Nephrology in a Resource Limited Setting, Gaza Edition

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by Nimra Sarfaraz

What did I expect from the healthcare system going into the Gaza strip, seemingly one of the most inaccessible and dangerous places on earth ?

It’s embarrassing to say that media portrayals played a role in my notions. I was expecting to see a lack of physicians in a weak system with destruction all around. What I saw was simultaneously heartbreaking and comforting. I went with a team from MedGlobal, a non profit aimed at providing sustainable health care services to refugees, the most vulnerable in crisis areas and in low resource settings. Through MedGlobal, a diverse team from a professional, ethnic and religious backgrounds formed. Our team consisted of specialists in pulmonary critical care, Ob/Gyn, pediatrics, colorectal surgery, surgical oncology, anesthesia, pediatrics, nephrology, heme/onc and neurology. The team had clinicians from both the UK and the US with members identifying as Hindu, Jewish, Muslim, Catholic, Christian and agnostic; our unity around a common goal was beautiful to be immersed in. Our goal was to provide patient care, teaching and donating direly needed medical supplies, all of us were there on our own time and paid our own expenses.

On our first day there, we met with officials from the Ministry of Health and heard from leaders in the oldest and biggest hospital, Al-Shifa . What I will always remember more so than the jarring statistics was the sense of pleading to be heard, heard by the global community about what is happening. There’s a mingled guilt and helplessness in situations like this and I always come away wondering what sheer dumb luck has led me to such a position of comfort and privilege to sit across from individuals ever capable and exemplifying resilience. Later in the day the clinicians dispersed to meet with their Palestinian counterparts in one of two of the main hospitals we were working at, Al-Shifa Hospital or Nasser Hospital with the purpose of understanding each specialty’s work flow and assessing needs for future missions. I was paired and rounded with Dr. Riad, a bright nephrologist who had studied and trained in Egypt. We rounded on patients together and saw cases that ranged from run of the mill AKI to more complex cases such as steroid resistant childhood nephrotic syndrome that was now worsening, prompting a change in therapy. We visited the dialysis unit where many patients greeted Dr. Riad more as a friend. At the end of the day, when the group reconvened over dinner, all our experiences were similar – the lack wasn’t of human capital or education, the handicap was in a stifling lack of resources and mobility. Half of basic necessary drugs are at zero stock level, meaning there are not enough essential medications to effectively run a hospital to last through the next month. Astounding. The average amount of electricity per day is 7 hours. Dr. Aarti Garg, who did laparoscopic colon surgery on this trip, witnessed firsthand electricity flickering mid operation: luckily, big hospitals have generators but what of regular people?

What was I able to contribute as a nephrologist ?

Honestly the nephrologists there are capable and bright. They are deft at managing complex cases and have access to medications such as tacrolimus, mycophenolate and steroids. Uptodate is a highly cherished resource. Some of the more expensive medications, such as rituximab, are impossible to access because of the blockade. If a patient needs these medications, they need to be transferred out of the Strip. Transfer to more advanced centers is an onerous process, as on average 43 people are given permission to leave per day. Thinking comparatively to Las Vegas, a city of about the same size, to imagine only 43 people allowed to leave Las Vegas per day is mind boggling. People can’t leave to study, to visit family or to get more advanced and necessary medical care. Kidney biopsies that are done are sent across the border to neighboring countries to be analyzed. There is no doubt room for improvement, though it would be remiss to comment without also noting that these limitations will be difficult to overcome unless the prevailing root circumstances change. One notable example was the number of patients in the dialysis unit and the space each patient was allotted. The dialysis unit was full to the brim with one patient able to reach over and touch their neighbor, privacy and space, you see, is a luxury in a densely populated area with limited resources. Medications such as erythropoietin and calcitriol were not available; many patients asked us if we were able to provide these medications on a regular basis. 

I have gravitated towards point-of-care ultrasound particularly because of ease of use, rapid diagnostic ability and practicality of use, especially in low resource settings. I’ve previously taken a course with MedGlobal and have been using the Butterfly ultrasound probe on a regular basis. The Intensivists at my home institution have guided and taught me along the way as well. I was tasked with teaching a Point-of-Care Ultrasound workshop to the Internal Medicine and Intensive Care physicians at Nasser and Al-Shifa Hospitals; around 35 med students and attendings attended between two hospital systems. The workshop was well received and we did bedside ultrasound on patients in the Intensive Care Unit there. This part of my time there was likely the most beneficial of contributions to the most amount of people as the clinicians there are going to be using what they’ve learned on an ongoing basis. 

I encourage anyone with even a fleeting curiosity to delve for themselves into the complexities of the situation and with intentional conscience not forget the humanity of people, approach learning about this situation with empathy. Often times the most common narrative is not reflective of reality.

Pearls From a Successful Nephrologist

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Hello #medtwitter; we have one of the #nephtwitter legends here with us! He is our very own Dr. Lerma; with almost 8000 followers on twitter. You might know him from his famous #nephpearls or his amazing nephrology secrets book that he co-authored with Dr. Sparks and Dr. Topf.

How do you describe yourself in one sentence?

Dr. Lerma: I am a lifelong learner who believes that no matter what stage in life we are in, there are always new things to learn and explore.

Where did you do your nephrology fellowship?

Dr. Lerma: I did my Fellowship Training at Northwestern University between 2000-2002 under the tutelage of Drs Dan Batlle, Robert Rosa, William A. Schlueter, Murray Levin, David M. Roxe, Serafino Garella, Peter Ivanovich and Cybele Ghossein.

What makes nephrology interesting to you?

Dr. Lerma: Even when I was just student, I was always fascinated by mechanisms and how things work or not; so in medical school, I was really enthralled in learning more physiology and pathology; being able to understand the mechanisms of various conditions, and formulate therapeutic strategies based on that knowledge was very appealing to me.

You are currently on private practice based in Chicago; what are the most important key factors to become successful in private world? (in 5 words)

Dr. Lerma: Below are 5 things that I think are important when you’re practicing medicine whether you’re in private practice or academics.

Patience: You have to be patient in navigating today’s medical system, e.g., EMR, etc. You have to take time to talk with your patients and their families and not have them feel that you’re hurrying them up. Explain what they need to understand and answer all their questions.

Hard work: Everybody else around us is working hard. In order to set yourself above the rest, you have to keep doing it, and be consistent at it.

Respect: In medicine, you are working with people from all walks of life, from all socioeconomic and educational levels, whether they are your patients, staff, colleagues, or higher ups. Some people may not agree with your decisions and assessments; hear what they have to say. Give them the respect that is due to them and they will offer you the same.

Honesty: I cannot help but emphasize that the old adage “honesty is the best policy” is very important. Be trustworthy and you will earn utmost respect.

Politics: There is politics in everything. Try to steer away from it.

When you show that you’re patient, you consistently work hard, and you’re trustworthy, you will earn the respect of ‘almost’ everybody and you won’t have to change your beliefs and values on account of somebody else’s proclivities.

How many hours a day do you spend on twitter?

Dr. Lerma: I can’t really put a number to it. I think my hours on Twitter vary. Anyone who follows me on Twitter would attest that I tweet more when I’m in a conference or meeting, e.g.,  #KidneyWk #NKFClinicals or when I’m in a chat, e.g., #NephJC #AskASN #HealthXPH. I also tend to tweet more in the wee hours of the morning. There are times when I just read other tweets.

What’s your secret of being this popular on twitter with thousands of followers?

Dr. Lerma: I don’t really consider myself as popular. I do not consider myself in the same rank as #NephTwitter giants such as @kidney_boy @Nephro_Sparks @hswapnil to name a few. I will say though that #Nephpearls is probably what resonates with most Nephrology enthusiasts and that’s why they tend to follow me. I am also very cautious in tweeting about certain topics, e.g., politics, religion, etc. If someone would ask a question regarding a Nephrology topic, I always try to answer to the best of my knowledge, or I would try to find the answer and include a reference. There are occasions wherein, I just don’t know the answer, and I would suggest posting either on ASN Communities or using the hashtag #AskRenal.

How do you balance your personal life and your busy day schedule?

Dr. Lerma: Work Life balance is particularly challenging at the start. I do not think that there is a single algorithm for that. I am blessed to have a very understanding and supportive wife and 2 daughters. When I initially started practicing, it was very difficult to have such a balanced life. I had difficulty saying ‘no’ to projects and commitments (publications, leadership positions, etc.) outside work. As a young novice, you tend to accept all opportunities to the point that you’re multi-tasking over multi-tasking; this can be detrimental not only to your health but also to the project(s). When you do this, the result can be a sub-par product. However, as I grew older and had more experience, I’ve learned to become more efficient by taking on only what I can handle.

Which one is harder? Residency or nephrology fellowship? Fellowship or new job?

Dr. Lemra: Each step in your career, from being a medical student to residency to fellowship to ultimately becoming an attending, has its own sets of challenges and tribulations. I think that support from your family and colleagues is of paramount importance. One thing is for sure. As you get up on the ladder of your career, the amount of responsibilities increases significantly. More importantly, with time, and with more experience, you are able to handle situations with more ease.

What makes you happy during the day? What is the most precious thing that you have achieved in your life?

Dr. Lerma: In an existential way, I think this is a difficult question. In a way, I would answer this question differently if you asked me 20 years ago as compared to 10 years ago, and now. Well, I will say that, my family makes me happy. Being able to spend time with them and seeing my daughters grow up and carve their own paths makes me happy. Everything I do in my career, day in or day out, now, really revolves around them. The academic successes and financial rewards I have received, are all trimmings under the tree that are now in the back seat.

Do you think if interest in nephrology will increase in the next two years? 5 years?

Dr. Lerma: The results of NRMP’s Medical Specialties Matching Program for appointment year (AY) 2018 seem to be similar as compared to AY 2017. There was a 42% increase in the number of US graduates matching into Nephrology programs while a 16 % decline was seen with IMGs. I do not know exactly how Nephrology as a specialty will be in the next 2 years or 5 years.

While there are multiple factors (lifestyle, reimbursement issues, complexity of patients, hospitalist movement) that are contributory to this decline in interest in Nephrology as a career choice, personally, I think that mentorship is a key component that is crucial in making the specialty more attractive. There are also programs that are geared towards encouraging our younger colleagues to join the Nephrology work force, e.g., ASN Kidney Stars Program, Origins of Renal Physiology: Mount Desert Island Biological Lab (MDBIL), etc.

I am uncertain if the recently signed Executive Order will translate into making Nephrology more appealing as a career for the younger generation.

What kind of activities are you involved in for education purposes on social media?

Dr. Lerma: I am involved with various Nephrology centered social media activities, e.g., #Nephmadness (Joel Topf, Matthew Sparks, Anna Burgner, Timothy Yau) #NephJC (Nephrology Journal Club founded by Swapnil Hiremath and Joel Topf) #NSMC (Nephrology Social Media Collective). I am also involved with the AJKD Blog, and the Interventional Nephrology Series (Aisha Shaikh, Buck Bucktowarsing, Crystal Farrington) of Renal Fellow Network (Editors: Samira Farouk, Sam Kant). I also try to help those Internal Medicine residents interested in Nephrology who rotate with me by giving them opportunities to write for ‘Disease A Month,’ and AJKD Blog.

What is the best thing about nephrology online community? What’s the worst thing about it?

Dr. Lerma: The best thing about it is the ‘collegial atmosphere.’ Everybody is supporting everybody. You won’t be afraid to ask a question for fear of being embarrassed or dejected. And anyone interested in participating is welcome to do so.

There are a lot of opportunities, from blogs to chats, etc. and that can be good or bad. To a beginner, it can be overwhelming.

As you go through your career as a future nephrologist, enjoy the ride … find your niche… and once you find it, focus on it. But don’t ever forget your family. They are the most important part of this ride… they will be with you always whether you’re in the ups or downs.

What is your main message to the Nephrology fellows in general? 

Take it 1 day at a time. There will be successes and there will be failures. Enjoy the successes but don’t take too long in doing so. Learn from your failures because you can change it to a success.

What is your advice to new Nephrology fellows?

No. “We are what we are because we have been what we have been …” – Sigmund Freud

Last comment…?

Dr. Lerma: In your career (just as in life), there will be challenges and there will be disappointments; always try to find the silver lining to help you get through these.

“When God closes a door, He opens a window.” (Malachi 3:10)

During these challenging times, think back to when you were in the beginning of your career. Why did you go into medicine? Why did you go into Nephrology? The answer(s) will hopefully give you the inspiration to continue to persevere and turn adversity into opportunity.

Then there will also be successes … always be humble and thankful.

“Gratitude is not only the greatest of virtues but the parent of all others.” (Cicero)

Thank you very much for taking the time to answer our questions. You are amazing and your contribution to #nephtwitter is really appreciated. We have learned a lot from you!

Thank you!

Yasar Caliskan @yasar_caliskan

Sayna Norouzi @saynanorouzi