Tag: teaching

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Links to useful podcasts for residents and students rotating on nephrology

Michael Eastman sent me this list of podcasts. He send out an e-mail to residents at the beginning of a nephrology rotation so that residents and students can use their windshield time to brush up their nephrology skills.


Hi all:

I wanted to pass along a compilation of nephrology-related podcasts that I’ve been sharing with the residents.  I find them quite entertaining (and educational!).  Feel free to listen or share with the residents as well, since I usually don’t come on service until halfway through their rotation.  All are quite good.  My favorites are the ones on hyperkalemia and hyponatremia.  The ones on dialysis and transplant are also very good.  Finally, check out all 3 of the links at the bottom from the EMCrit website.

#2: Are You Treating Hypertension Adequately? Discussing the Implications of SPRINT.  

#20: Hypertensive urgency and severe hypertension  

#31: Diuretics, leg cramps, and resistant hypertension with The Salt Whisperer  

or:  Diuretics, leg cramps, and resistant hypertension (Reboot)

#39: Secondary hypertension, hyperaldosteronism, Cushing’s, and pheochromocytoma 

#48: Hyponatremia Deconstructed

Or: REBOOT #48 Hyponatremia Deconstructed

#61: Vasculitis and Giant-Cell Arteritis: ‘Rheum’ for improvement 

#65: Scott Weingart of EMCrit on Emergency versus Internal Medicine: The Devil of the Gaps

#67: Chronic Kidney Disease Pearls with @kidney_boy, Joel Topf

#69: CKD Prescribing Do’s and Don’ts with @kidney_boy, Joel Topf

#77: Hypertension Guidelines Showdown

#87: Toxicology 101: Talking Tox with The Dantastic Mr. Tox & Howard

#88: Acid base, boy bands, and grandfather clocks with Joel Topf MD

#104: Renal tubular acidosis with Kidney Boy, Joel Topf MD

#108: Point-of-care Ultrasound for the Internist

or:  Reboot #108 POCUS: Point-of-care Ultrasound for the Internist

#137 Hyperkalemia Master Class with Joel Topf MD

or:  REBOOT: Hyperkalemia Master Class with Joel Topf MD – #137

#143 NephMadness: Fluid Wars

#144 NephMadness: Inpatient Hypertension

#145 NephMadness: Hepatorenal Syndrome vs AKI 

#146 NephMadness: Pain Meds in Chronic Kidney Disease 

#150 HFpEF Update with Dr Clyde Yancy MD

 #170 Hypernatremia is Easy with Joel Topf MD

#192 Dialysis for the Internist with Joel Topf MD 

#199 NephMadness: Hyperkalemia, Diet, K+ Binders, Exercise

#204 NephMadness 2020: SGLT2 Inhibitors

#210 Kidney Transplant for the Internist

#226 Kidney Boy on Acute Kidney Injury: Myths & Musings

#230 Kittleson Rules Acute Heart Failure

#250 Nephritic/Nephrotic

Other podcast episodes which you may enjoy while on your nephrology rotation:

Hyponatremia w/ Kidney Boy:   https://emcrit.org/emcrit/ed-nephrology/

Right heart failure w/ Sara Crager:  https://emcrit.org/emcrit/right-heart-sara-crager/

Central Line pro tips:  https://www.youtube.com/watch?v=XUjncj6ybak

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hypokalemia and metabolic alkalosis

A few years ago I was talking one of my mentors at Kidney Week, John Asplin. He mentioned

that he taught an integrated lecture on metabolic alkalosis and hypokalemia. I thought this was an inspired idea.

Teaching separate classes on both subjects results in a lot of overlap because the renal mechanisms for both disease are the same, this means that many of the diseases that cause one, also cause the other.

Additionally hypokalemia can cause metabolic alkalosis and metabolic alkalosis can cause hypokalemia, so it makes sense to teach both of these conditions in an integrated lecture.

Lastly, teaching each electrolyte individually in isolation from each other is a missed opportunity. One can only appreciate the beauty of electrolyte physiology when one understands how each electrolyte fits together and how abnormalities in one is associated and affects all of the other electrolytes.

Unfortunately, I botched the lecture. I gave this lecture for the first time for the Oakland University Beaumont Medical School this past August. I knew it didn’t go too well, but this week I received the class feedback. Overall my statistical evaluations were excellent but when I read the comments the students were jackals. They savaged this lecture.

Timing was on my side, I was scheduled to give this lecture the day after I received feedback. I’m not done tweaking it but what I did for my Tuesday lecture was add more connective tissue between the concepts, and fill in with some additional summary slides.

Right now, I’m using it as a lecture to follow-up my potassium lecture, but at OU the students didn’t have any baseline potassium knowledge. In order for this lecture to work the students must already understand the basics of potassium, especially the central role that renal potassium handling has in potassium homeostasis. Hopefully I will be able to negotiate another hour into the GU schedule for this lecture.

My next plans for this lecture is to cut out a lot of the opening slides. The purpose of those slides is to quickly move from introducing potassium and hypokalemia to getting to the truth that hypokalemia is almost solely a disease of increased renal losses.

I want to add a slide about disease opposites:

  • Pseodohypoaldosteronism type 1 and Liddle syndrome
  • Godon’s syndrome and gittleman’s syndrome
  • Adrenal insufficiency and AME

I want to add some slides on how hypokalemia causes (specifically, maintanes) metabolic alkalosis and then how metabolic alkalosis causes hypokalemia.

Here is the lecture (Keynote version | PDF)

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Blogging as an academic endeavor

From Skeptical Scalpel (twitter)

Since I dropped out of the business of training residents, I have been actively blogging and not cranking out mindless publishable research. Here is an interesting fact. I have no doubt that far more people have read what I have written in my blog for a year and a half than ever read all of my 95 published works combined.

Sing it brother! It takes me about a hundred hours to prepare a de-novo talk for grand rounds. I will then deliver it to an cohort of 50-80 docs with a collective GCS of 10. After the last audience question the lecture video will be filed in the medical library never to be found again. The lecture is not searchable or discoverable and the work is largely lost.

An average post at PBFluids will get more views than the grand rounds in the first few days and if it is linked by RenalWeb other aggregator it will get enough page views to fill one of the great conference halls of the national meetings. After the first week the post continues to be an eternal flame of searchable and discoverable data. To me the relative impact tips way toward blogging as a more significant form of academic communication but to the powers that grant career advancement it is a meaningless toy.

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Dogs, squirrels and evolution

This is my dog Bo.
Bo is a Woodle. I wanted to name him Chewbacca.


He loves to chase squirrels.
On google image search the top suggested related-search for squirrels is squirrels with guns

He was chasing squirrels all over my neighbor’s lawn, much to the delight of the 6-year old twins that live there. I proceeded to tell them the story of the only time Bo caught a squirrel.

I was jogging with Bo and he saw a squirrel. He chased the rodent for 10 feet until the squirrel climbed a tree. Bo looked up the tree and tried to jump a few times but the squirrel was too high. I told Bo that maybe he’d catch the next squirrel and we started to run down the block. Then the squirrel fell out of the tree and landed right in front of Bo. Well, Bo grabbed that Squirrel in his jaws and killed it faster than you could say “rabies shot.” It happened so fast all I could remember was the sound of his little lungs being punctured by Bo’s teeth. (Six year olds love the gory details. Bilateral pneumothorax, gotta be a quick way to die.)

Then I asked the twins, do you think that squirrel was a good climber?

They answered, “No.”

Do you think that squirrel’s babies would be good climbers?

They answered, “No.”

Do you think that squirrel is going to have any more babies?

They answered, “No.”

That’s why squirrels are so good at climbing trees. The ones that are bad at climbing, die and can’t have babies. We call that evolution.

And I call that a teachable moment.

Come on America, Its not that hard.

Gallup Poll Feb 2009

Level of support for evolution from wikipedia

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Crazy idea or genius? Nephrology Merit Badges

I want to create a series of buttons to give to residents and students to mark achievements in nephrology.

My birthday is coming up, looking at the 1 inch beginner button system

One of the common resident complaints regarding nephrology is that it’s too hard. The nephrologist response to this complaint  is usually to deny the difficulty, because its not hard for the nephrologist. Perhaps that denial is counterproductive, first it’s hard to disrupt a widely held belief that is continually reinforced by the community of medicine, secondly when you deny the difficulty you insult the intelligence of the student struggling with new concepts. Its essentially saying, “Hard? differentiating among the pulmonary renal syndromes is easy, what are you stupid?”

Instead of denying the difficulty we should re-frame the meme. Yes, nephrology is hard and look how cool it is that you mastered these concepts.

Merit badges, or pieces of flare as my fellow interjected, would add levity and encourage residents to tackle deeper concepts.


Potential nephrology merit badges:
  • It’s the heart, no it’s the kidney, no it’s the heart, no it’s the kidney…: diagnose and successfully treat a case of cardiorenal syndrome
  • ABG guru: interpret ABGs showing all four primary acid-base disturbances
  • Quinton: insert a temporary dialysis access to provide emergency dialysis access
  • Tissue is the Issue: perform a renal biopsy
  • Look Closely: correctly interpret a urine microscopy specimen
  • K/DOQI Genius  : use the K/DOQI guidelines to craft a plan of care for a CKD patient
  • RIFLEry: use the rifle criteria to correctly stage a case of AKI
  • RTA (pronounced like Fonzie would RTAAAAAA!): use urinary anion gap and other clues to correctly diagnose and classify an RTA
  • Bud Rose: use free water clearance to draw meaningful conclusions about hypo- or hypernatremia
  • Put on your Helmut (Rennke): be a star in the pathology room
  • Gerry Appel: exceptional management of nephrotic syndrome
  • Ron Falk: diagnose and manage a patient with ANCA-associated vasculitis
  • The Town Schrier: Use FENa, FEUrea and BUN:Cr ratio in a meaningful way to diagnose a subtle case of pre-renal azotemia
  • Mark Halperin: Master of the Cortical Collecting Duct: use the TTKG equation intelligently to help in the management of a patient
  • Wisdom of Solomon: prevent a case of contrast nephropathy
  • Cry me a river: for expertise in the use of high dose diuretics
  • EPA Super Fund Site: use dialysis to correct uremia in AKI
Suggested merit badges from other creative nephrologists:
  • Way to Go KDIGO: use the KDIGO guidelines to do what ever you want to your dialysis patient 
  • Golden Pocket: Forgetting to tighten the cap on the urine that you are bringing back to the lab to spin
Thanks to Steve Rankin and Edgar Lerma
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I love the smell of July 1st in the morning

As has been the tradition since 2008, I had the honor of giving the morning report on July 1st for the St John Hospital and Medical Center Internal Medicine Residency Program. July one, openning day of the academic year. The conference room was crackling with the energy of fresh interns and the equally excited second years ready to run their own teams.

Giving the lecture was a lot of fun. There were a lot of insightful questions, some because the questioner is terrified and others to show how smart she is. Nobody looked sleep deprived, so the ratio of deer-in-the-headlights to asleep-at-their-desk was unnaturally high.

The lecture covered three topics:

  1. total body water and how to choose an IV fluid
  2. diuretics
  3. dysnatremia
There is no way I could get through the deck in the 50 minutes of time we had. It probably would take 90 minutes to cover it all. In delivering the talk I focused on the mood of starting this great adventure.
Here are some tips to using this presentation:
The first slide has Munch’s Skrik, which I explain translates as July 1st

Slide 4 has my favorite quote about kidney function. Homer Smith essentially uses 150 words to explain the point that the job of the kidneys is not to make urine anymore than the job of a factory is to make smoke.

The lungs serve to maintain the composition of the extra-cellular fluid with respect to oxygen and carbon dioxide, and with this their duty ends. The responsibility for maintaining the composition of this fluid in respect to other constituents devolves on the kidneys. It is no exaggeration to say that the composition of the body fluids is determined not by what the mouth takes in but what the kidneys keep: they are the master chemists of our internal environment. Which, so to speak, they manufacture in reverse by working it over some fifteen times a day. When among other duties, they excrete the ashes of our body fires, or remove from the blood the infinite variety of foreign substances that are constantly being absorbed from our indiscriminate gastrointestinal tracts, these excretory operations are incidental to the major task of keeping our internal environments in the ideal, balanced state.  

Slides 5-9 emphasize that this topic is not a niche topic, the issues of fluids and electrolytes comes up everyday, on every patient.

Slide 11, warn everyone that the unfortunate person who gains 30 kg in this slide is a medicine resident gorging on donuts at morning report.

Slide 18, remind everyone that LR is for surgeons. Deny any knowledge of the reason for this peculiarity. Explain that this is further evidence that they are an alien species unrelated to hard working, honest IM docs.

Slide 27 Explain that the question, “Would you give a drowning man a glass of water?” was taught to me by one of the most foul-mouthed senior residents when I was an intern. I want to show that the lessons learned this year will be the stories you tell interns decades later. Interns will learn more this year than any other year of their life, except their first year of life.

Slide 29 recommend everyone read House of God. 

Here is the lecture in PDF and Powerpoint

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Not “Death by PowerPoint” but “Death Star by PowerPoint”

I love this scene in Star Wars because it is pretty rare in movies to see a formal lecture. The presenter, General Dodonna, knocks it out of the park.

What if the Dodonna used Powerpoint?

Garr Reynolds from Presentation Zen deconstructs Dodonna’s presentation style and compares it with contemporary powerpoint presentations. FYI, anyone who wants to do a better job creating and delivering presentations should be reading Presentation Zen.

Here is a movie with the same idea from YTMND: