sense for him. If you want to be a generalist, don’t sub-specialize. If you want to be a specialist well then you need to be a specialist where you need to focus on just the patients that you’re going to be taking care of.

Why he chose adult nephrology over pediatric nephrology is primarily because of the way higher demand for an adult nephrologist. He has heard stories of people finishing pediatric nephrology fellowships and not being able to find a job or they’re not able to use that training having to spend for years waiting for a position to open up so in meantime would have to do general pediatric work so they don’t get to use their training.

[18:30] Competitiveness of Nephrology Fellowship and the Hospitalist Boom

A nephrology fellowship is not competitive, in fact, Dr. Topf reckons it’s close to two nephrology spots for every one applicant. So it’s absolutely a buyer’s market. Therefore, the residents are in great positions where they will definitely get offered interviews everywhere and they will be able to put a very aggressive rank list since there would still be a match system. Very few people who want to be a nephrologist are unable to become a nephrologist.

What they want to see in nephrology fellowship applicants is somebody who has a strong desire to be a nephrologist rather than just someone who sees it as a fallback. They’re looking for someone who really loves the specialty and wants to be a nephrologist and not just what’s available to them.

This is demonstrated through a research experience in nephrology or letters of recommendation from fellow Nephrologists they know or have done rotations in their institution or they’ve contacted them early on and shown interest to it. All these could put any applicant way higher on the rank list.

Six years ago, they had 200 applicants for their two to three spots a year but the number has waned this year to just 22. The demand thereby fell off to 90% in six years. Dr. Topf’s theory is that this could be caused by the hospitalist boom, a huge new specialty that emerged from nowhere that they have to staff up every resident plus they pay excellent salaries, offer shift work, and they start getting paid the next day their residency ends. Whereas in a nephrology fellowship, you have two more years of postgraduate training to go through and then you get a job where you’re going to work more than 40 hours  a week. Compared to a cardiologist or a G.I. doctor that gets a much higher salary than as a hospitalist but at the end of a nephrology rainbow, the salary may just be modestly better or the same as with a hospitalist.

[22:30] Subspecialty Opportunities

Subspecialties available include Transplant Certified, which happens one year after fellowship, and Interventional Nephrology, which is less regulated. Some fellowships do that, others have two or three-month courses run by dialysis access companies that give them all the training needed for those procedures (no board certification for that). Others do Hypertension subspecialties, which is just a test given by the American Society of Hypertension. You can do fellowship and get formal training for it but a lot of people just take the test and gain that certification.

[23:45] Primary Care and Other Specialties

Dr. Topf thinks primary care physicians are doing a good job with it but they should be more aggressive with hypertension and less aggressive with glycemic control since he sees a lot of patients suffering from over-emphasis on trying to get the A1c all the way down causing a lot of hypoglycemic spells. But these are style issues more than knowledge gaps.

Among other specialties he works closest with include critical care, E.R. cardiology and endocrinology. They also get consults for the same diseases oftentimes such as hypercalcemia.

[26:10] Special Opportunities Outside of Clinical Medicine

A huge opportunity outside of clinical medicine is a Dialysis Medical Director. There are thousands of dialysis units around the country that cannot operate without a medical director.

Medical directors need to be board-certified in Nephrology. Dr. Topf adds that this is a different type of medicine than you’ve ever practiced before since you will be providing population health and be looking at all the infections that happened in, say, 80 patients there that month and try to find patterns causing these infections.

They also have to go over the water treatment system considering the massive amount of water used in dialysis, meaning 5,760 liters per shift and you run three shifts per day so that is close to 20,000 liters of water being treated in a dialysis unit everyday. Keeping all that equipment up-to-date and functioning is a continual exercise and you have experts that help you with it but the medical director is at the top of all those experts to make sure they’re doing a good job and doing all the reports on water quality, infections, and meeting targets in hemoglobin, albumin, and phosphorus. You will also be working with a Nutritionist or a social worker.

Apparently, there are a lot of different benchmarks of a dialysis quality and as a medical director, you’re responsible for those.

[29:30] The Best and Least Good Thing

Dr. Topf finds being a nephrologist to be a rewarding career for him. His advice to a brand new nephrologist is that your first few years coming out of Fellowship are still a major learning moment. You are nowhere near the top of the mountain so there’s still a lot of learning you need to do so be humble.

What he loves best about being a nephrologist is the teaching side of it. He also loves having that longitudinal experience with his patients where he is able to see and take care of patients through all the different phases of their kidney disease.

On the flip side, what he likes least about being a nephrologist is those four dialysis visits a month for each dialysis patient which he considers as an overkill. He thinks he didn’t need to do this that much since you could do all the medically important stuff in just two visits but this is a requirement(which is also a reimbursement-driven thing) that ends up being unnecessarily burdensome for him .

[32:15] The Future of Nephrology

The advancements in technology and techniques taking over much of the diseases have significantly reduced the numbers of procedures needed in treating diseases related to, for example, cardiology.

Nephrology is highly dependent on dialysis so if a new technology comes on, whether it would eliminate dialysis or dramatically reduce its need would be a major earthquake for the specialty.

Nanotechnology creating smaller filters to create a transplantable artificial kidney is something he doesn’t see being viable for a long time. It sounds cool but it doesn’t really address the biggest problem with current dialysis which is access, the mere process of getting the blood in and out of the body safely. Unfortunately, this technology doesn’t address that.

[35:30] Final Words of Wisdom

If he had to choose Nephrology again, he would still have chosen it in a second. Lastly, Dr. Topf wants students to know that if they find the kidney to be interesting but intimidating because of how difficult it is, then it’s not that difficult. You will be able to learn the kidney from its very fundamentals when you go to fellowship and you will be building a model of it in your brain. Once you have that model, everything makes sense and it all falls into place. That is difficult to understand how much simpler everything will be when that happens. Once you get it, you get it and it’s not very hard. If you’re interested in it, pursue it because it’s not that hard.

[36:40] Bias Among DOs and Caribbean Graduates

Dr. Topf said that they have a DO on the board in their practice and will likely be the next CEO. Their assistant program director is also a DO. So there no bias, not even close to having a bias. They also have a Caribbean graduate who is an excellent doctor as a partner.

Links:

Get connected with Dr. Joel Topf on Twitter @kidney_boy.

Shoot me an email at [email protected]

MedEd Media Network

Specialty Stories Podcast Episode 06: A Private-Practice Nephrologist Talks About Her Job

American Society of Hypertension

Transcript

Introduction

Dr. Ryan Gray: The Specialty Stories is part of the Med Ed Media network at www.MedEdMedia.com.

This is the Specialty Stories Podcast, session number 16.

Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.

Welcome back or welcome to the Specialty Stories Podcast if this is your first time here. Thank you for joining me. My name is Dr. Ryan Gray and I’m the host here at the Specialty Stories Podcast as well as many other podcasts on the Med Ed Media network. If you’re a premed student, I have a bunch of shows for you to listen to. Just go check out everything we have to offer over at www.MedEdMedia.com. That’s www.MedEdMedia.com.

This week is one of our first weeks where we are doubling up on a specialty, and doubling up isn’t the right word. We are re-engaging or- we’re doing something with a specialty and covering it again, and this is my goal with Specialty Stories. So Nephrology we covered back in episode 6 of the Specialty Stories Podcast, and when I spoke to Dr. Robey, she is a private practice nephrologist. And the nephrologist, Dr. Topf, that we’re going to talk to today is also a private practice nephrologist, but is involved in academics as well, and we’ll ask some of the academic questions. You’re going to hear some differences. Go back and listen to episode 6, and then- or listen to this one and then go back and listen to episode 6, and you’ll hear some differences in both of those settings, and that was my goal for this podcast; not only giving you insight into what a cardiologist does, and a nephrologist does, but what are those differences between an academic nephrologist and a community nephrologist? What are the differences- or private practice nephrologist. What are the differences between a community cardiologist and an academic cardiologist? As you go through your medical training, most of the exposure that you get is the academic side of medicine, and that is not the majority of medicine that is practiced, and so I wanted to give you some insight into all of the different aspects. And so you’ll get to hear that for the first time here, being able to compare before back in episode 6 a private practice nephrologist, and now here in episode 16, more of an academic nephrologist. So let’s go ahead and dive right in.

Meeting Dr. Joel Topf – Clinical Nephrologist

Dr. Joel Topf: My name is Joel Topf and I’m a clinical nephrologist.

Dr. Ryan Gray: And are you in an academic setting or a community setting?

Dr. Joel Topf: I am in a hybrid setting. I work for a private practice but we’ve been hired by the hospital to run their fellowship program, and I do teaching for medical students, second years, third years, fourth years, and the residency program. It’s not a pure academic position, I don’t do a lot of research. We do some but that’s not a primary part of my job.

Dr. Ryan Gray: Okay how long have you been practicing?

Dr. Joel Topf: I finished fellowship in 2003.

Dr. Ryan Gray: Okay so a little while. When did you know you wanted to be a nephrologist?

Dr. Joel Topf: So coming out of medical school I wanted to do a specialty that would allow me to sub-specialty. I kind of always kept that in the back of my mind, so I chose Med-Peds, and then probably in second year or third year of residency- it’s a four year residency, I really came to the conclusion that I wanted to do a fellowship and specialize in Nephrology specifically.

Dr. Ryan Gray: What do you think led to that decision?

Dr. Joel Topf: So the thing about medicine is that the more you learn about one subject, the more that same subject becomes enjoyable. And so it’s kind of like these gravity wells. You’ve got to be careful what you start studying because you never know- what you start studying becomes more interesting, and then you start studying it more, and it becomes even more interesting, and before you know it you can’t escape. And so that was what happened to me and Nephrology. I’m totally delighted with it, and I loved the field that I did, but I was working on another project, writing a textbook on fluids and electrolytes so I was reading a lot of Nephrology, learning a lot of renal physiology, and I just fell in love with it. And by the time I was choosing my specialty I kind of felt like Nephrology had picked me more than I had picked Nephrology. There was just nothing else I would ever consider doing.

Dr. Ryan Gray: Were there any- at that time were there any other specialties that were in the running?

Dr. Joel Topf: There weren’t, though I think had I had a more open mind, critical care would have been something I would have really considered, but I’m happy in Nephrology. I see a lot of the very interesting cases that I like in Nephrology are shared with critical care, extreme electrolyte abnormalities for one.

Traits of a Good Nephrologist

Dr. Ryan Gray: Okay. What traits do you think lead to being a good nephrologist?

Dr. Joel Topf: So the most important one is being detail oriented and being fastidious. Like there’s a lot of numbers and a lot of balls to keep in the air when you’re taking care of these patients. All of our patients have a number of problems, especially when it comes to dialysis or transplant patients. Most other primary care doctors and other specialists want to take a hands-off approach and then leave it all up to the nephrologist to take care of that, and so you end up being a generalist for a wide span of patients. Everybody that’s on dialysis and most patients have had a kidney transplant. And so even though you spend much of your time focusing on Nephrology at least in training, you still need to keep your internal medicine skills sharp, and in fact I’ve re-certified in Internal Medicine, not just kept my Nephrology boards.

A Day in the Life

Dr. Ryan Gray: Yeah. Describe a typical day for you.

Dr. Joel Topf: So I usually will start my day at an outpatient dialysis clinic or two. The way dialysis works is we see all of our hemodialysis patients once a week, and I have fifty or so outpatient hemodialysis patients. And so I’ll spend- I’ll go to a couple of different dialysis units in the morning, see a few of my first shift dialysis patients. Then I’ll go to the hospital and I’ll see hospital patients the rest of the morning, and then I will have clinic patients in the afternoon, and then I’ll sometimes steal away in the middle of the day to see dialysis patients on the second shift, and then at the end of the day I’ll often, though not always, stop in the dialysis unit to see patients on a third shift.

Dr. Ryan Gray: Explain what that first shift, second shift, third shift means.

Dr. Joel Topf: Right so hemodialysis patients need to get dialysis three days a week, and so people are either on a Monday, Wednesday, Friday schedule, or Tuesday, Thursday, Saturday schedule. And each dialysis patient typically runs about four hours, and so they will- dialysis units will start patients off somewhere between 5:00 and 6:00 in the morning, and that’s your first shift will go from 5:00 to 9:00 or 6:00 to 10:00. And then at 10:00 to 11:00, the second shift will go on. And then at 2:00 to 3:00, the third shift will go on. And so I have patients at multiple units on all of those different shifts, and I need to find a way to see them once a week.

Dr. Ryan Gray: You talked about some hemodialysis patients. What types of patients are you treating? What sort of diseases do they have?

Dr. Joel Topf: So in the United States about 45% now of people that are on dialysis get there via diabetes, and then another 30% or so get there from hypertension. Those numbers are off probably by a little bit, but essentially somewhere between two thirds and three quarters will be diabetes and hypertension, and then the balance will be everything else that causes kidney disease. So glomerulonephritis, or a severe acute kidney injury that never recovers, or polycystic kidney disease, or cancer, myeloma, et cetera.

Dr. Ryan Gray: Are there any procedures related with being a nephrologist?

Dr. Joel Topf: So there are nephrologists that are interventional nephrologists. That’s not what I’ve chosen to do. The procedures that I do, boy almost none unless you consider spinning urine and looking at a urinalysis a procedure. But in my fellowship I did a lot of kidney biopsies and put in a lot of temporary dialysis access, and then I have partners that are more interventional and they’ll continue- they still do kidney biopsies, and others will put in peritoneal dialysis catheters and hemodialysis catheters, ones that have more interventional training. Just not what I like to do.

The Academic Setting

Dr. Ryan Gray: You’d mentioned with you practice setting, how it’s a hybrid kind of community academic. Describe the academic aspect of it. How does that come into play as a nephrologist?

Dr. Joel Topf: Well I have a standard lecture that I give once a month, I give a morning report to the residents at our hospital which is a big internal medicine program. And then I also give lectures to our fellows, we have five Nephrology fellows, and I participate in that fellowship so I help interview and select the next year’s fellows, and participate in evaluating the current fellows. I run one of my outpatient clinics is a fellow clinic, and so I will staff that fellow in that clinic. I also have a standard position where I teach the third year medical students on a rotating basis, so essentially it’s a three lecture series that I go through as each new group of internal medicine third years rotate through the hospital. We go over foods and electrolytes, and acute kidney injury, and other basic Nephrology concepts. And one of my responsibilities in the fellowship is I coordinate the fellow research program- research projects, and so I help them guide their- it’s a requirement for our fellowship program that they have to do a research project. And so I help coordinate that and help them get that to fruition.

Dr. Ryan Gray: Now from the sounds of it, it didn’t sound like you sought out an academic spot. So now that you have a little bit of academic responsibilities, how do you see those two sides of Nephrology; one being in the community, and the second now interacting with fellows, and residents, and the like?

Dr. Joel Topf: So really what attracted me to the job was the opportunity to teach. Like that was something that I really wanted to do, I just didn’t want to be kind of locked into the bureaucracy of a traditional academic program with lots of pressure to publish and get grants. It seemed like something that wouldn’t be very fun to do. And so I found this kind of hybrid model that fits my practice nicely. It’s what I like to do.

Dr. Ryan Gray: Okay so you weren’t in the practice when it was bought or changed over? You sought this out specifically.

Dr. Joel Topf: No, this is how the practice always has been. The hospital did not have a Nephrology fellowship program, did not have a transplant program, and my practice was the driving force to bring both of those things to the hospital.

Work Life Balance

Dr. Ryan Gray: Great, okay. Do you feel like as a nephrologist you have enough family time, or work life balance, however you want to say that?

Dr. Joel Topf: Yeah I mean I work a lot and I enjoy my work, and it’s not shift work, this is much more like the traditional physician model. Like I don’t have set hours, and I have call generally once a month, but if a partner is on vacation, or gets sick, or has a death in the family, it might be twice a month, and sometimes it’ll be three times in a month. It’s rare but it does happen. I don’t think that’s as much specialty driven as in the specific circumstance that I’m in. But Nephrology in general, it’s more of a traditional internist model, it’s not a hospitalist, it’s not an ER doc, you’re not punching in and punching out. You’re working until the work is done. And also I’m a business owner, and anybody who owns a business knows that you work harder because you own it, and so the work that I put in is delivered back to me in monetary rewards.

Dr. Ryan Gray: You said taking call once a month. For you, what does call look like? Are you just at home on the phone? Do you have to go in a lot? What does that look like?

Dr. Joel Topf: Right so we have to cover all the patients that are in the hospital and so I will typically see somewhere between twenty and thirty patients in the hospital each day that I’m on call on the weekend on Saturday and Sunday. So they’re our full days.

Residency and Fellowship in Nephrology

Dr. Ryan Gray: What does residency look like- the path to being in nephrologist residency and fellowship?

Dr. Joel Topf: Right so you need to do three years of internal medicine, or if you want to be a pediatric nephrologist, three years of pediatric nephrology. And then you need to get a nephrology fellowship and they are traditionally three years long, though probably more commonly today they are two years. In the old model it was one year clinic, and then two years of research. And now it’s two years of- for most fellowship programs probably two years of clinicals with some clinical research in the second year.

Dr. Ryan Gray: Okay so less research heavy they’re moving towards.

Dr. Joel Topf: Yeah I think that’s what we’re seeing.

Dr. Ryan Gray: You mentioned that you specifically went to a Med-Peds residency. Does that allow you or open up the possibility to see pediatric patients?

Dr. Joel Topf: So I spent a lot of time during my adult fellowship doing pediatric nephrology. I did special rotations at a children’s hospital, and got a lot of experience doing that. And what I really concluded from that experience was that it really is a different specialty, that there is some crossover but there’s not all that much, really the diseases you see are quite a bit different, and that if I lived in an area that didn’t have pediatric nephrologists I would absolutely see them. What other alternative would these parents have? But I live in Detroit, there’s a children’s hospital two miles away or four miles away from my hospital. Like it would be absurd for any parent to decide to take their kid to see an adult nephrologist when they had a pediatric nephrologist essentially right next door. And though I thought about doing that early on in my training, as I began to appreciate what being a specialist really meant, it became to make less and less sense. Like if you want to be a generalist, don’t sub-specialize. If you want to be a specialist, well then you need to be a specialist and you need to focus in on just the patients that you’re going to be taking care of.

Dr. Ryan Gray: What was that decision process like for you deciding to do adult Nephrology versus Pediatric Nephrology to begin with for fellowship?

Dr. Joel Topf: Right so the demands are wildly divergent. There’s just not a lot of pediatric kidney disease. I mean thank God there’s not, right? And there’s this epidemic of adult kidney disease. And so the demand for adult nephrologists way outstretched the demand for pediatric nephrologists. And I don’t want to speak with authority on it, but you hear stories about people finishing Pediatric Nephrology fellowships and really not being able to find a job where they’re able to use that training, and they will spend sometimes years waiting for a position to open up. And in the meantime they do some other type of pediatric work as a generalist, maybe with a little more hypertensions than you normally would see, but they don’t get to use their training. And so it became- once I decided on this it was a pretty easy decision to go into adult.

Competitive Nephrology Fellows

Dr. Ryan Gray: You mentioned that you conduct fellowship interviews and decide what lucky students or residents are going to become the next fellows for your program, the program at the hospital. What makes a competitive applicant to a Nephrology fellowship? And then is it competitive?

Dr. Joel Topf: So it’s not competitive. I think there are two- I think it’s close to two Nephrology spots for every one applicant, and so it is absolutely a buyer’s market. Is that right? A buyer’s or a seller’s? No, buyer’s market.

Dr. Ryan Gray: A buyer’s market, yeah.

Dr. Joel Topf: Yeah the residents are in great positions and they are going to get offered interviews everywhere, and they will have their- they will be able to put in a very aggressive rank list, there is still a rank- a match system, and they should have an excellent experience. Very, very few people that want to be nephrologists are unable to become nephrologists. So that’s good for them. In terms of what makes a good applicant, I’m sure the hardest thing, or the thing that we most want to see is we want somebody who’s always wanted to be a nephrologist- or excuse me, not always wanted to be a nephrologist, but that really wants to be a nephrologist rather someone who says, “I want to be some sort of sub-specialist and I can’t get into Cardiology.” Right like that’s the reality for a lot of our applicants, but that’s not what we want. What we’re really looking for is someone who really loves the specialty and that wants to be a nephrologist, and it’s not just what’s available to them. And so trying to pick that out of a CV is really what we’re looking for. And so the ways people demonstrate that, it’s pretty obvious, right? You’ve done research in Nephrology, you have letters of recommendation from people that we know that are nephrologists, you have done maybe an away rotation at our institution, a try-out rotation and we’ve been able to work with you, you have contacted us early on and shown interest into it. All of these things put you way higher on the rank list.

Dr. Ryan Gray: The competitiveness for Nephrology, having two spots for every one applicant, obviously not very competitive, is that something that kind of waxes and wanes with the tide, or is that something that you’ve seen for awhile that Nephrology just isn’t a very popular specialty?

Dr. Joel Topf: Six years ago we had 200 applicants for our two or three spots a year. This year we had- I think we had 22.

Dr. Ryan Gray: So something changed.

Dr. Joel Topf: Demand fell off by 90% in six years.

Dr. Ryan Gray: What happened?

Dr. Joel Topf: I think hospitalists happened. I think that the hospitalist boom, a huge new specialty essentially emerged from nowhere, and they are having to staff up. They have tremendous demand, they can suck up every resident, they pay excellent salaries, they offer shift work, and they can do- they start that excellent salary the moment- on July 1st, right? They finish their residency on July 30th, and they immediately start getting paid while if you do a Nephrology fellowship you’ve got two more years of postgraduate training to go through, and then you get a job where you’re going to work much more than forty hours a week.

Dr. Ryan Gray: Interesting theory.

Dr. Joel Topf: That’s tough to compete against.

Dr. Ryan Gray: That’s very tough, yeah.

Dr. Joel Topf: And at the end of the rainbow if you’re a cardiologist or a GI doctor there’s a much higher salary than you would get as a hospitalist. But at the end of the Nephrology rainbow the salary may be modestly better or the same as with a hospitalist.

Sub-Specializing as a Nephrologist

Dr. Ryan Gray: Yeah. Alright. What do the opportunities to sub-specialize look like?

Dr. Joel Topf: So Nephrology is a sub-specialty, and so if you want to go further you can get transplant certified, and so that’s usually one year after fellowship. And then the other thing you can get is there is this interventional Nephrology, and that is less regulated. And there are some fellowships that do that, but they’re also two or three month courses run by access companies- dialysis access companies that will give you all of the training you need to do those procedures without a formal fellowship. And there’s no board certification for that, nor is there one for transplant. And then there’s other people that do hypertension sub-specialties or further sub-specialization, and that’s essentially just a test given by the American Society of Hypertension, and people will- you can do a fellowship and get formal training, but a lot of people will just say, ‘Hey this is something I’m really interested in,’ and they’ll do a lot of studying and a lot of additional reading, take that test, and gain that certification.

Working with Other Physicians

Dr. Ryan Gray: What do you wish primary care providers knew about Nephrology to make your job easier to help the patients?

Dr. Joel Topf: Yeah I don’t have a lot of complaints about primary care doctors. I think they do a pretty good job with this. I think there was a time when people just looked at creatinine and didn’t understand its relationship to GFR but I think we’re really past that and they’re doing a much better job with that. You know I would say be more aggressive with hypertension and maybe less aggressive with glycemic control. I see a lot patients suffering from too much emphasis on trying to get that A1C all the way down and causing a lot of hypoglycemic spells. But I mean those are style issues more than knowledge gaps. I think in my experience primary care does a pretty good job of taking care of the major renal issues.

Dr. Ryan Gray: What other specialties do you work closest with?

Dr. Joel Topf: So we work really closely with critical care, so a lot of acute kidney injury patients will require dialysis. We spend quite a bit of time in the ICU providing dialysis, continuous forms of dialysis, dealing with toxicology for intoxications. Of course we work with the ER a lot. Cardiology, there’s a real tight relationship between chronic kidney disease and heart disease. And so patients are always bouncing between those two specialties pretty regularly. And again, they’re both end organ damage from diabetes and hypertension so we have kind of a similar patient population. And then Endocrinology for the diabetes also, and we also cross- we get consults for the same diseases oftentimes. So a hypercalcemia will sometimes go to Endocrine and sometimes go to Nephrology, and so we work with them quite a bit also.

Dr. Ryan Gray: Does being a nephrologist give you any special skills or open up any doors for any opportunities outside of clinical medicine?

Dr. Joel Topf: Yeah so the big one is Dialysis Medical Director. So every one of these dialysis units, and there are thousands of them around the country, can’t operate without a medical director, and medical directors need to be board certified in Nephrology. And this is a totally different type of medicine than you’ve ever practiced before. You will be providing kind of population health. You’ll be looking at all the infections that happened in the eighty patients there that month, and trying to find, ‘Is there a pattern? Is there something that we’re doing that’s systematically causing these infections?’ You’ll be going over the water treatment system. There’s a phenomenal amount of water used in dialysis. We can do quick math. Dialysis runs at 800 CC’s per minute times 240 minutes.

Dr. Ryan Gray: You can tell you’re a nephrologist, plug in the numbers.

Dr. Joel Topf: Right times thirty patients on a shift is- divide that by 1,000 to get liters, so that’s 5,760 liters per shift, and we want three of them a day, you’re getting close to 20,000 liters of water being treated in a dialysis unit every day.

Dr. Ryan Gray: Yeah.

Dr. Joel Topf: And keeping all of that equipment up to date and functioning is a continual exercise, and you have experts that help you with it, but the medical director sits at the top of all those experts and makes sure they’re doing a good job, and going over the reports on water quality and infections, and are we meeting targets on hemoglobin, and albumin, and phosphorus? And do we have the correct staffing? And you work- again you have other experts. There’s a manager, and there’s a nutritionist- excuse me, a dietician, and a social worker, but there’s a lot of different benchmarks of dialysis quality and you end up being responsible for those. And so that’s an interesting job, and that’s something that you kind of spend a few hours a week around your other practice taking care of this. And some of that is meetings, and some of that is signing papers, and some of that is going over reports. But that’s a huge opportunity in Nephrology.

Dr. Ryan Gray: Now you mentioned- the words that you used, you said you need to be a board certified nephrologist. Why does the Medical Director for a dialysis unit have to be a nephrologist? Why can’t it just be a normal physician that understands the business workings of a dialysis unit?

Dr. Joel Topf: So the large dialysis organizations, there’s a number of them, the big ones are Fresenius and DaVita, they have it in their bylaws that they will not allow a medical director to be anything but a board certified nephrologist.

Dr. Ryan Gray: Okay, there you have it. What do you wish you knew about Nephrology before you went into it?

Dr. Joel Topf: I don’t know if I have a good answer for that. I mean I feel like it’s delivered what it promised to deliver, and it’s been a real rewarding career for me.

Dr. Ryan Gray: So switching it up, what would you tell a brand new nephrologist coming in what the biggest takeaway that you’ve now learned over the course of your career?

Dr. Joel Topf: Well that your education, though you’ve studied a lot, and you completed your boards, and you feel really smart when you finish fellowship, that those first few years coming out of fellowship are still a major learning moment. You are nowhere near the top of the mountain and there’s lots of learning that’s still going to go on. That would be what I would say, be humble.

Best and Worst of Being a Nephrologist

Dr. Ryan Gray: What do you like the most about being a nephrologist?

Dr. Joel Topf: I love teaching and I kind of like the longitudinal experience with my patients. I’ve had patients that I’ve taken care of with pretty good kidney function, watch that kidney function deteriorate, I had them go onto dialysis, take care of them on dialysis for a year or so, watch them get a kidney transplant, then take care of them with the kidney transplant. It’s just being able to see and take care of patients through all those different phases of their kidney disease is really great.

Dr. Ryan Gray: On the flipside, what do you like the least?

Dr. Joel Topf: Those four dialysis visits a month for each dialysis patient. It’s overkill. I don’t need to do that that much, and that requirement to see them four times is burdensome. It ends up being I think a lot of busy work. I think I would get- I could do all the medically important stuff in two visits, and so it feels unnecessarily tiresome.

Dr. Ryan Gray: Is that an insurance driven thing or something else?

Dr. Joel Topf: Yeah it’s a reimbursement thing. You get reimbursed X amount for two visits, and X plus amounts for four visits. And it’s a private practice, and the partners- we’ve all decided that we’re going to do four visits, and so it’s a burden I carry.

The Future of Nephrology

Dr. Ryan Gray: Okay. Do you see, whether it’s technology, or disease progressions, or changes, do you see any major changes coming to Nephrology?

Dr. Joel Topf: Nephrology- well I mean the thing to think about, the classic one is the cardiothoracic surgeons, right? They were cabbage doctors. This is what was driving the volume for their business, and when the cardiologist developed the techniques and technology to take over much of coronary vascular disease, the volume on cabbage just dropped through the floor. I mean we’ve seen it in our hospital. Our hospital was completely oriented around CT surgery, did a ton of bypass surgeries, and the volume has evaporated, and they didn’t want to admit it but they were really a one procedure speciality. And Nephrology is highly dependent on dialysis, and if a new technology comes on, and I don’t see anything on the horizon, but sometimes what you don’t see doesn’t mean that it’s not there, were to eliminate dialysis or dramatically reduce its need, it would be a major earthquake for the specialty.

Dr. Ryan Gray: I’ve seen some stuff floating around about with nanotechnology creating smaller and smaller filters to create artificial kidneys that can be implanted, is that something that you don’t see being viable for a long time?

Dr. Joel Topf: Yes.

Dr. Ryan Gray: Or you hope?

Dr. Joel Topf: No it’s not that I hope, I mean I would love for that technology to work, I just- I look at that technology and it seems to not address the biggest problem with current dialysis which is access. Which is if you look at what causes the most hospital days and the most complications on dialysis, it is the mere process of getting the blood in and out of the body safely. And those technologies do not address that. And so I kind of feel like it’s cool, and it would be really neat, I’d love to see that work, but like the wearable artificial kidney which gets a lot of press, I look at that and I was like, ‘Really? We’re going to take the access, which is already the most fragile component, and now we’re going to let the person move around and live their life with that access working?’

Dr. Ryan Gray: God forbid a hose comes undone and the person just bleeds out immediately.

Dr. Joel Topf: That’s exactly right. So maybe I’m the person who doesn’t understand it, and maybe they’ve already solved that problem, but I’m highly skeptical. I would love to see that. There are other implantable solutions that would may not have the access problems, and maybe because you wear this thing all the time, the flows are much lower and so the access is not as complex, but I am skeptical. I would love to see it come to fruition but I’m not losing sleep over that concern.

Dr. Ryan Gray: If you had to do it all over again, would you still choose Nephrology?

Dr. Joel Topf: In a second.

Words of Wisdom to Premeds

Dr. Ryan Gray: What last words of wisdom do you have for the premed, or even the internal medicine resident right now thinking about Nephrology as a career?

Dr. Joel Topf: So if you think the kidney is somewhat interesting but you’re intimidated by how difficult it is, it’s not that difficult. That when you get to fellowship you will finally spend the time learning the kidney from its very fundamentals, and you will build a model of how works in your brain, and then once you have that model everything makes sense and it all falls into place. And that that is difficult to understand how much simpler everything will be when that happens, you’ve just got trust that once you get it, you get it and that’s not very hard. I hear a lot of people throw away or ignore Nephrology, say that they could never do that because they’re not smart enough, and I just don’t think- it’s not a cleverness thing. If you’re interested in it, pursue it, it’s not that hard.

Words of Wisdom to Premeds

Dr. Ryan Gray: Alright there you have it. Again, that was Dr. Joel Topf, academic nephrologist. One question that I forgot to ask Dr. Topf was is there a bias among DOs? And so I reached out to him afterwards and he says, ‘We have a DO that is on the board of our practice and will likely be the next CEO. Also our Assistant Program Director is a DO. So no, not even close to having a bias. We also have a Caribbean graduate who’s an excellent doctor as a partner. Might be interesting to interview him.’ So there you go, there is according to Dr. Topf not a big DO bias out there. So if you are interested in going to an osteopathic medical school, or if you are an osteopathic medical student or osteopathic resident looking at Nephrology, there’s not a big bias out there for you.
If you have any questions about Nephrology, he loves answering questions. He is a Twitter maven, he’s written books all about Nephrology, you can go hit him up. He’s @kidney_boy on Twitter. Again @kidney_boy on Twitter. Go say hi and let him know you heard about him here on the Specialty Stories Podcast. Thank you Joel for your time, for coming on the podcast and sharing your wisdom about Nephrology and the future of Nephrology.

If you have any specialties you would like me to cover sooner rather than later, shoot me an email, [email protected] What I’m going to be trying to do as we move forward is be a little bit more organized and try to batch these comparison episodes. So for instance if I was a little more organized to begin with, we would have had Dr. Robey, the episode six about private practice Nephrology, and then immediately following the next week, this episode here with an academic nephrologist. So I want to try to batch the specialties a little bit closer together. It’ll make it easier for me to find people that way too, so I know what specialties I’m looking for. So if you have any thoughts on specialties, again shoot me an email, [email protected]

If you enjoy this podcast, I’d love for you to share it with somebody. Take their phone, grab it from them, give it back eventually, but make sure to subscribe to this podcast and if they’re a premed, all of the other podcasts here at the Med Ed Media network. Have a great week, we’ll see you next week here at the Specialty Stories.

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