The Road to a Renal Hypertension Specialist

Session 226

Today, we chat with Dr. Derek Larson about his journey to specializing in Nephrology and Hypertension. If this is something you’re interested in, go check out the American Society of Nephrology.

For more podcast resources to help you with your medical school journey and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:14] Interest in Nephrology

In medical school, Derek already knew he wanted to do something based on internal medicine. He was actually deciding between Nephrology and Oncology, which were the two things that sort of sparked his interest in medical school.

Then he found his niche in nephrology after taking an elective in his first year. He found a charismatic mentor that continued throughout his internal medicine residency. And after meeting him, he wanted to be like the guy. From that second year of residency onwards, it was just where he knew he wanted to be.

'What specialty you want to do is the one that you go home and continue to read about.'Click To Tweet

[03:26] Finding a Mentor

Derek says that a lot of it happens just by finding it randomly. That being said, you have to go into things with an open mind. And sometimes, you will find that person accidentally. Even if it’s not the specialty you think you’re interested in, find the people that you want to be around and you feel comfortable being around.

'Sometimes your mentor doesn't even have to be in the specialty that you find yourself wanting to go into.'Click To Tweet

Derek adds that a mentor is a type of person that you respect and can learn from. There’s a lot of overlap in medicine. So a lot of times, they can help guide you even if it’s a different specialty where you really see yourself ending up.

[04:21] Collaboration in Nephrology

One of the myths Derek wishes to dispel is that they don’t like to collaborate or that nephrologists are always right. But it’s the other way around because it’s one specialty that thrives with collaboration. They’re very curious and have a love for problem-solving.

'Having that collaboration with all of the other doctors is one of the most important parts of nephrology.'Click To Tweet

If someone doesn’t have good math skills, Derek says they can still be a great nephrologist. Math is his least favorite subject. There’s certainly some math in nephrology, but you just have to know where to find the calculators and understand the physiology behind the math.

[07:29] Traits That Lead to Becoming a Great Nephrologist

Derek says curiosity is the number one trait of a good nephrologist. You should have a love for problem-solving. You will be doing detective work so you have to want to answer the why question. You want to take the time to ask those questions to go through the history to figure out what diagnostics may help you get to the right answer, then ultimately, stick with it.

One of Derek’s favorite parts of nephrology is the lifelong continuity of care with patients. You also need a strong internal medicine base since you’re doing nephrology, cardiology, internal medicine, rheumatology, as well as palliative care.

You’re dealing with patients and their families and having that long-term relationship with patients is one of the most rewarding aspects of Derek’s specialty. And he adds it’s something students should want to have to go into it.

'Every day is challenging, but every day is different... that's one of the neatest parts of being a nephrologist.'Click To Tweet

[09:08] Types of Cases

Derek explains that nephrology is generalized. He’s in the hospital every day, in the outpatient clinic, and in the chronic kidney disease clinic. He deals with dialysis patients and transplant patients and home hemodialysis and peritoneal dialysis.

The bread and butter in nephrology is chronic kidney disease. They deal with patients with diabetes or high blood pressure that have chronic kidney issues. So they try to optimize and prolong their kidney life.

Additionally, they deal with patients in the inpatient setting with acute kidney injury and acute kidney failure. It can be either from sepsis or blood pressure issues or other infections or inflammatory conditions. They also deal with preventing kidney stones as well as acid-base balance and electrolyte abnormalities. They get referrals for high potassium and referrals for low sodium.

They deal with transplant patients and follow their immunosuppression. They do hemodialysis at dialysis centers and they also do home hemodialysis clinics. They have peritoneal dialysis clinics, and certainly transplantation clinics. So it’s a little bit of everything.

“The bread and butter in nephrology is chronic kidney disease.”Click To Tweet

[11:28] The Biggest Myths or Misconceptions

One of the biggest myths about nephrology is that they spend the whole day in the dialysis clinic. In fact, they do inpatient and outpatient and different types of dialysis.

“Although dialysis is a part of what we do as nephrologists, it's so much more of a wide spectrum than that.”Click To Tweet

Another myth is that there’s nothing you can do for kidney failure. And Derek clarifies that there’s not much to do in terms of preventative medicine. They try to prevent the worsening of chronic kidney disease and optimize their risk factors.

[12:51] What a Day Looks Like in the Nephrology World

Although they have their own patients, they use the dialysis providers to provide the dialysis services such as the nurses, the technicians, and the equipment. There are many different dialysis providers around the country.

As a nephrologist, they have patients at multiple different dialysis centers. Hence, collaboration with these dialysis providers is an important part of their everyday life.

Derek is the medical director of a couple of different dialysis centers. Although he’s not an employee, he contracts through them and oversees the safety of the dialysis center. You also get to have opportunities for joint ventures so you learn a little bit of the business of dialysis as a medical director.

As a private practice nephrologist, he goes to two different large hospitals, contracting with large hospital systems as well as dialysis providers. So you’re actually communicating with a lot of different higher-ups. Although he’s not employed by them, he works with them on a very close, day-to-day basis.

[14:28] Community vs. Academic Setting

'With nephrology and a lot of other specialties, the big first step you have to decide is: do you want to do academics versus community?'Click To Tweet

Derek is working in a hybrid setting. Their community hospital is their academic base. He enjoys teaching. They have residents and pharmacists that round with him and follow him in the office. So Derek loves the teaching aspect of it.

Being in private practice also affords him the opportunity to be his own boss. He wanted to be able to spend the amount of time he wanted to spend with patients. He wanted to make his own. He wanted to practice how he was able to practice. And he’s happy private practice gives him that opportunity.

[15:46] Procedure Potential for Nephrologists

“As a fellow, kidney biopsies and dialysis catheters are the bread and butter as far as procedures.”Click To Tweet

There are subspecialties in nephrology that you can do after a general nephrology fellowship. There’s transplant nephrology, which is managing patients pre and post-transplant. They’re not actually doing the surgical procedure, but managing them pre and post.

There is interventional nephrology as well for those that like to work with their hands. A lot of times they are doing things like Fistulagrams and helping to maintain and develop dialysis accesses. There is also a fellowship in glomerular diseases which isn’t quite as hands-on based.

As a community nephrologist, Derek doesn’t do procedures. But he has a lot of colleagues that still do their own kidney biopsies and catheters. Those are now sort of outsourced to interventional radiology. But you do have the opportunity to do those depending on your interests and your realm of practice once you’ve finished the fellowship.

When asked about the Sherlock Holmes aspect of the field, Derek explains that a lot of times what you don’t have is the full clinical story. You might have bits and pieces and you may have another history that was taken from other doctors. But it really comes down to the history and physical exam.

It’s that detective work where you find out when it started, put it all together, and find out the systemic process behind this disease.

[18:34] The Training Path

After three years of Internal Medicine three years, Derek did one year of chief residency after internal medicine. It was not a mandated thing, but he enjoyed the teaching aspect of it.

A nephrology fellowship is typically two or three years. In the decades past, nephrology was a mandated three-year fellowship. Derek’s was a two-year fellowship and the third year was a research year that a lot of programs still offer and some still mandate.

Clinical nephrology fellowship has transitioned to two years. After that, you have the opportunity to continue to do a subspecialty fellowship if you want to. For instance, transplant nephrology is another year after that.

Derek thinks the chief residency position has followed him throughout his career. He points out that it’s a hot topic employers want to ask about as well as when applying for different board memberships. Derek feels he has grown a lot from that experience within medicine and outside of a clinical setting which has helped him become a well-rounded physician.

[20:50] Taking Calls

Derek explains there are certain emergencies where you need to go into the hospital such as emergent dialysis for critically ill ICU patients, although this doesn’t happen often.

They also have a call schedule kind of built-in with that since they have patients in the hospital on the weekends. They have a weekend coverage as well that he splits between his partner. Another emergency that would warrant him to go in would be severe hyponatremia or low sodium levels.

[22:22] The Future of Kidney Transplants

“Diabetes and hypertension are the number one and two most common causes of kidney disease in this country, and it's only getting worse.”Click To Tweet

Derek emphasizes that the kidneys are one of the more sensitive organs because they can be affected by everything, systemically. Therefore, collaboration with other doctors is really important.

According to Derek, in terms of the supply and demand of kidney transplants, the demand outweighs the supply. And so, he’s really looking forward to some type of bioartificial kidney technology in the next several decades.

[23:47] Thoughts on an Opt-Out System

Derek thinks a lot of patients just don’t know about kidney donation and the whole supply/demand mismatch. There are a lot of philanthropic and empathetic people who would be interested in donating.

Derek even recalls having patients that found their donors through Facebook. And so, there’s a lot more supply out there but it’s about reaching them.

That being said, the idea of changing to an opt-out donation system is an interesting topic and he doesn’t think there would be as much pushback, hopefully.

[25:04] Message to Future Primary Care Physicians

Collaboration is key and Derek thinks that primary care doctors are probably the biggest source of referral. And there’s a wide variety of comfort levels for doctors since while some refer early, others refer late.

And so, it’s nice to let the internal medicine doctors know that you want to be a part of the patient care. It’s nice to let them know that you want to collaborate and work with them considering the complexity of the patients coming in. And so, there needs to be a lot of interdisciplinary care that has to happen. And being able to do that will greatly impact the progression of a patient’s condition.

[26:01] What He Could Have Taught His Younger Self

Derek says that if he had to do it all over again, he still would have chosen the same field. But he could have told his younger self to really learn and understand how important it is to be learning all these things.

“It’s understanding the nuts and bolts of physiology and understanding how things work normally because you need to have a strong understanding of that to be able to fix things when they're broken.”Click To Tweet

[26:51] The Most and Least Liked Things

What he likes most about his specialty is that every day is different and his patients are going to be different every day as well. You’re able to find new issues and new problems and new diseases. And it keeps him on his toes.

The patients are always appreciative and being able to see the difference that you make in the lives of these patients is truly rewarding.

What he likes the least is the on-call weekends because you’re still working weekends and some days are long. documentation is everyone’s least favorite thing as well.

That being said, he does feel like he has a good work-life balance, especially since he has very supportive colleagues.

“You're able to choose the practice environment that goes along with your goals, your values, your lifestyle, and what you're looking for. So you can make it your own.”Click To Tweet

Not every nephrologist is a one-size-fits-all even with private practice. People have different lifestyles and Derek found what best worked for him. And so he encourages others to find the job that best works for them as well.

[29:18] Major Changes Coming to the Field

“We're closer now than we ever were before with bioartificial kidneys and kidney regeneration technology.”Click To Tweet

In terms of technology, Derek is looking forward to the home dialysis services that have completely revolutionized patient care.

They now have real-time flow rates with their home dialysis and they’re able to communicate with their dialysis nurses. They’re able to see their blood pressure in real-time. And that ongoing real-time monitoring has come a long way.

It would be a big way moving forward with patients monitoring their blood pressure, their weight, their labs, titrating, and their diuretics, which avoid hospitalization. Those are short-term technologies that help keep patients out of the hospital.

Nephrology is a very numbers-based field and being able to look at those data all in one place and in real-time is going to be a big push moving forward.

[31:02] Final Words of Wisdom

Derek thinks Nephrology is an increasingly competitive field in that 73% of the fellowship spots are being filled, which is a big difference compared to previous years. And there are so many different things you can do in the field of nephrology, going into those sub-fellowships.

There’s everything from transplants to interventional to glomerular diseases. You can do research and work for dialysis centers and the pharmaceutical side of things.

“It's such a wide spectrum of different things so give it a chance to see its breadth beyond just chronic kidney disease and dialysis. There's really a lot to nephrology.” Click To Tweet

Even if you’re not interested in nephrology, as a career, at least give it enough respect to do an elective or two electives. Even if you hate it, you’re going to have to live with it. That’s why some level of understanding will go a long way, regardless of what specialty you join.