Nephrology and US News and World Report Rankings

 

Traditionally, all fields in medicine had some sort of ranking in US News and World Report. July 2021, Nephrology was removed and was changed to rankings based on " Renal Failure".  What does that even mean?

Traditionally, what consists the score is patient experience, structure, mortality and length of stay and nephrology used to include reputation related to both med and surgical procedures. We don't know what the "kidney failure" consists of when the new rankings were assigned. 

Even the old way of ranking was flawed- as many of us know that when you include surgical procedures- you are not involving other fields like vascular surgery, transplant surgery and perhaps Urology. That is " Kidney care" but not " Nephrology". And " Kidney failure" alone is not nephrology either.

ASN President and ASN timely released a rebuttal and I think this needs to be read by all. This is extremely important. 

https://www.asn-online.org/about/press/releases/ASN_PR_20210727_Hospital_Rankings_S.pdf

The " Kidney Failure" is not a good way to advertise nephrology to patients as most patients see US News World report.  Nephrology is a field that includes quality care in Prevention, Treatment and then Management of AKI. In addition, other hospital acquired disorders such as acid base, hyponatremia and so forth are part of Nephrology. Complex GN cases are not easy to define treatment and are also part of nephrology. Social components are also critical when we discharged ESKD patients and obtaining an outpatient dialysis spot in certain parts of the country is not easy for patients. Lot of key stakeholders are involved in this and length of stay can get affected. 

As pointed out in the rebuttal by ASN, during the initial surge of COVID19 in 2020, many states experienced AKI and dialysis shortages-- how did we all manage this as a community- we can't prevent the AKI in some cases- but how did we manage it.. that is extremely important. As a field in medicine, we really excelled and did our best!

In general, rankings are not good in certain fields that are more as a result of other fields like Nephrology. What I mean is - our AKI cases in general are NOT caused by us- they are either drug induced, sepsis induced, ct surgery induced, contrast induced, etc... So how can the field of Nephrology be responsible for this or the respective program in that hospital. It really is a more complex and more large system issue that needs more collaboration and dedication from other fields in medicine to PREVENT AKI and associated complications. Intrinsic renal causes such as GNs or TMA are a rare entity in a large scheme of things.

In another editorial, the authors say that it is about time we stop ranking hospitals based on their reputation mainly but look at the crucial layers of data within the state. The author suggests that look at the areas in which a hospital performs , measure each of them and give a score set- simple- remove the reputation component and keep it fair.

Perhaps the ranking systems needs consultants to guide them from both academic and community nephrology to help create a rank list -if we still even want to do that. I say we bow out and just focus on providing good care!

Kudos to ASN for saying what is on our mind

10 Years of Nephrology Social Media

10 years and a few months ago, I wrote the first nephronpower post. It was simple and about a historical event in nephrology. My inspiration was the Late Nate Hellman from Renal Fellow Network. What has transpired since then is truly amazing for the field of Nephrology.

Few of us started blogging at National conferences, some of us tweeting like a storm. Finally, the academic community noticed this and soon ASN, NKF and all wanted tweets and blogs of their events. The first landmark paper summarizing some of this was in AJKD in 2011.

Following that, was the birth of AJKDblog or then called eAJKD. This allowed for more collaboration and more social media to flourish in nephrology and leading to the ultimate- Nephmadness ( mastermind game by the Topf Sparks team) in 2013.

After 2013, nothing was stopping nephrology to take the lead in social media.
From NephJC to tweetorials to whatsApp to creation of NSMC-- happening so fast and furious!

Nephrologists quickly stormed the social media world to lead and show how it's done!
In NDT is a brief tutorial for how to be social media savvy.

Academic journals- AJKDBlog
Journal club- NephJC
Well ironed blogs- Renal Fellow Network
Online Successfully run interactive game for over 7 years- Nephmadness
Online academy of educators for future social media wannabees- NSMC
Every fellowship program trying to have a twitter account and social media presence.

What else can you ask for?
All this is summarized in recent issue in Seminars in Nephrology by guest editor Joel Topf and includes all various aspects of the social media
Here is a nice tweetorial by Chan on the entire issue

Seminars in Nephrology has an entire issue devoted to social media in the discipline of nephrology.

The mastermind @kidney_boy highlights the contents here:https://t.co/1XhYQLpEyS pic.twitter.com/OQs757SxmI

— Teresa Chan (@TChanMD) June 20, 2020

Introduction to social media
Tweet or not to tweet
Twitter based journal clubs
Tweetorials
Podcasting
Newsletters
Visual abstracts
Slack
Semi-private Apps ( WhatsApp)
FOAM quality 
NSMC

Congratulation to the nephrology community to being leaders in education via social media in medicine!

HATs off to Nephrology: The various HATs of a nephrologist

As I finished my 2 weeks on consults, I just realized why I love nephrology because it let's me wear various types of HATs

Day 1:- Consult 1: - Minimal Change Disease on kidney biopsy- starting steroids, no secondary cause. Nice GN to start the day ( putting on the GN hat)

Day 2: Consult 3: AKI on CKD in someone with CHF, getting diuresis but serum creatinine rising. Intern says, we stopped diuresis as AKI ensued.  On exam, +JVP, + B lines on our portal lung US exam, Ascites and + LE edema. Dear Intern, please don’t be nephrocentric but continue diuresis as this is renal venous congestion and bingo- 2 days later serum creatinine downtrends. Pre renal success shall we say( putting on the critical care or cardioneph hat)

Day 2: Consult 5: Na of 167, Diabetes Insipidus, bring on the ddavp please!( putting on my electrolyte hat)

Day 3: Consult 3: AKI in someone getting vanco-zosyn combination, rising vancomycin levels and creatinine going from 1mg/dl to 5mg/dl in 3 days. Kidney biopsy confirms ATN/AIN.  That vanco-zosyn combo is becoming lethal to the kidneys. How many drugs can we stop? – NSAIDS, PPIs, Vanco-zosyn. I feel like the medication police!( putting on my AKI hat)

Day 4: Consult 4: Hypomagnesemia severe enough to be admitted 3 times. PPI still on board and FeMg<2%.  Sorry but those PPIs are causing Ulcers for us the Nephrologists!( putting on my electrolyte hat)

Day 5: Consult 5: AKI in a 85 year old with MODs, septic shock and overall poor prognosis. Surprise question asked and dialysis not offered. Palliative care nephrology is important as well. Not every patient is an ideal dialysis candidate( putting on our palliative care nephrology hat)

Day7: Consult 6: Hypercalcemia and an elevated 1,25 vitamin D level- lymphoma, TB or Sarcoid and the only hypercalcemia that responds to steroids!!( putting on the onconephrology hat)

Day 8: Consult 2: AKI with someone with severe AS. Diuresis begins but guiding volume management is a tough decision. Severe AS scares me. Point of care lung US daily assessing for B lines guides management proves to be a great addition to our physical exam.( putting on the ICU nephrology hat)

Day 9: Consult 1: AKI, low platelets, low hemoglobin, rising LDH, down-trending haptoglobin and worsening HTN—bring on the TMA team. From what- virus, systemic disease, complement deficiency, not sure—but oh well onconephrology rocks! ( putting on the onconephrology hat)

Day 10: Consult 1: HTN HTN, HTN severe HTN—adrenal mass, and record high metanephrine levesl- pheochromocytoma in the house!, get the surgeons and endocrine on board( putting on the HTN specialist hat)

Day 11: Consult 2: Hyponatremia 127 but serum osmolality is 290. Hmmmm!! Paraproteins made an appearance and masquerading myeloma- more onconephrology! ( ofcourse this hat comes twice)

Day 12: Consult 3: Acute ESRD, doesn’t want HD--- but would consider acute PD –so urgent start PD done.. The new wave in PD care. Not every patient needs HD, you can in the right environment get urgent start PD and get PD arranged as outpatient- we need to make this mainstream. ( putting on the ESRD hat)

Day 12: Consult 4: AKI and proteinuria in someone with history of SLE. Kidney biopsy shows nodular sclerosis and diabetic nephropathy. No active lupus. Not all kidney biopsies in SLE are lupus nephritis.( putting on the Rheum-Renal hat)

Day 13: Consult 1: AKI, proteinuria - biopsy confirms Post infectious GN, ongoing infection treatment needed. ( putting on the GN hat)

 

Now with the above case listing- wouldn’t you feel so excited. This is why Nephrology is so much fun!! Which other field in medicine allows for so much variety!

In the NEWS: Fake Nephrology Conferences and Journals: Have you have been getting these emails?

Recently, few of us have noticed we get emails inviting us to submit to " Journal .... nephrology.. and .." The best one I got one was " New England Journal of Nephrology". In addition, there are apparently these emails inviting you to be presenting at conferences that sound so real but for few of us who have been in academia- know that they are a money making scam.  What is gained from these conferences? 
Series of these conferences are run by OMICS. They are apparently for many different fields in medicine.  When I clicked on the Nephrology section for the journals, I got this

https://www.omicsonline.org/nephrology-journals.php ( mostly Non nephrology journals)
When clicked on conferences, you get these
http://www.conferenceseries.com/nephrology-meetings 

Now take a look at the locations: Las Vegas, Orlando, Dubai!!
It seems that they are happening for many years. Has anyone gone to these? Based on the NYT article that was recently published, The Federal Trade Commission formally has charged OMICS with deceiving academics and researchers on such publications and fees.

The author in the NYT says nicely at the end and I quote "So it’s not surprising that some academics have chosen to give one another permission to accumulate publication credits on their C.V.’s and spend some of the departmental travel budget on short holidays. Nor is it surprising that some canny operators have now realized that when standards are loose to begin with, there are healthy profits to be made in the gray areas of academe."

Perhaps as a community in Nephrology we need to create a page that lists which of these journals and conferences are FAKE and prevent our colleagues on spending money on these ventures.

Nephrology at crossroads in 2014-2015

Looking back at the year 2014, where do we stand in terms of Nephrology?

                Compared to last year, this year bought a spectrum of kidney diseases to light and the number of articles published in high impact journals was astounding. NEJM and JAMA had great articles from amazing clinical research done this year in Nephrology.  There has been no research done in hyperkalemia in decades, but of recent, 3 top tier articles with 2 new agents in NEJM and JAMA.  And if you look by category- nephrology in NEJM, this year had 13 original articles, up from 10 in 2013. There was significant review articles as well in NEJM this year on various topics.  Simplicity 3 and CORAL trial being some of the major Hypertension highlights but the JNCVIII also made way to affect the world of Nephrology. The science of nephrology is clearly advancing.  Even though some of the trials were negative trials, we know what DOES NOT work and keep trying rather than doing something based on observational data and then finding out it caused harm.  The renal fellow network has a top 10 nephrology story countdown. Go and vote for your top study.  The new allocation system for transplantation is a positive step for clinical patient care in nephrology.

                In the realm of education, Nephmadness 2014 ( brainchild of Topf and Sparks) was well received with much more participation then 2013 version.  Watch out for the upcoming Nephmadness 2015 this upcoming year.

                The NRMP Nephrology match was met with a debacle and many spots going unfilled. ASN has a special report on this.  While this might be a setback for our field, this should not stop us from continuing what we do best – be passionate of nephrology and continue to shower enthusiasm and knowledge about renal disorders for our trainees.  Trainees ultimately have the right to choose the field that they desire to be happy with.  The last thing we want is “just filling the spots” and unhappy fellows in making.  The ASN is planning to create a match Taskforce to help in this matter.  Tejas Desai, creator of NOD has come up with a creative solution that suggests a short term solution of fixing the match process- decreasing the number of fellowship spots. Which programs should do this and which should not is the question and he address that in his proposal… have a look and comment on what you think?

                So as we look into 2015, think positive and let’s create the same magic as we did in 2014 for science in nephrology. Every field has their bumps and so does nephrology. We shall overcome this barrier as a community as well.  Collectively, we need to inspire students, residents at ground level and every institution needs to light this candle. No large society can make this happen. Even if one person at each institution can inspire students and resident, we will make it happen.  This is a collectively call for all academic, and private practice nephrologists who love what they do to shed their experience and passion to trainees.  For those who don’t like what they do- I have no comments but to ask yourself why you went into it for the first place?

Nephrology: Salary and compensation

Salary and compensation myths in Nephrology

There is a misconception that salaries of nephrologists are low.  One needs to look at actual data before making such conclusions.  Salaries of physicians in general are being disturbed by variety of factors that are currently not under our control.  Besides that, here is some data from peer reviewed publications talking about different compensations and comparative earnings.  This first publication by Leigh JP et al looked at life time earnings of medical specialties.

This figure suggests that life time earnings of a nephrologists are not that bad. We are right in the middle and actually close to dermatologists and allergists. For a limited procedural field, we are actually not doing that bad.  

This figure from an  article that had looked at work hours spent less or more than family practice as bench mark and we do spend more time ( hours) but so does some of the other specialties.  But overall, we are not that far off from the center.  So far, to me – nephrology is not looking that bad based on this data( which compiles not just academic but private practices as well). One has to keep in mind that the private practice nephrologists can earn substantially more than academic counterparts. Some of my fellows over the last few years have gone into practice in private settings all around the country and are very satisfied with their compensation. 

A different  study compared mean hourly wages of nephrologists to other fields and general surgery was the bench mark.  Also the table below shows the mean number of hours.

We are right up there after GI and Cards in medical subspecialties. 

I think the three tables from articles in the fairly recent era suggest that myths of poor compensation is exactly what it is- a myth.  

Open access journals: is this the future? Or not?

In terms of high impact journals, nephrology is on the lower end of the impact factor scale compared to our counterparts in hematology/oncology and cardiology.  An emerging option for publishing scientific data is open access journals.  This form of information sharing is beginning to penetrate the publishing/academic world.  While open access allows for all to view the article without paying for fees to the journal- are they offering quality articles? What do nephrologists think about open access journals?

First and foremost, why would an author want their work published in an open access journal?

Many reasons exist:-
 1. Rapid turn-around and availability to the world to view.
 2. The manuscript was rejected by traditional journals.
 3. E xperiment a different form of publishing. 

Are “non” PubMed ‘able journals in nephrology worthy for consideration of academic promotion? For now, it is unclear what “promotion” committees thinks of manuscripts that appears in these journals. 

Let’s take a few of these journals for example:   

Plos One:. Interestingly Plos One has a decent impact factor (4.0 in 2011) and the turnaround time appears to be quick (told to give review back in 10 days). The peer review is still a standard process (i.e. blinding reviews) like any other journal.  Great outlet, popular, PubMed’able – but comes with a cost for publishing in it.  Nephrology papers have been published in these journals. Check out this interesting commentary by an author. Here is Wikipedia’s view on Plos One

F1000 research: This is the newer journal. The concept is interesting. Peer review is open (meaning everyone including the author knows who the reviewer is) and happens after your manuscript is online.  The peer review is open for all to view and comment as well.  Great outlet, novel concept, they state it is PubMed’able (but I could not do it yet)- hopefully it’s coming soon.  How fair can a peer review be if this is open for all to review?  I think it’s very hard when a review is not anonymous to be honest in the review. But let’s see what scientists will think of this journal.  Another downside- cost for publishing in it. Many have voiced their concerns regarding this journal. Here is another one.

The table below I created reviews some common Open access novel journals in nephrology. Be your own judge

Journal Name and Link	Type of Articles	Cost involved?	Pubmed indexed( Y/N)
BMC Nephrology	Original investigations, basic and clinical, case reports, review articles	US $1950 after acceptance	Yes
International Journal of Nephrology	Original research, review articles	US $1000  after acceptance	Yes
International Journal of Nephrology and Renovascular disease	Original( basic and clinical), review, case reports	Cost but no amount disclosed on website	Yes
The Open Urology and Nephrology Journal	Case reports, reviews, images	Not disclosed on website	No
Journal of Nephrology and Therapeutics	Reviews, Original( basic and clinical), case reports	Yes, varied from 900-1300 based on type of article	None I found on pubmed but on their website it says NIH funded studies will be pub med indexed
Nephrology Reviews	Reviews	Yes, 500 Euro	No
Open Journal of Nephrology	Original articles( clinical), reviews, case reports	Yes, US $500	No
Journal of Nephrology and renal transplantation	Reviews, original articles( clinical)	Not disclosed on website	Found one article in 2009 indexed in pubmed, rest not
World Journal of Nephrology and Urology	Case reports, original articles( clinical), letters	Not disclosed upfront on website	No
Clinical Nephrology and Urology Science	Case reports, reviews, original articles( clinical)	US $300	No

A few obvious advantages of open access journals include the free access to scientific papers regardless of affiliation with a subscribing library, lower costs for research in academia and industry, in addition to improved access for the general public and higher citation rates for the author. Here is a view by someone on top nephrology journals.

The major concern is damage to the peer review process. Peer review is extremely important for good science. Eventually a bad paper can be published somewhere, but sometimes good papers can get published in low impact journals as well.  Publishing quality is important and unclear to me how the open access is preserving that.  PLoS and BioMed Centeral journals are regarded well among the open journals.  Hoax papers have been published in some open access journals. A list of questionable open access journals that promotions committee needs to be worried about have been listed at this website. Wonder if there is one for nephrology. We should likely come up with a list.

Recently, the NY times had done an interesting article on exploitation of scientists for use of such journals that charge significant amount for publishing. At least, the good quality opens mention this up front. Many of the low quality ones later distinguish themselves. Even Nature had a dark side talk on this.

So, you decide what you would do? Would love to hear nephrology community thoughts on this.

Blogging in nephrology: Local versus National conferences

Desai et al show in a study that scientific blogs can be a great tool in sharing and viewing scientific local meetings. Most of the recent literature and live blogging that has been done has been of national meetings. Most non academic practitioners want to hear about the happenings are national meetings. In Nephrology, many online blogging sites have done this in the last 4 years.  The data presented here in this manuscript suggests that while the number of viewers were less in local meeting blog posts, the minutes spent and time spent were equally comparable to national blog posts. The authors suggest that this would be a great way to share and use local conference material. Bogoch et al looked at blogging site of intern morning report and had subjective rating scales but knowledge content was not looked at. 

Overall,this manuscript is a step in the right direction and allows for openness of presentation of data in national and local conferences via blogging. Both conferences can be equally useful to the learner.  

Interestingly, publishing in formats as such( F1000 research journal) when peer review is also open and allows for free commenting before completely being accepted for publishing allows for more information to be discussed and an open dialogue. More and more journals should be moving to such platforms of publishing( at least partly). There might be red tape and other factors preventing this. The Plos Journals are a great example of the futuristic journal platform. Cost, and potential bias based reviews might be reasons why this might be not as attractive to many journal editors. 

CJASN eJC: September discussion

CJASN's eJC is discussing an important topic regarding nephrology fellows. Please go comment and share your thoughts on the recent article on career choice and satisfaction of nephrology fellows in the Sept issue of CJASN. Use your ASN log in and password to get to the discussion board.

http://ejc.cjasn.org/phpBB3/

Nephrology education: Where do we stand?

Nephrology is facing a workforce shortage. Desai et al  have estimated this via a prediction model as well and confirmed the ASN predictions.  While we are trying to tackle the workforce matters, are we watching out for our renal fellows in training? The nephrology fellowship format hasn't changed much in many years. Satisfaction of our fellows might be perceived to be optimal but is it? A recent study published in CJASN by our group shows otherwise. While good amount of fellows are satisfied, fair amount are not.  While we keep increasing interest in nephrology among residents and medical students, we have to make sure our own fellows remain satisfied. They are THE NEPHROLOGY representation to the residents and students.

In addition, are our fellows getting the right amount of inpatient and outpatient experience? Since the inception of nephrology fellowship, lot has changed in the field of nephrology. Now fellows are spread between dialysis, transplant, research and might not have the same amount of time they had to do pure consult months and outpatient experience as previously perceived.  A recent editorial in AJKD proposes a novel format. Are fellows willing to change to that format? We would like to hear from the fellows about this.
Novel ways to teach our fellows is required. Using e learning or other means, try utilizing these in your institutions.

While our fellowship possibly get re examined, medical residents rotations might need changes as well. A study by us published in AJKD compared a combined inpatient and outpatient rotation to pure inpatient rotations and the residents knowledge and perception of nephrology was improved with the combined rotation. Larger more robust studies might be needed to prove this.

International Nephrology Education Foundation(INEF)

The international nephrology education foundation or INEF was founded in 2010 by Dr. Meguid El Nahas from United Kingdom.  Its a charitable foundation to fund and support training, education and leadership in Nephrology and Medicine in emerging countries.

It is the same leadership as for the Global Kidney Academy website.  Have a look at this excellent resource for many.

http://www.inef.co.uk/index.html

2009: The first few Nephronpower posts

As the year ends: And we mark the 2 years of completion of this academic renal blog
Lets take a look at what were one of the first few posts on this blog
http://www.nephronpower.com/2009_12_01_archive.html

eAJKD : Nephrology and the Internet

Check out the new post on eAJKD blog regarding Nephrologists and the Internet

http://ajkdblog.org/2011/11/15/the-nephrologists-and-the-internet/

E Journal Club:- CJASN feature

CJASN is doing live journal clubs or e journal clubs of the articles published in CJASN.

Take a look at this new and innovative feaure

http://ejc.cjasn.org/phpBB3/

eAJKD, the official blog of AJKD

I would like to introduce to the blogsphere:- eAJKD: the official blog of American Journal of Kidney Diseases.
http://ajkdblog.org/

The American Journal of Kidney Diseases (AJKD) is the official journal of the National Kidney Foundation and is recognized worldwide as a leading clinical kidney journal. AJKD is pleased to now offer eAJKD, the official blog of the journal. A central goal ofeAJKD is to highlight selected journal content in an engaging, timely format.  The blog will have interviews with authors, educational material, as well as podcasts and video. We are looking forward to bringing AJKD into the future and offering engaging new means for authors and readers alike to interact with the journal!

It's also a landmark as this is the first time all prominent Nephrology bloggers or e-nephrologists are uniting for a single mission:- Education and sharing of knowledge. Please welcome: Matt Sparks, Tejas Desai, Vinay Nair, Joel Topf, Sidharth Sethi, Kellie Calderon and Jordan Weinstein to this. 

Come visit us all at the eAJKD and we shall show you many new things in the coming months.

ASN Abstracts 2011 online

ASN 2011 abstracts are now online live at
http://www.asn-online.org/education_and_meetings/kidneyweek/archives/KW11Abstracts.pdf

Check out the google page of ASN as well

http://www.google.com/reader/shared/06308306117959986613?c=CM_W4__Z9KsC