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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 .
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.
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.
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.
Get connected with Dr. Joel Topf on Twitter @kidney_boy.
Shoot me an email at firstname.lastname@example.org