Medical Specialties - Renal Medicine (20 Mar 2024)

SPEAKER_00 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal with live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. Today I'm joined by Dr. Hannah Preston, who is also on the committee, and we will be talking about renal medicine. So Hannah, welcome.

SPEAKER_01 0:55

Thank you. Thank you for having me. It's well interesting to be on the other side for once.

SPEAKER_00 1:00

Yeah, I guess we've done this before, but now a slightly different way of doing it, slightly different topic. So you're obviously a renal registrar based in Scotland, and we just want to go over, you know, kind of how you got there, why you got into it, how other people that may be considering renal medicine can go about it. So let's start with why did you go into renal medicine? So that's a great question.

SPEAKER_01 1:28

And I guess I went into renal medicine for a variety of reasons. Initially, it wasn't a career that I had thought at medical school, FY1, FY2, I wasn't dead set on what I wanted to do. And I think that has then led to kind of why I ended up in renal, because of the variety that it brings within the specialty and the real kind of holistic components that you need to apply because it not only involves just looking after the kidneys, but you think about the patient as a whole, and there are so many other organs involved when a patient comes to renal. And not only do I enjoy the variety, so that would be kind of the disease presentations, manifestations, types of patients that you get, but also you've got that acute nature to it. So we might talk about this more. I did my training in ACCS rather than IMT, and I really like that acute nature of looking after sick patients, and that's certainly present within renal medicine, but you've also got the continuity of care for patients through clinics or dialysis, seeing them through their transplant journey. I think you get the best of both worlds, so I'm going to be biased. And you get to see a real range and variety of patients and the population. So I think it was the breadth of your patient cohort that you have to look after, the acute and chronic nature of it, and also the fact that you rely so much on working within a team and you work with pretty much everybody in the hospital, which is also fantastic. So you definitely need to enjoy teamwork and communication, be that working with your nursing staff, physios, OTs, dietitians, dialysis unit. But then you're also so heavily involved with the transplant surgeons, with the ITU team. You'll be speaking to referral teams from across the hospital, across different hospitals. And I think you just keep up the skill of general medicine as well, which I really enjoy. So yeah, lots of reasons.

SPEAKER_00 3:48

And I guess it wouldn't be right to ask you what a typical day would be like given the whole breadth of things that you can do, which you've just mentioned. So what is a typical week like?

SPEAKER_01 4:01

So a week in the life of a renal reg is totally varied. If you've got a ward day, so when you're not on call, it might be that you are doing a ward round, be that we split ours into three. So you're either on the acute team with patients who are either in our high dependency unit or they've not previously been known to the renal team before, or you might be doing a ward round with our general nephrology patients. So these are patients who are on the ward who are known to our services before, be that with dialysis or chronic kidney disease, or you might be with the transplant team doing a ward round of your transplant patients. Then you might have a clinic in the morning or the afternoon, and that could be a general neprology clinic, it could be a transplant clinic. There are then more kind of specialized clinics that you might either be involved in or get exposure to as other registrar more from a kind of training perspective. So that might be something like vasculitis or polycystic kidneys or stones or metabolic disease. So yeah, you'll have clinics and kind of ward cover. If you're on call, you might have the luxury of just holding the on-call phone, but often you won't. You might be doing a wardround and be on call at the same time. And for us, we take phone calls and referrals from the hospital that we're based in, but also a couple of other peripheral hospitals as well. And the phone is pretty manic. It's certainly not a kind of once-a-day it will ring. It can be constant from the time you pick it up to the time you hand it over. And that will be a mixture of people that you need to go and see in person within your own hospital. So be that in the acute receiving unit or AE or other wards, or it might be things that you can deal with just over the phone, giving advice. It can also include for us GPs and community referral teams as well. So that's the on-call side of things. And we do both day on calls and night on calls as well. They're probably the main components of the days you might need to put lines in, so temporary dialysis lines in some hospitals. The renal team will do renal biopsies themselves. For us in our hospital, it's done by the interventional radiologists. And then there'll be various MBT meetings, transplant listing meetings, dialysis and periconeal dialysis meetings. So that's really, really varied. And each week is different, which I think is what makes it probably so enjoyable.

SPEAKER_00 6:36

And you mentioned the on calls and how busy they are. Am I right in thinking that renal is a group one specialty, which means you would need to dual a credit with general medicine? Yeah. When you're on call, are you on call for renal or for general medicine, or does it just kind of depend what stage of training you're at, which hospital you're at, and so on?

SPEAKER_01 6:57

Yeah, so we do dual a credit, and certainly like general medicine is really important to being a renal physician, I think, because a lot of our patients are very complex, they're comorbid. So I think having that dual accreditation is really useful. I think that it definitely varies hospital to hospital, how you go about that. But us in Edinburgh, when you are on renal, you just do renal. So your on calls will purely be renal, and then you go and do two six-month blocks of pure general medicine within your registrar training period. And you'll be doing general medicine during the day, you'll cover Han at night, so the hospital at night team. But when you're on medicine, you're also covering renal. And that's purely from a service provision rotor perspective. Because whilst you'd love there to be enough trainees to cover the night, when you're on medicine, you're also on renal. But when you're on renal, you're purely on renal.

SPEAKER_00 7:57

Okay, cool. I guess is there a difference between being in a tertiary hospital, though, and a DGH?

SPEAKER_01 8:04

So for us in Edinburgh, and again, this will vary around the country. We do our renal blocks within the tertiary hospital, and our general medicine blocks could be within the tertiary or DGH hospitals. But your night shifts, because you're covering renal, you'll always be pulled to do your nights at the tertiary hospital. But you might not necessarily be there in the day doing medicine, if that makes sense. But that is because you need to be able to cover the renal HDU overnight. That's the way it works for us, certainly. But I'm sure there's variation across the countries.

SPEAKER_00 8:41

Yeah, because I think in my region in England, if you're a renal reg in a tertiary centre, you just cover renal and it's your renal on course. If you're in a DGH, then you might do renal during the day, you might do, you know, referrals and so on, but at night time. And if you're on call, it's general medicine. But you said it's so variable, it depends on where a trainee will work and the system's already set up. And you mentioned a bit about lines, which terrify me. But you also mentioned your background in ACCS. I can only imagine that ACCS actually probably uh gave you confidence with lines and probably more experience than someone coming from IMT. Do you think that you needed that, or actually people thinking of doing it the more traditional route going through IMT would have the support that they need for lines? Or do you think that actually you need to search for other opportunities to get support? And if so, where could people go for that?

SPEAKER_01 9:39

I think that's a really good question. I personally really enjoyed ACCS training, and that was at a time when IMT didn't exist. So it was ACCS or core training. Now, with the IMT training and that you get time in critical care and HDU, that was predominantly where I did learn how to do lines. So you would hopefully gain the same experience. I think as with anything, if you know or think you're going to apply to a specialty that requires a practical skill, then just letting the teams know when you're working with them that actually you'd really love to get involved. Can they let you know when there's something to do? Be that a central line, a dialysis line, an acidic drain, a tap, a chest drain, you know, whatever specialty you want to go into, I think just letting people know when opportunities may arise to get in touch with you and that you're keen not only shows enthusiasm, but also it will help you down the line. I then actually didn't do any lines at all in my IMT3 year. I was in a DGH for the year, doing a year of acute and gen med. So I had to do ACCS and then IMT3, just the way the whole structure had changed. And our HDU in the DGH didn't take central lines. So I actually hadn't done any for the whole of an IMT. So I was reasonably confident at the end of ACCS, um, having done a handle and then done an IMT3. And I think again, it's just being open with the team that you're joining to tell them about your experience. But you could have come from core training and have had no line experience, and it wasn't a requirement to gain entry into registrar level. So people do not expect you, and certainly they do not expect you to be proficient. And these skills are scary. I can't say like I'm a line lover, but there'll always be someone to help you. We have a really good mastery program. So practicing out with the clinical environment to brush up your skills again and just remind yourself in a kind of safe space, I think is absolutely fantastic. And I would definitely recommend that for people if you've had year out, a couple of years out, or actually you just haven't had the opportunity to do a procedure for a wee while. And I know certainly when I come back from maternity leave, I will be going to the mastery program just to refresh things. So utilising those opportunities, I think, but I certainly wouldn't let that cut you off. But I would seek out opportunities where you can. And given that everybody within IMT now has HDU or critical care experience, you would hopefully at least get to see some and be a bit more OFA with them.

SPEAKER_00 12:34

And I think it's that of as soon as you get your reg number, literally over one day, you're all of a sudden a specialty registrar in a specialty that you may never have worked in. Or if you have, you have worked in the specialty but in a completely different capacity. But we put pressure on ourselves that actually, oh, I'm now the renal reg, or I'm now the cardiology reg and I need to know everything. But the safest and most important thing you can do is actually know your limits and remember that your consultants don't expect you to know everything. You've joined that part of the training program, they're expecting you to know nothing and to teach you. And the best thing that you can do for yourself is be aware of your limitations, be aware of what you know and what you don't know, and just say, I want to learn, which I think sometimes we're really bad at realizing that it's okay to not know.

SPEAKER_01 13:22

Yeah, definitely. And I think as you said, you know, you switch from being on the SHO junior rotor, be that even when you're, you know, you're quite a senior IMT or ACCS trainee, and then you go into the registrar rotor and roll. And it's really daunting. I probably felt on edge for the first five or six months. I definitely did. And felt like maybe I was like a duck in water and my feet were paddling really, really, really fast underneath whilst I was trying to maintain this air of calmness. But actually, the consultants expect you to discuss cases that you've had over the phone with them. I would say I probably, if I can, if the patients in the building, see more of the patients than just give advice over the phone, because I think you get so much more from eyeballing a patient. And I think if you use the electronic notes, someone gave me the advice of if you've got a phone referral asking for advice, just say, I'm just gonna have a look through the notes to gather some more information and then I'll either call you back or I'll document it electronically. And that just gives you a bit of breathing space and a bit of time so that you don't feel pressurized to answer a question immediately. You can ask your other registrar colleagues for a bit of advice, certainly if it's around kind of practicalities about how things are done or followed up and stuff, because a lot of that is really tricky to start with. You know what you want to tell them, but it's more about where they're going to be seen, who follows them up, why, etc., which just logistics of the department that you work in, especially if you move for a training number, you know, understanding all of that will come with time. But yeah, don't feel rough to answer a referral question within that phone call. You can write something down or call them back.

SPEAKER_00 15:11

Yeah. I think I got given something similar and it's just kind of stuck with me. And you don't need to answer everything. You don't need to know everything, you need to know what you don't know, basically.

SPEAKER_01 15:21

Yeah, definitely. And I also think from giving advice, if you are on electronic notes, for you to document it yourself on the system, just so that a message that you're trying to convey doesn't get lost in translation and then increase the risk of error, I also think is really useful. Because if you can write down what you want to happen as a plan, it's much more likely to happen than you're trying to explain something over the phone and you're not quite sure whether the person on the other end has all the information. Yeah.

SPEAKER_00 15:50

Yeah. So while we're on the topic of advice, if someone, you know, is thinking about going into renal medicine, what advice would you give them about maybe building their portfolio or you know, how to prepare for following that career?

SPEAKER_01 16:05

Yeah. I would say don't be afraid if you've come to it later on in life. I wanted to do emergency medicine, I liked acute medicine, I liked everything. So as I said earlier, I wasn't kind of gung-ho on being a nephrologist from day one. So my CD to start with wasn't geared for that, but don't worry. Obviously, the application system is quite generic. And I think as long as you show that you've got the skill set which is on the person requirement and you can demonstrate how you can match those skills, then that is completely fine. But you also do need to show a degree of commitment to specialty and enthusiasm. So if you get a renal job within your IMT rotation, ACTS rotation, then amazing, utilize it. That might be where you suddenly decide that this is the career for you. That's how it was for me. And just seize the opportunities that you can within that, show enthusiasm and willingness and make your colleagues aware that you're interested in that specialty. And I think that occurs across the board of regardless of what specialty you want to apply for. You can think about how an audit or a QI project within any area of medicine or surgery can be related to renal. I mean, acute kidney injury and prescribing happens across the board. So those are kind of quite common areas which you could apply to various settings. And then things like attending the Royal College of Edinburgh renal symposium is a really good day. The diabetes and endocrine one often has renal aspects of it as well because they're so closely linked. There's within Scotland, we've got the Scottish Renal Association Conference, which happens in kind of a November of each year. And I think like any specialty application or career, thinking about even if you're in one specialty at the present time or you've been to something, how is that translational? Because a lot of your skills are translational and it doesn't necessarily need to be within that topic. I think if you've got the opportunity to attend mastery programs aligned, then great, do that. That counts. If you can go to other linked areas, I don't know, if you're working in surgery and there's a vascular part, we work really closely with the vascular surgeons, diabetes and endocrine, you know, going down and seeing the dialysis units. Most hospitals have got one. So I think just looking a bit outside the box if you don't have a rotation in the job. And then just getting in touch with registrars within the department and asking them for advice, really like anyone that's in their specialty will be happy to chat about it, give you insight, help you out, will know if there's projects going on that you think they should get involved in, or is there department teaching that you can go to? So I think just going and chatting to people is really useful because people are in their specialty because they enjoy it. So therefore they'll be happy to tell you what's going on and how you can get involved.

SPEAKER_00 19:16

Yeah, definitely. And I know that you've mentioned this quite a bit, but maybe if I ask what do you think are the three most important skills that an aphrologist needs?

SPEAKER_01 19:30

Oh I think communication is massive. I think you need to be able to communicate clearly with the patient, understand their journey, and you're probably going to be seeing them more than just one occasion. So I think communication building up a rapport is really key, and you're probably going to be communicating with wider teams for that patient. So communication is definitely important, I think. Enjoying that detective medicine as well, renal does take up quite a lot of thinking, often kind of outside the box or laterally. So if you enjoy scratching deeper than the surface and thinking about what's going on, why is this going on, then yeah, you've got to enjoy that kind of investigative nature. And I think you need to be able to look after sick patients. Patients will become sick and they can become sick really quickly. So you definitely need to be able to deal with that aspect as well. So I think a lot of our patients are stable, but you will need to be able to deal with sick patients. So having that awareness is key.

SPEAKER_00 20:42

And finally, if you can answer this without having prepared, do you have an interesting case which you could maybe share with us whilst abiding by, you know, the rules of confidentiality? But maybe so that our listeners who perhaps haven't had a lot of experience in renal medicine can kind of get a tiny bit more of a taste?

SPEAKER_01 21:02

Yeah, so I do actually have a case because I'm writing up for a poster at the moment for the SRA. So it's an elderly gentleman who was admitted into AE with quite non-specific symptoms. It was a bit hypotensive, looked a bit dry, was quite radicardic. GCS was maybe like 13, didn't look well. Bloods came back, he's got a severe acute kidney injury. Creasin would say 400 to 500. Potassium was maybe borderline, so he wasn't kind of dangerously hypercholemic. But they looked at his medications, and he'd been done well. I can't remember why. Maybe he had D and B or something or a viral illness, and had continued to take all of his medications. So education around six-day rules is vital within renal medicine, and he'd continue to take everything, which had included digoxin. And it turns out that he had severe dexroxin toxicity. And the AE team were great, and they had done a dexin level and had treated him with dexin-specific antibodies, but he wasn't passing very much urine. And his toxicity symptoms, so the hypotension, bradycardia, reduced GCS, weren't resolving. So they rechecked his levels and his level had rebounded even higher. And within this time, he'd been given a whole load of fluids because he was dry. Trouble was he wasn't passing any urine. So he was then referred to renal when he was in pulmonary edema. Lovely. Because he wasn't passing any urine and he'd kind of tipped over that threshold. His kidneys still obviously weren't working, and he still had symptoms of digoxin toxicity. And digoxin's renally excreted, but interestingly, it's not dialysable, and neither are the digoxin-specific antibodies. So they bind to digoxin and they form complexes, which then normally pass out through the kidneys. But the complexes are too big to be dialysed out because the dialysis membrane allows smaller molecules to pass through. So he needed a dialysis line put in to get some fluid off, really, essentially, whilst we worked out what to do, because actually there aren't any guidelines on how you manage the digoxin toxicity in someone with acute severe renal failure. So we spoke with toxicology, hox based, and we spoke with hematology about using plasma exchange, because plasma exchange allows bigger, complex removals. So there's only been a handful of case reports rather than kind of protocolised guidelines. So the kind of theory was, well, yes, that will work, but it required a little bit of kind of toing and froing about whether it was the right thing to do for him. And he was still asymptomatic from his dejoxin. He had had some fluid removed on dialysis. So he had some hemodialysis with ultrafiltration to take some fluid off to make his breathing more comfortable. And then we decided to go for plasma exchange. So he got given another round of the digoxin-specific antibodies. And then about four hours after that, based on the kind of pharmacological timings, he had plasma exchange. And it was remarkable. His heart rate came up, his blood pressure came up, his GCS improved whilst the plasma exchange was going on. And then over the next couple of days, his renal function started to improve and he didn't need any more dialysis. And his renal function eventually came back to baseline and he was able to be discharged home. Cool story to be a part of. And I think it required kind of all of those skills that I talked about before. So communication with different teams and the patient and the patient's wife. And it required a bit of lateral thinking and kind of some head scratching with various consultants and teams. And then you also needed to be able to look after the sick patient at the forefront of that.

SPEAKER_00 25:11

It highlights how acute renal failure can be and how good dialysis can be. Because probably in our heads, those of us who don't work in renal medicine, dialysis is for your chronic kidney patients, and very rarely do we actually give it for the acute patients, in which case we would just wash our hands with patients and say, okay, it's not my responsibility, it's somebody else's. And I definitely did know that about dejuxin, so I've definitely learned something. So yeah, thank you for that.

SPEAKER_01 25:37

That's right. So that might be a patient who wasn't suitable for long-term chronic dialysis. He was quite old, quite comorbid. Long-term dialysis probably wouldn't have been in his best interest. And again, that's where communication comes in, you know, with discussing with the family. But he had a kind of acute reversible cause. And we knew that his creatinin two weeks ago was 150 and now it was 500 and something. There'd been some kind of acute event which you would hope with time would resolve. So the chat was very much, we're going to try this, it's very invasive. And then we will need to see. And you have to kind of explain to the patient and their family that whilst you might be trying acute dialysis for this patient and it is warranted in this case, actually, it's not a long-term option. And actually, if the kidneys don't get better, then we need to think about the kind of conservative management down that route. So I think it's being very kind of upfront and having those discussions with patients. Obviously, if patients are young and fit and can take it, then actually the acute dialysis may turn into long-term dialysis if they don't recover. And again, those are discussions to be had. But I think it's just about what's the picture in front of me right now? Can we do anything? And that might be yes or no. But then you also do need to think about the longer-term trajectory of the patient too.

SPEAKER_00 26:55

And I guess it's really nice the fact that you have options that you can give, whether they are acute or chronic. And not all specialties have that. And that must be one of the big drivers to picking your specialty. And also something that you have to be aware of that you will have acutely really sick patients, which isn't for everyone. But if you do like it, then that's always a reason to consider renal medicine.

SPEAKER_01 27:17

Yeah, it's a great specialty. And I think if you like Brett's, if you like teamwork, if you like being a thinker, then it's definitely one to consider. Anyone can get in touch if they have any more questions about the application process. I know obviously we've done podcast episodes on the application process, so I would say go and listen to those. But if there's anything a bit more about the kind of specialty stuff specifically, then people can get in touch.

SPEAKER_00 27:44

Perfect. Thank you so much for talking to me, for teaching me things. And thank you to our listeners for listening to us. We hope you found it useful. You can always have a listen to our clinical conversations podcast where we cover more clinical topics, and we hope to see you at one of the events at the college soon. Thank you so much for having me.