Satellite Healthcare is a non-for-profit dialysis company. They partnered with NephJC to do Bloggger’s Night the last three years and sponsor the NephJC Kidneys. This year they launched a Podcast, NephTalk. I was lucky to get invited to help out. I have hosted one, an interview with Sumi Sun about preventing blood stream infections. Here is her abstract from Kidney Week:
Background: CVCs are associated with catheter-related bloodstream infection (BSI) resulting in increased morbidity and mortality. Following our report of significantly reduced infection when 320 μg/mL gentamicin in 4% citrate is used as the CVC locking solution (Moran AJKD 2012), this has remained the standard of care in patients dialyzing with a CVC, unless physician order requested otherwise. The infection rates were monitored through an internal QC program developed for National Healthcare Safety Network (NHSN) reporting.
Methods: This study evaluated NHSN data with self-reported infection rates from January 2014 to December 2016 in a non-profit dialysis provider with a total of 57 free-standing dialysis facilities serving more than 5000 HD patients. BSI was reported according to NHSN criteria. Data were audited through comparison to an internal infection control report and discrepancies reconciled prior to final NHSN submission. Blood cultures were mandated before any antibiotic administration for suspected BSI, and 85% or more are sent to one internal lab (Ascend).
Results: The rate of catheter-related bloodstream infection over the three years was 1.00 episodes/100 patient months, 54% lower than the national average of 2.16 for CVC-related BSI (2014 NHSN BSI Pooled Mean Rate/100 patient-months). Monthly BSI rates showed minor fluctuations, however none exceeded the national average in any given month.
Conclusion: Gentamicin 320 μg/mL in 4% sodium citrate as a routine catheter lock demonstrated sustained low CVC-related BSI rates in HD patients, with approximately half the infection rate compared with the national average. Gentamicin-citrate lock should be considered the standard of care in patients with CVC access.
I was invited by the Curbsiders to talk about CKD. The discussion went a little long and our discussin got divided into two podcasts, #67 and #69. Here is the second half. I don’t think I made any major mistakes except when discussing combined ACEi and ARB therapy I said ALTITUDE was a study of RAAS inhibtion and endothelin antagonists. Actually ALTITUDE was RAASi and Aliskiren, the direct renin antagonist. And it was stopped not because of hyperkalemia but due to a CV signal (though the combination did have more hyperkalemia). The trial I was thinking about was ASCEND which added the endothelin antagonist avosentin to an ACEi or ARB in patients with diabetic nephropathy. This trial was also stopped early, again for CV issues after only 4 months on the drug!
The two year slog from from gleefully saying “Wow, that sounds like fun” to a published book is wrapping up. I am working with Edgar Lerma and Matt Sparks on Nephrology Secrets fourth edition. It is an amazing amount of work.
Yesterday I was proofing a chapter and found a pretty profound error.
Not a typo.
Not a misspelling.
Not an awkward turn of phrase.
This was a hardcore, error-of-fact that would have confused readers that didn’t know better and cause significant loss of authority for the book by the readers that did.
This error had travelled a long and perilous editing river to finally arrive intact at the final page proof.
I don’t know how the authors proofed their own chapter, but I assume it went through multiple drafts and rewrites. Then the chapter was sent to the editors and for Secrets, each editor read and commented on each chapter. After each editor the chapter was sent back to the authors for revision. This rinse, wash, and repeat went through three cycles. One with each editor. Then the text was turned over to Elsevier and they converted it into a book. The publisher returned proofs to the authors with specific questions that came up during the page layout. Another independent set of eyes. And then the authors signed off on the proofs.
And after all of that I found the error. A significant error.
This error came within one-step of being a permanent, written-in-ink error in the book. That chain of revisions and proofs is what makes books as good as they are. What type of checks are there in social media delivered medical education? How do we assure that the lectures and pearls we push through our blogs and tweets do not contain subtle (or not so subtle) errors. Very little social media has anywhere close to the editorial infrastructure that an Elsevier textbook enjoys.
In my post about Kidney Week I received three different DMs and @s notifying me of 3 different typos and misspelling. Fix and move on.
Great article! (but I laughed at the "powerboat" typo)
Typos are easy. There is more embarrassment than ego in those mistakes. Mistakes of content are harder to accept. The instinct is to defend our work, push back against the unsolicited peer reviewer. But we need to keep our ears to the crowd and our minds open so that…
If we are wrong
It is not for long.
Because the strength of social media is using Linus’s Law to uncover mistakes and then it is up to us to put away our egos and make it right.
given enough eyeballs, all bugs are shallow
I really feel the success of FOAMed depends on the crowd notifying authors of mistakes and then the authors fixing those mistakes. A failure on either side of that equation (either side means that if you are reading FOAMed and see a mistake you have an obligation to point it out. Noticing a mistake in medical education material and moving on without notifying the author is like seeing a discarded pistol by the playground and not telling the authorities. That dead seven-year-old is on you) and FOAMed becomes a joke as it morphs into a minefield of crappy, error filled resources.
The NSMC internship was created a few years ago to assure that nephrology had a surplus of dedicated people creating varied, compelling, and creative FOAMed resources. In the early years of Social Medicine, I believed that digital natives would join #NephTwitter and quickly and effortlessly create original content without guidance.
The medical school class of 2016 began high school the same year Facebook was launched. They literally have been using social media for their entire adult life.
However after a few years I became impatient with how fast young doctors were joining #NephTwitter and wanted a way to incubate these digital natives so that they could become contributors quicker.
The Digital Native Myth is the belief that young people will intuitively understand how to contribute to FOAMed.
The 90, 9, 1 rule is that for any social media experience 90% of people just consume, 9% will comment on other people’s content, and only 1% will contribute content. The idea behind the NSMC Internship is to move as many people as possible to the right. We want to move doctors from the 90% to the 1%.
A few weeks ago in New Orleans we graduated our third class of interns.
This class was our largest yet and some of the graduates are already standouts on #NephTwitter.
The interns provide us with detailed feedback to further develop our internship. Based on that feedback we are going to be adding a new module to the curriculum to teach interns how to build a website as part of a complete social media presence. One of the roles that our graduates have repeatedly been asked to fill, is to develop a social media presence for various projects. This may be for a large study, or an institution like a division or fellowship program. Our feeling is that many programs created twitter handle and that is where they stop. In order to have a real social media presence, Twitter needs to be backed up by by a website and a blog. We are now going to teach our interns how to do that in either WordPress or SquareSpace. Additionally we will teach them how and when to use Medium.
If you look at the blog posts linked in that second post you will see posts written largely from the notes created and archived on Twitter. For a more contemporary example take a look at the post I wrote about the late breaking and high impact trials at this year’s Kidney Week. This post uses the Tweets written during the session to tell the story of the session. I think it does a far better job of conveying the mood of the audience during the session than other posts about the session that I have read.
My other post for KidneyWk (#KidneyWk: Serum and Dialysate Electrolytes and the Risk of Sudden Cardiac Death) was also based on tweets but since there were fewer tweeters in the audience the post relies on their voice less and reads like a more traditional post. But don’t be fooled, it was also largely a product of the notes I took as a damned live tweeter.
Painting faced an existential crisis with the invention of photography. The platonic ideal of making a picture that fully represented reality was made meaningless by the invention of photography. The goal of painting pivoted from realism to impressionism, surrealism and subsequent movements. Painting faced its crisis by changing the definition of what it strived for. And to be clear artists that spent their career mastering realism didn’t covert to the new movement. New artists came along to fill the niche that had growth and potential despite photography.
Medical education is facing a change in the way students digest information.
Go to a pre-clinical lecture at any medical school in the US and you can find yourself a seat. It doesn’t matter the size of the lecture hall or the size of the med school class, students don’t go to class. Lectures are videotaped and streamed. Students gravitate to the most efficient way for them to learn and surprise, it is not sitting in lectures watching slideshows. If the students likes slide shows they will watch it at double speed with the PowerPoint open in front of them, available for them to make notes. This is nothing like the lectures I attended in med school.
Slideshows are tired, shallow, and inefficient. Students are routing around them. Good for them. I love that students are finding ways to learn in ways most efficient to each individual’s mind.
ASN’s problem is that Kidney Week is slideshow-learning. Selling slideshow-learning to millenials who don’t go to slideshows even when they paid tens of thouands of dollars is going to be like selling sand in the Mojave.
ASN has to make like 19th-century painting and pivot to a different platonic ideal.
What do I mean?
I mean a Shark Tank with real money on the line
Cytology Shark Tank has started. Four sharks. Three fish. One winner. The prize? A $50,000 research grant from the ASC Foundation! #ASCyto17pic.twitter.com/OYkTB0rfXI
I mean an American Idol-like competition for the best educational lectures.
Have educators around the country compete to make the best lecture on the same subject. Have them compete with the finals at Kidney Week. Rotate the subject every year, but make it a fundamental lecture that everyone needs to give:
Acid-base
Hyponatremia
CKD
AKI
Dialysis for the internist
Pathology lecture that uses microscopes rather than slides
Simulations
Biopsy training with cadavers
Ultrasound training with patients
A recreational run
With pre- and post- sodium levels and AKI biomarkers
Cooking classes
Panel discussions with patients
ASN is using a fifty year old model of what makes a medical meeting and if they don’t adapt there will be fewer and fewer, and older and older, people attending. The ER and critical care crew have layed the blue print with SMACC, nephrology should be the first specialty to follow it down the rabbit hole.
Saturday November 4, 2017 I accepted the Robert Narins Award from the ASN. This is the highest honor I could ever receive for the work that I have done in medical education.
Here is how ASN describes the award:
The Robert G. Narins Award honors individuals who have made substantial and meritorious contributions in education and teaching. This award is named for Robert G. Narins, who is also the first recipient of the award.
Dr. Narins’ contributions to education and teaching started in 1967 when he was appointed to the faculty of the University of Pennsylvania. At Penn, and on the faculties of UCLA, Harvard, Temple and Henry Ford Hospital, he taught and mentored many residents and fellows. For eight years he chaired the ABIM’s Nephrology Board and also worked on the ACP’s Annual Program Committee. His contributions to education in the fields of fluid-electrolyte and acid-base physiology are prodigious and well-recognized.
Dr. Narins was also involved in the creation and planning of many ASN educational programs during Renal Week and throughout the year, including: Board Review Course and Update, one and two day programs at Renal Week, Renal WeekEnds, and NephSAP. He also was instrumental in the decision to develop the Clinical Journal of the American Society of Nephrology (CJASN), the establishment of the Fellow of the American Society of Nephrology (FASN) program, and negotiated the successful partnership agreements with HDCN and UpToDate. Dr. Narins has been at the forefront of collaborative efforts with the American College of Physicians to increase the exposure of nephrologists to relevant updates in Internal Medicine and internists to chronic kidney disease. Collaborative educational programs with societies in Europe and Asia have helped to spread education and teaching in nephrology on a global scale.
To be recognized for this is amazing. I feel that social media and internet-based, distributed learning that leverages the skills and perspective of a large group of self-appointed experts is, and will, continue to swamp the old model of a few, highly selected, experts.
In many ways, the reality of internet distributed medical education is the opposite of what people believed it would represent. I remember hearing people speak about the best lecturers being able to distribute their wisdom to the world through IP switching. The conventional wisdom was that the internet would allow all medical students to learn from the best teachers. The internet would eliminate location and size limits of the lecture hall so we would all get the Harvard education.
Social media altered that future.
Instead of one vision being distributed to a million impressionable minds we got a million visions being distributed so that each mind could find the one that worked for them.
We are in the midst of a massive democratization of medical media.
Social media in medical education is moving us from broadcast video to YouTube, from radio and audio books to podcasts, from books and journals to blogs and tweets, from a few highly selected authority figures to a large number of educator hobbyists.
And I am just a participant in this. I am an early adopter. I am at the front of the wave. However, I didn’t create the wave, and I can’t control it; I’m merely surfing the leading edge. And I believe ASN recognizes that. I believe that the ASN awarded me the Narins award as a symbol that distributed, social media-powered-learning, is now a valid and growing part of primary and continuing medical education. ASN is among the first of the medical societies to recognize this. I salute ASN for resisting the urge to circle the wagons and fight the inevitable. ASN should be commended for recognizing and embracing this new epoch in medical education.
That said, as much as I believe I was a just a symbol of the revolution that I am part of, they did pick me to be that symbol and for that I am grateful. And I would like to thank the people that have brought me on this journey.
True story. I didn’t know there was a thank-you speech for the Narins award until 10 minutes before the morning session started #KidneyWkpic.twitter.com/AacOLqCPwv
That tweet is totally true. And in the rush to compose a coherent thank-you speech in my adrenalin addled brain I glossed over and missed some essential people.
The Patron Saint
Burton D. Rose. My favorite part of the Narins Award Legacy Video is when Rose says that Robert Narins brought fluid and electrolyte and acid-base teaching into the mainstream (1:35) and set the path for him.
I love this because Rose set the path for me, in two ways.
One: Rose’s Clinical Physiology of Acid-Base and Electrolyte Disorders was the bible that taught me renal physiology and inspired me to pursue a career in nephrology. I bought it during my third year of medical school when I told the intern that I was working with that I was confused by eletrolytes. He suggested this book. Talk about a bad answer to a small question. I wanted a 5-minute lecture on what fluid to order and my senior suggested a 916 page, $70 tome.
But I was an idiot and I bought it.
And though it sat on my shelf for a year before I started it, when I began, I could barely put it down. I truly believe that one can draw a direct line from that terrible advice given to me at the Allen Park VA in 1993 to my position today. Sometimes bad advice can lead to the greatest of outcomes.
Rose’s book is a masterpiece because it strives to make the reader build a robust mental model of how the kidney works. Once that model is complete, it becomes easy to understand all of the electrolyte disorders.
Two: When I was an intern I was telling a doctor how much I loved Rose’s yellow electrolyte book and he told me to look him up in PubMed. I had previously looked up Berl and Schrier and I expected much of the same, but this is what I got:
Seven. Seven articles in pubmed by the great Bud Rose. The man that has done more for medical education and patient care than anybody since Osler (based on his work with UpToDate) had seven articles in PubMed in 1996. Go ahead, see for yourself. This convinced me that I could be a medical educator without being a medical researcher. I could pursue what I loved, without being distracted doing what I had little interest in doing.
The Inspiration
Joshua Schwimmer. Josh was the first nephrology blogger. I had been a long time reader for years before following his trail and starting Precious Bodily Fluids. And after a few months, Joshua gave me my first link and turned the microphone on. Thanks Josh.
The Collaborators
PBFluids and @Kidney_Boy stand apart as the only signifigant projects I have done alone. Everything else of significance has been done with a collaborator, co-author, or co-creator. This is an indisputable case of “I couldn’t have done it alone.”
Sarah Faubel as a co-author on the Microbiology Companion and The Fluid Electrolyte and Acid Base Companion
Joel Smith as co-creator of Alert and Oriented Publishing
#NephTwitter is a colorful and engaging place with an always on conversation anchored by people around the world. Here are a few of the people that populate that community.
Tom Oates, Roger Rodby, Paul Phelan, Michelle Rheault, Francesco Iannuzzella, Hector Madariaga, Graham Abra, Nikhil Shah, Matt Graham-Brown, Ian Logan, Scherly Leon, Dearbhla Kelly, Silvi Shah, David Goldfarb, Richard McCrory, F. Perry Wilson, Raymond Hsu, Benjamin Stewart, Brian Stotter.
The Enablers
My partners at St Clair Specialty have been involuntary partners on this journey and have been great. St Clair Specialty is a practice that values people that contribute to nephrology. This was clear from past CEO, Robert Provenzano, who was a major contributor to nephrology as a scientist and president of the RPA. And it is also clear with Keith Bellovich, RPA board member and chief of nephrology at St John Hospital and Medical Center. At a more single minded-practice, I could not have contributed to nephrology education as I have.
And lastly, and most importantly, I could never have contributed to medical education without my family. I need to thank the eternal patience and understanding of my wife, Cathy, and my kids, Laura and Simon Topf. Thank-you.
If you have been annoyed at all of the broken links at PBFluids. My apologies. Blogger doesn’t host any files so to use them you need to host elsewhere. For this reason alone I recommend WordPress or SquareSpace for people who want to start blogging.
Tonight I fixed the Handouts tab. A few weeks ago I fixed the Books tab. All of those links now work. Next up: the Lectures tab.
Question: Should old lectures that may contain out of date material be taken down, or remain up?
The medical school class of 2016 began high school the same year Facebook was launched. They literally have been using social media for their entire adult life.
