Sunday, October 20, 2013

Calling all Apple nerds! See if you can predict what will be announced...Updated!

Apple already announced new iPhones and has a media event scheduled for October 22nd. If you think you have some Apple game see if you can predict the announcements. Go here to fill out your entry. Voting ends Tuesday morning.

The winner is...Milos who crushed the competition with a score of 40! He correctly nailed the price of the price of the two iPad minis, the camera specs of both new iPads, almost perfectly nailed the specs of the iPad Air (only blemish predicting an A7x rather than the A7). But where he really lapped the competition was predicting that the program would ignore the iPods and Apple TV. Strong work!

Second place was Steven with 30 points. I tied for fourth with Mhallang at 28 points. Thanks for playing.

You can see all of the submissions here.

Kidney Week Approaches!

This year for the first time (that I am aware of) Kidney Week is in Atlanta.

I was lucky enough to get both an abstract and oral presentation accepted. Both are on social media.

The Oral presentation is on the lessons from NephMadness. I will be speaking at 5:30 on Friday, November 8, in Room 409. The session is titled Nephrology Education and Research and runs from 4:30 to 6:30.

The poster presentation is on Thursday November 7 from 10 to 12. The poster is a review of productivity, longevity and consistency in nephrology blogs. It is poster number TH-PO880.

I would love to meet any readers of the blog, so stop by. Also if you post your abstract/poster information as a comment to this post I will make every effort to visit your poster and review it on from a design and nephrology perspective. Think of it as The Blogger Eye for the Scientist Guy.

See you in Atlanta!

Friday, October 18, 2013

Journal Club Wasteland

Nephrology and social media has some notable successes:
  • The Kidney Group has charted a unique course with Facebook by breaking the so called rules of social media in medicine. The Kidney Group regularly highlights individual patients, and the private lives of the doctors, nurses and families of the people who work at this private practice. They have a unique voice and engage with a community.
  • Renal Fellow Network has created a website that that is remarkable for its scope, longevity and quality. They are the only nephrology website that has mastered succession, an essential element of long term success. 
  • eAJKD and NephronPower, the twin brain products of Kenar Jhaveri have demonstrated remarkable creativity in making nephrology more approachable and interesting with word games, detective stories and NephMadness.
  • Twitter has increasingly been an amazing social media destination for intelligent nephrology discussion. Two particular tweeterari standout: 
    • Ed Lerma is doing great work with his #NephPearls project. 
    • And Christos Argyropoulos (feels like I should get some kind of reward for spelling that correctly) is defining nephrology on twitter by his frequent engagement and general cleverness.
  • The Ajay Singh and The Kidney Doctor has had tremendous success, it is fascinating having an A-level scientist join the social media ghetto. His productivity and gravitas provides a unique voice. 
  • This is by no means a comprehensive list. Notable additions which immediatly come to mind include Tejas Desai, Mathew Sparks, Jordan Weinstein, Mahesh Krishnan and I am sure I have forgotten too many others. (Please post your umbrage in the comments)
Each success teaches us something about how social media works in nephrology. Failures are generally less interesting, but since we still do autopsies let's take a look at one of the highest profile failures in NephSocMedia: The CJASN journal club.

This project had a simple, straight-forward goal. Take an article from CJASN every month or so. Highlight it by giving both it, and the editorial away. Make the author available for some questions. Create an interesting online discussion of the article. Create, a national or even international nephrology journal club.

Here is a list of the discussions for this month's article on Mediterranean Diets (October):

Here are the discussions for the initiation of RRT in CKD (September):

The April '13 article on marajuana has no comments! If you can't get the internet to comment on weed, you have a problem (the likely issue here was posting article on 4/22. Total missed opportunity, 4/20 was just sitting there waiting for a post on dope).

March and February, no comments.

You get the idea. Here is the data in aggregate

The January '13 post has 3 comments, unfortunately they have nothing to do with The effects of hemodiafiltration on quality of life:

This is a failed project. Why did it fail?

I can't get past the lock on the home screen of the project

What a way to turn people away. The site literally has a padlock on the front door. The idea of an online journal club is that the wisdom of the crowd can shine through. With enough eyes and mouths all aspects of an article can be turned over and vetted. By establishing this barrier to entry they limitted participation and turned people away. Most internet forums allow everyone to view discussions and only require logging in to comment. I can't think of any reason to prevent people from browsing the discussion without first logging in.

The discussions are labelled not by first name but by e-mail address. So you know is going to be reluctant to leave a comment due to profound e-mail address embarrassment. Though I have to say I got a bit of a thrill seeing the e-mail addresses of George Bakris, John Asplin, Dave Goldfarb and other rock stars of nephrology revealed in their forum posts. In my opinion people want some degree of anonymity. CJASN did not allow that. But compared to other mistakes, I think this one is unimportant. Fixing this will not fix the Journal Club.

The funny thing is that the head of the site gets it. David Goldfarb has this blurb under latest news (note: if the link is from May 2012, time to change it from latest news):
This link is to an interesting editorial from the NYT about the value of free access and opening yourself up to critique by the public. I wonder if that blurb was Goldfarb's way of nudging the gatekeepers that put the lock on the door?

But the reason CJASN Journal Club failed is this is a project that depends on a community it does not have. I spoke with Dr. Goldfarb about this and he realized this and told me that he hoped to create the community with the journal club itself.

The idea of an online journal club is a good one and has been executed in multiple venues successfully. The one I am most familiar with is the Twitter Journal Club run by Natalie Silvey. Transcripts from the journal clubs can be found here and here. I spoke with Natalie about her experience over twitter. Some interesting tidbits:
  • choose articles with general appeal
  • you don't need to be a twitter superstar, she had only 500 followers when she launched it
  • publicity helps: the project was featured in Nature(!) and a number of her friends and followers were medics who helped stoke interest. This has started an avalanche of publicity and imitators. (see here, here and here)
  • The twitter format is very accessible to everyone
  • Since the host had no specific authority (she was a junior attending when she started it) it radiated approachability by other people. Having an author or similar authority figure can stifle discussion with presumed expertise.
One thing that I like about the Twitter Journal Club is that it's an event. It convenes at a set time and you are either there or you miss it. You can go back afterwards to scan the transcripts but the event is done. Having people discuss things in real time makes it feel more collegial and interactive, a static forum is one derivative further away from the tradition journal club. An important part of the success of the twitter journal club is a blog that holds the transcript and the opening statement. A blog can be indexed by google so it is findable and preserved. Putting the journal club behind a password blocks this utility.

In fact, the password protection gives the impression that this knowledge is off limits, It is a rejection of one of the core principles of Medicine 2.0: openness, transparency and accepting the truth that the monopoly of information that physicians used to have no longer exists.

So where does this leave CJASN Journal Club? Dr. Goldfarb admits that they are at a cross roads and shuttering the whole site is being openly discussed. I think that unless they are willing to try a whole new strategy they should just put the thing out of its misery.

If they want to try CJASN Journal Club 2.0 I would suggest:

  • No paywall, password, or mandatory e-mail collection
  • Run the journal club on twitter or in a Google Hangout
  • Make it an event by partnering with other nephrology social media hubs (essentially admit that you don't have a community so you will borrow RFN's or PBFluid's or NOD's for a session
  • Dump the forums and
  • Replace them with a blog with three or four posts per month:
    • first post: introduction to the article
    • second post: editorial or author interview
    • third post: post for the twitter event (this could be combined with #1), include the questions that will be addressed during the chat
    • Fourth post: summary after the event with the transcript and analytics from Symplur
  • Allow comments on the blog to be the replacement for the forums
I allowed Dr. Goldfarb to review this before it was posted and I gave him an opportunity to respond.
I appreciate the opportunity to read your post and reply. I have to admit that I was hoping for more participation by the nephrology community in eJC; I too envisioned something more active. We at CJASN are very receptive to this feedback, as, in truth, we have had little feedback from ASN members before your post. So we are glad that you wrote and glad to consider ways to make eJC better.

There are other measures of participation, other than the amount of discussion, that perhaps are evidence of a higher level of success than you suggest. Maybe that participation is more passive. I’m not sure what measure of “success” you are applying to some of the online activities you cite. The Renal Fellow Network is terrific but the very thoughtful posts there usually have 0 to few comments made.

Perhaps you will judge eJC as less of a wasteland if I give you some recent stats.  There are 969 people subscribed who get the monthly email. In October 44 new subscribers have enrolled so we have not stopped. For September-October we have had 350 visits by 295 unique visitors, with close to 4 page views per visit. All of those sound pretty good to me.

I also have some anecdotal tales to share. My fellow’s father is a nephrologist in India: his group discusses the eJC article every month. “He loves it”, she tells me. There were a couple of formal discussions of eJC papers at King Faisal Hospital in Riyadh under the leadership of a former NYU fellow. MAYBE there are nephrology fellows choosing our article to discuss for their fellowship program’s journal club…maybe fellows are less likely now to ask their faculty to suggest an article to present.

I have thought several times that we need to do a survey of the subscribed members and figure out what activity out there is actually ongoing, because clearly I do not have the data about those sorts of activities.

One nice service that eJC, CJASN, and ASN provide is that the article is distributed free when it would otherwise remain available only to ASN members. So if it is simply a good will gesture of ASN and CJASN to the world, I don’t think that’s a bad thing.

As for “building a community”, I was inspired by Nephrol, Kim Solez’ listserv that started in the late ‘90s and remains intact and useful. I have seen it nearly every day for more than 15 years. People have been reading it and participating in case discussions all that time…it’s self-sustaining. Maybe I have to put more time into it myself, keep the conversation juiced and pertinent and engage the authors in some dialogue, but I didn't want it to be MY opportunity to chat and exchange talk with the authors, I wanted to offer that chance to the nephrologists reading out there.

As for posting anonymously as you suggest; Nephrol is not anonymous, the participants are adults and posting serious stuff, not fooling arounds. It’s like nephrologists you never heard of getting up at a microphone at the annual meeting and saying “I’m Jones, from New York, and I’d like to know what you do with calcium phosphate stones in the salivary duct”, I didn’t think it was too important to offer anonymity. There have also been discussions showing that anonymity is responsible for many of the internet’s abuses and uglier sides. But we are willing to try that.

The journal clubs that happen at a particular time on Twitter are great and novel. Everyone has a time that they can participate and a time to browse what’s online. The one from BJU on stones and soda was useful and entertaining. But how to judge the success of those events is not clear: are you satisfied if there are 5 participants? 10? As a former chief resident, I gave up counting housestaff attendance at conferences: if one person yearning for knowledge shows up and thinks about the subject, I’ll be satisfied.

On a more minor note, I see your point about the lock on the entrance being slightly off-putting…maybe an open door would be a more welcoming symbol. ASN reasonably wants everyone getting to the site to have an ASN password. It’s free and does not require ASN membership. Perhaps some shy people see the lock and feel turned away.

We’ll have further discussions about this interesting subject. I’m grateful for this opportunity to think about what we have done and what we will do. Believe me, I am much happier being a “high profile failure” than a “low profile failure”, though I’m contesting that term, and I’m looking forward to you telling me how many people read your post and my reply.

I admire the hard work you put into your website and lectures, and your intelligent critique of the nephrologic world.


David S. Goldfarb, MD, FASN
Associate Editor and eJournal Club Editor, CJASN
Chief, Nephrology Section,
New York Harbor VA Healthcare System
Professor of Medicine & Physiology, 
NYU School of Medicine

Monday, October 14, 2013

Rules for giving really excellent, super good, top notch lectures

Thirteen rules for giving a really bad talk!

  1. Don’t plan too carefully; improv is the name of the game with technical talks.
  2. Begin by thanking an enormous number of people, including blurry little pictures if possible. It comes across as humility.
  3. Waste a lot of time at first on some small point, like the correct spelling of “Chebychev.” Whoever heard of running out of time? (See Rule 13.)
  4. An elaborate outline of the talk to come, phrased in terms the audience hasn’t heard yet, really sets the stage, and saves saying “I’m going to present the beginning, the middle, and the end.”
  5. Don’t give away your simple motivating example early on. That’s like stepping on your own punchline.
  6. A good way to start is with the most general, abstract statement possible.
  7. The best notation is the most complete notation — don't skimp on those subscripts!
  8. Blank space on the screen is wasted space. There should be an icon for everything — if you say the word “Apple” an apple should tumble in from the right, etc. And don’t forget to read every word on the screen out loud.
  9. Humans are incredibly good at reading tables, so the more rows and columns the better. Statements like “you probably can’t make out these numbers but they are pretty much what I said” are audience confidence builders.
  10. Don’t speak too clearly: it isn’t necessary for those in the front row.
  11. Go back and forth rapidly between your slides. That’s what God made computers for.
  12. Try to get across everything you’ve learned in the past year in the few minutes allotted. These are college grads, right?
  13. Oh my, you are running out of time. Don’t skip anything; show every slide even if it’s just for a millisecond. Saying “This is really interesting stuff, I wish I had time for it” will make people grateful for getting “Chebychev” right.

From here, Hat tip to David Juurlink, author of this great potassium paper.

I took the nephrology recertification exam this past Thursday.

It was hard. It was harder than I expected.

The Test

Many of the questions were second derivative type questions. They would describe a renal disease and then ask a question that required you to know what the hidden diagnosis was and then some additional bit of knowledge about the disease, i.e. diagnosis, treatment or prognosis.

I felt the test was hard and initially complained that I thought it was unfair but with some more time I feel that it was actually a pretty fair test. One complaint I heard among my fellow test takers was that the test did not reflect their practice. There was essentially no peritoneal dialysis. There was very little chronic hemodialysis and I felt that chronic kidney disease was under emphasized. There was a lot of electrolytes, acid-base and secondary hypertension.

One aspect of the test that bothered me was how the test seemed to have no clue how a modern, networked, doctor actually works. For example, there were questions that asked about a specific drug look the correct dose up on my phone. I am not arguing that drug dosing in renal failure questions are irrelevent in the era of the networked doc but the relevent fact is not what the dose is, but which drugs need to be dose adjusted. Provide a list of drugs and ask me which ones need to be dose adjusted in renal failure. Give me a list of drugs and ask in which ones are drug levels not indicative of biological activity. Adapt the question to be relevant in today's connected world.

Similarly, regarding rare diseases in nephrology. Do not ask me how to treat Fabry's disease. I have never seen a case of Fabry's. I need to be able to diagnose the condition, and then the correct next step is not to reach back in the recesses of your memory for how to treat this one in a million disease. The right answer is to hit the books and brush up on the disease. Recognizing the pattern of symptoms and making the diagnosis is what is important. Treatment can wait for the practitioner to review the latest data. The best time to get up to date on a disease is right when you suspect it so you have the latest knowledge. Forcing people to memorize treatments of rare conditions de-inforces the better habit of hitting the books when something rare comes up (and by books I really mean UpToDate).

The Prep

To prepare for the recertification test I put all my wood behind the ASN Board Review Class. My results are not back, so it may be a bit premature to make a recommendation but, as of today, I feel that it is an excellent way to prepare.

  • The breadth and depth of the lectures was right in line with what I saw on the test.
  • I feared that the ASN would try to get the biggest names in nephrology rather than an all-star bench of great teachers. They did not fall into this trap. They found some really big names in nephrology who are also really good lecturers.
  • They provide a wealth of resources to help you extend your learning beyond the week at the conference.
    • practice test
    • paper syllabus with copies of all the slides
    • CD-ROM with all the slides
    • Audio synched to the slides for online review

I went to the lectures in Chicago and was an active learner by live tweeting the lectures for eAJKD (coverage provided by the excellent uKidney).

After the week in Chicago I carefully went through the practice exam provided by the ASN BRC. One hundred fifty questions with answers and good explanations. I loved this tool and only wish they were a bit more indulgent with the answers (in other words love it, just give us more). I feel that questions and answers I think are one of the best ways to prepare for the test.

In the weeks leading up to the test I listened to hours of the ASN BRC lectures on my computer. The online component has audio synched to the slides, so it really is a way to relive the Chicago experience. The site is a bit balky to navigate but this resource is worth its weight in gold. Tremendous value.

You know how you memorized all the fibrillary diseases as a fellow. Here's a great chart to memorize it again. Joy.
From the ASNBRC who got it from Brenner and Rector*.

* I do not know who the Rector from that duo is but I do wonder if he gets a lot of "Rector? I barely met her!"

In terms of the quality of the lectures, I am a connoisseur of good lectures and a lecture snob when it comes to poor lectures. When I go to Kidney Week or other conference I usually feel that most lectures are actually pretty bad. However, ASN BRC broke mold with excellent lecture after excellent lecture. They had had a few clunkers and the bade ones looked even worse because the bar was set so high by the other speakers. What a crew they assembled.

The one weak point of the course is when the organizers tried to provide some alternative learning strategies. The organizers were not very forthcoming with the motivations for the afternoon interactive sessions but my guess is it goes something like this:
Every year the primary criticisms they get when they look at feedback is the sheer number of hours in lecture is both mind and butt numbing.
The directors response to this is small group, interactive learning sessions. An attempt to flip the class room. Their attempt at this was stymied either by poor planning or limited by physical space. They were able to divide the 500 odd participants into a group of about 100 and a group of 400. Neither of these qualifies as small groups. They did some case based questions but they really were just lectures in disguise. The professors read a question, did the audience-response thing, then proceeded to give a short lecture, sometimes with up to a dozen slides.
Despite inviting audience interaction there was not enough time or an appropriate venue for meaningful audience participation.

A small black mark on an otherwise impressive and highly recommended nephrology review.

Friday, October 4, 2013

Lecture cancelled

I was supposed to give a lecture to the St John Residents. Stayed up late working on an ARF lecture, showed up and...I was the only one there.

Turns out they had an inservice exam today. All those late nights for nothing.

Well here are the slides:

Keynote (43 mb)
PDF (25 mb)

Wednesday, October 2, 2013

News Flash: IV contrast still toxic. That is all.

This tweet came through my time line yesterday:
You really should check out the tweet on twitter to see all of the discussion it generated (I sampled some of the best tweets in the Storify below).

I skimmed over the full text article and it is not very convincing. The study is a meta analysis of 13 non-randomized trials that compared iodinated contrast imaging to non-contrasted imaging. I suspect most of the imaging was CT scans. No intra-arterial contrast was allowed, this eliminated all of the cardiac cath data (though the idea of a non-contrasted cardiac cath is ludicrous).

Before I started reading the article I suspected he would be pulling lot's of old studies form the early days of iodinated contrast, I mean who today is questioning the existence of contrast nephropathy. Wrong:

Additionally almost all scholarly activity in this corner science was directed at finding safer contrast
Red: contrast causes renal failure
Blue: contrast protects from renal failure
not determining if the contrast itself was safe. Looking at the references it becomes clear why I hadn't been familiar with this supposed controversy, this stuff is not published in general medicine or nephrology journals. All doctors live inside specialty defined bubbles and, besides a single negative study published in Archives of Internal Medicine, none these articles pierced the bubble.

The thrust of the article is that renal dysfunction following IV contrast administration is no more common than renal dysfunction without contrast administration. If one looks at placebo (or placebo-like) controlled studies there was no signal that contrast increased the risk of acute renal failure:


Contrast: 6.4% (1004 of 15582)
No contrast: 6.5% (675 of 10368)


Contrast: 2.4% (178 of 7359)
No contrast: 6.7% (81 of 1216)


Contrast: 0.3% (24 of 7270)
No contrast: 1.2% (15 of 1214)

Not only was their no indication of increased ARF with contrast, there was a mind bending trend to lower risk of dialysis and death in patients given contrast.

Reading this article I could not forget the faces of the patients I had taken care of who had died of contrast nephropathy. My disbelief was practically palpable. Trying to reconcile the data and my experience some of my thoughts were:

  • If you had a patient at risk of ARF you would avoid contrast, so maybe we have a lower risk population getting contrast? 
  • Patients getting contrast may get prophylaxis with IV fluids and N-acetyl cysteine, both of which can lower creatinine. Does that lower the creatinine mask renal injury?
From Tepel. NEJM 2000. Shows NAC not only prevents CN but lowers creatinine.
These justifications are just another way of pointing out the problems that come from a lack of randomization and secondarily a lack of blinding. These methodology shortcomings are not solved by a meta-analysis. 

This is obviously an important question, but in my mind, and by my experience it is one that has already been solved. I have seen contrast nephropathy with my own eyes and I would need to see pretty compelling data to change that fact, and this study isn't it.

UPDATE: My resident just pointed out that two of the authors have received money/grants from GE Healthcare, a manufacturer of CT scanners and iodinated contrast.

Here are some of the responses from Twitter

Note: My first grand rounds after finishing fellowship was on contrast nephropathy. I think it was the first time I used Keynote, way back in 2004. When I look at most of my presentations from that era I usually cringe but I think that old presentation holds up pretty well.:

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