Blog — NephJC

The thing that gets us to the thing...

Matt and I wrote a wrap-up post for NephMadness that went up on MedScape today. Please go read it. In it we explain what we are trying to do with the various social media events and projects we promote for nephrology:

“We have established an informal curriculum of digital mentorship. The goal is to provide a vibrant community of always-available, academically minded nephrologists who are interested in sharing their skills, knowledge, and wisdom. Most of these conversations are spontaneous. Examples include recent discussions on the relationship between sodium linked glucose transporter-2 (SGLT2) inhibitors (a new drug for the treatment of diabetes) and diabetic ketoacidosis and another about whether one should stop antiplatelet agents before kidney biopsy. The tweets were a mixture of references, pithy bits of insight, images from primary sources, and opinions.”

NephJC and NephMadness are stepping stones to this always available online community. They are important for setting the tone and attracting people who share our vision and academic values. But in the end, NephJC isn't the thing it is just the means of getting to the ultimate goal of a viable, self-perpetuating, professional network, of academically-minded, nephrologists particiapating in social media. I was reminded of this while watching the pilot of Halt and Catch Fire. The plot turns on an old article written by the protagonist, Gordon Clark, where he states that computers aren't the thing, but rather the thing that gets us to the thing.

Being Mortal: Chapter one

Suzanne Norby is a nephrologist and fellowship program director at the Mayo Clinic and recently joined the NephJC advisory board. She wrote the first of our eight (fingers crossed) chapter summaries of Atul Gawande's Being Mortal. 

Chapter one The Independent Self

In the first chapter of his book, Being Mortal – Medicine and What Matters in the End, Atul Gawande begins by introducing the reader to the dissimilar aging experiences of his grandmother-in-law, Alice Hobson, in Alexandria, VA and his own grandfather, Sitawan Gawande, in India.  He then explores several historical and cultural influences affecting how societies view elders and aging.

When Gawande first met his future grandmother-in-law, Alice was a vibrant 73-year-old widow living an active and independent life: residing in her own home, driving her own car, and even regularly going to the gym with a friend.  In contrast, his own grandfather was hard of hearing, walked with a cane, and lived in the home of one of his sons in India. He not only had assistance with activities of daily living but also occupied a place of honor. One fateful day, at age 109, he was traveling with a family member on a bus to take care of some of his own business at a courthouse.  He fell and hit his head, likely suffering a subdural hemorrhage. Several days later, he died at home, surrounded by family, as he would have wanted.

Next, Gawande explains that relationship between older and younger generations has evolved in multiple ways.  First, the exclusive position once held by elders has eroded. Throughout most of history, life expectancy was considerably shorter than it is now.  Those who lived to an advanced age were respected, even revered, for their wisdom, perspective, and knowledge of tradition.  Now, living to advanced age is commonplace. Contemporary means of communication have largely eliminated the need for oral transmission of precious information to the next generation.  Moreover, older people are less likely to embrace the most modern technology, and members of younger generations have become the experts in knowledge transmission, reducing the relative importance of elders.

In addition, older people no longer remain as heads of households, providing a basis for family stability until their death. Children follow their own paths, move out of the family home, secure their own property, and become economically independent. They don’t depend on inheriting parents’ money and property to sustain their own families.  At the same time, this phenomenon also has brought financial freedom to aging parents, along with the concept of enjoying retirement.  Gawande notes that “intimacy at a distance” occurs when elderly people have financial means of their own and can choose not to live with their children after they are no longer working.  The percentage of elderly people living alone is increasing not only in the U.S. but also in countries in which it had been previously regarded as “shameful” when an elderly parent is left to live alone.  In fact, he points out that it has become “acceptable and feasible” for elderly people, such as his grandmother-in-law Alice, to live autonomously.  Generational power differences have shifted, allowing both parents and children to have more freedom and control.  Rather than valuing elders or even the younger generations, society’s ideal has become the “independent self.”

“Alice’s unsteadiness is not something that can be fixed”

The problem with the independent self, Gawande explains, is that inexorably, the realities of life eventually render independence impossible.  He poses the question, “If independence is what we live for, what do we do when it can no longer be sustained?”  He then returns to the story of Alice, now 84 years old, exhibiting memory impairment while on a family vacation and sustaining multiple falls in her home. Her son takes her to the doctor, who diagnoses osteoporosis and changes her medications.  Ultimately, though, Alice’s unsteadiness is not something that can be fixed:  she would not be able to remain independent as she continued to decline.  Her doctor, however, “had no answers or direction or guidance” and couldn’t describe what to expect going forward.  With that statement, Gawande foreshadows the message of the next several chapters of his book.

The book club is coming!

On July 13th and 14th we will be doing the first NephJC book club on Atul Gawande's excellent Being Mortal.

Don't lose hope the book has some supremely uplifting chapters like the story of Bill Thomas bringing life to a nursing home with pets, lots of pets:

To get ready for the book club I found this article about the twitter book club #1Book140. Pretty interesting. My favorite part of the article is

“But so what? For me, 1book140 was more enjoyable for its intimacy. Most of all, I liked how nice everyone was. So often the Internet is a place of derision and insult. But on 1book140, participants respected one another without having to be told to be nice.”

I would be so happy if the conclusion of people take away from NephJC is that the people are nice and the conversation civil.

Thoughts on tonight's #NephJC Social Media Chat

Last night I was reading John Weiner's personal reflection on social media in medicine. He posed the question of whether the definition of professionalism is fixed and we need to adapt our social media use to these standards or do we adopt our measure and expectations of professionalism to new tools and personal behaviors. His words:

For example, a joint initiative of the Australian Medical Association Council of Doctors-in-Training, the New Zealand Medical Association Doctors-in-Training Council, the New Zealand Medical Students’ Association and the Australian Medical Students’ Association has produced a document called ‘Social media and the medical profession’ (Mansfield et al., 2011). The advice includes, inter alia, this statement:

Our perceptions and regulations regarding professional behaviour must evolve to encompass these new forms of media.

I would argue that perceptions and regulations of professionalism, once properly espoused and documented, should be applied universally, in any day and age, and for any circumstance or technology. This is declared, for example, in the Royal Australian and New Zealand College of Psychiatrists Position Statement ‘Psychiatry, online presence and social media’ (RANZCP, 2012) where, although there are specific allusions to social media behaviour in the document, there is an over-riding clause that clearly states:

they must ensure their social media use and Internet presence upholds the ethical and practice standards required for Fellowship of the College. (RANZCP, 2012)

Others argue that social media is somehow different. After all, it has immediacy and reach and permanency. I cannot accept that a smart, well-educated student who has achieved entry to medical school does not know these properties of social media.

This question seems to be at the center of any discussion of professionalism in social media, we need to at least understand what we mean by professionalism. While at first blush it seems that standards are only standards because they do not change. But on deeper thought, it is clear society has evolved. Imagine 1985 Marty McFly driving his Delorean to 2015 Brooklyn. What would be his reaction to people:

  • publicly share vacation photos for the world to see
  • millions of public diaries open to the world
  • restaurants full of people snapping and sharing pictures of their food
  • people "checking in" to share their current location when they get to every social engagement

He would be shocked at this narcissistic hellscape. Our ideas of privacy have undergone radical changes in just a few decades. It seems to me that the codes of professionalism must evolve with the standards and behaviors of the time or they will lose relevancy and become just an exercise in conservatism.

Please join us for this chat tonight at 9PM Eastern or tomorrow at 8PM GMT (3PM Eastern/Noon Pacific), it should be great.

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#NephJC has RSS subscribers?

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A few months ago, we mentioned how to subscribe our feed with RSS. 

At that time, we had one subscriber (Swapnil) - and to our great surprise, it seems to be that RSS is back. Just see below:

Unless there are spam RSS subscriptions somehow....

In some other news, we would like to thank Marjorie Lazoff for mentioning us in the LITFL blog  - go check out their literature review here. 

Swapnil Hiremath, M.D.

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The AUA v ACP guidelines. Fight!

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Tonight's and Wednesday's #NephJC is going to focus on the ACP guidelines. But it is important to recognize that a different group looked at the same data and came up with very different conclusions of what CPG should look like.

The systemic review that is the primary source...

The systemic review that is the primary source...

...was the same in both clinical practice guidelines.

...was the same in both clinical practice guidelines.

The American Urological Association Guideline (PDF) consists of 27 guidelines covering:

  • Evaluation
  • Diet therapy
  • Pharmacologic therapy
  • Follow-up

The AUA did consider 18 additional studies that were not part of the AHRQ analysis. The recommendations are graded and the authors interpreted the grades thusly:

  1. Clinical Principle. This is a statement about a component of care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. My sense this is, that these recommendations are so woven into the fabric of stone care that people would not be able to get a study of these practices past an IRB.
  2. Expert Opinion. This is a statement, achieved by consensus of the Panel, based on clinical training, experience, knowledge and judgment for which there is no or insufficient evidence.
  3. A or B level evidence translated into Standards
  4. C level evidence becomes Recommendations
  5. Options are non-directive standards that may or may not be based on evidence. There is only one and it was evidence grade B

Background

  • The prevalence of stones is increasing. It has gone from 5.2% in 1988-94 to 8.8% in 2007-2010.
     
  • It is affecting more women so that it is much male dominated. The male:female ratio has slipped from 1.7:1 in 1997 to 1.3:1 in 2002.
  • They looked at the diet studies that used stone formation as the outcome. Those studies found that increased water intake reduced stones. It found beneficial effect by avoiding cola. 
     
  • They looked at multicomponent diets and described the ability of a low sodium, normal calcium, low animal protein to reduce stones more than a low calcium diet.
     
  • Two other studies restricted animal protein as part of a multicomponent diet and was unable to find any advantage.
     
  • The authors point out that changes to urinary stone risk factors has not been validated as an intermediate endpoint.

The authors are transparent about one of the primary gaps in the use of diagnostic information about the nature of a stone in the therapy for that stone.

One caveat, all the RCTs diet studies were done in stone forming men.

The Guidelines

The 27 guidelines themselves are pretty straight forward and read like a description of what takes place in a well run stone clinic. The authors are again transparent, labeling many of the guidelines as Clinical Principle and Expert Opinion. In terms of the final score it looks like this:

Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).

Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).

Here is the breakdown by section:

Not surprisingly, only pharmacologic therapy has received significant RCT attention.

Not surprisingly, only pharmacologic therapy has received significant RCT attention.

The AUA and ACP guidelines are based on the same evidence but ultimately look very different. The ACP guidelines look at this evidence desert and provide guidelines so sparse they end up functionally useless. The AUA, on the other hand, hitches the evidence to common sense, scientific innuendo, and long-held medical habit to provide fairly comprehensive guidelines that primary care doctors and part-time stone-physicians can use to actually take care of patients. The AUA guidelines paired with the AHRQ evidence analysis are documents I would have every fellow add to their iPad library. The ACP guidelines? Not so much.

In the end the ACP guidelines read like political statement protesting the sorry state of stone evidence, while the AUA guidelines provide a practical manual guiding stone care while still being transparent about the poor state of evidence.

Joel Topf, MD