Hills and Valleys is a podcast that uncovers stories from leaders in healthcare, tech, and everything in between. Straight from the heart of Silicon Valley, we give you a look at the good, the bad, and the future, one episode at a time. Brought to you by Potrero Medical.
Without better technology, nephrologists can’t catch acute kidney injury early enough to prevent it. We recently caught up with Dr. Michael Heung at the American Society of Nephrology (ASN) 2018 to talk about the challenges of Acute Kidney Injury (AKI) in Critical Care Medicine and what is needed to tackle them. Connect with Dr. Heung on Twitter @KeepingitRenal
Dr. Heung graduated from the Boston University School of Medicine. After finishing his Internal Medicine training at the University of Cincinnati Hospitals, he completed Fellowship training in Nephrology at the University of Michigan Health System.
He has been a member of the University of Michigan faculty since
Listen to the podcast on any of the platforms below, watch the full video interview, or continue reading this blog to see the transcript.
Interview at the American Society of Nephrology on Acute Kidney Injury, Predictive Health, and Nephrology Training
- Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical
- Interviewee: Dr. Michael Heung, Associate Professor of Nephrology at the University of Michigan
Khateeb: Hi everyone. My name is Omar. Khateeb and I’m here at ASN 2018 kidney week and I’m here to speak with Dr. Heung Dr. Heung. Thank you for joining us. And before we get things started, please tell us a little bit about yourself.
Heung: Sure. My name is Michael Heung and I’m a clinical nephrologist with a particular interest in critical care nephrology.
I work at the University of Michigan, in Ann Arbor, Michigan, and one of my roles there is the Associate Chief for Clinical Affairs for our division.
Khateeb: Fantastic. And I understand that you just co-chaired the critical care update this week. Correct?
Heung: Yes. It’s a great pleasure to serve as a co-course coordinator for the Critical Care Nephrology pre-course that we have here at ASN and it’s a great opportunity to chat up some of the real leaders in the field of Acute Care Nephrology and Critical Care Nephrology to get updates on what’s going on in the field and to get people up to speed on best practices.
Why did you choose to train in Nephrology?
Khateeb: So, when you were in medical school, what got you interested in nephrology? I take it you first got an interest in Internal Medicine then went into Nephrology. But what’s the story there?
Heung: Yeah. It’s like you said in medical school. I learned about internal medicine and I just really enjoyed the patient care aspects.
I really enjoyed the longitudinal aspect of managing chronic diseases and working with patients and families over time.
So, I did an Internal Medicine Residency.
I wasn’t necessarily interested in Nephrology coming out of medical school, but then in residency, I really got to know some of our nephrologists at the University of Cincinnati where I trained, and they were just fantastic teachers, fantastic role models, and eventually became fantastic mentors to me.
So, it’s really following in their footsteps seeing. How they manage patients with complex kidney diseases. They really inspired me to follow in their footsteps into Nephrology.
Khateeb: Was there any point in time or anything specific that you remember that inspired you in the direction of nephrology?
Heung: There was an attending of mine on one of my very first general medicine rotations. Dr. Jim Kaufman, who I still remember and have had a chance to catch up and talk with. He was
He’s a nephrologist in Boston. As I was presenting a case to him he had this ability to pull out what I thought were not necessarily relevant details from the case and synthesize it together.
He could just take pieces of a puzzle and make a full picture of it. The ability for him as a diagnostician to come up with what was most likely going on with our patient and be right just completely blew my mind.
At that time, I didn’t necessarily think I was going to be a nephrologist right away, but when I think back, he was probably my first Nephrology role model.
He really showed me the thought process and the breadth of knowledge that all nephrologists need to have in understanding all the different systems of the body and to come up with the right diagnosis for our patients.
Khateeb: What was the most memorable thing that he ever told you?
Heung: I’m not sure I can remember a specific thing that he might have told me but it was just moments like that on rounds where those classic light bulb moments happened. I had them watching him and seeing how he was able to put things together and that’s what I knew I wanted to be like.
Khateeb: From the critical care update, is there anything specific that is worth mentioning?
Heung:That’s a really challenging question because we had over 30 talks from different speakers covering a variety of topics, some more critical care focused like what nephrologists need to know when rounding in the ICU, but from an intensivist perspective and then several more that were more nephrology-specific. Like the tips for how to best run your continuous renal replacement therapy program, for example.
So there were a lot of great things, but one talk that I enjoy every year is given by Kathleen Liu, who is both an intensivist and a nephrologist. She’s from the University of California at San Francisco and she gave us an update in critical care nephrology over the over the past year.
It’s always nice to get real experts opinion as to how to interpret the literature and we got to talk about things such as the latest sepsis guidelines. We had a very well-known people, renowned experts like Dr. John Kellum and Dr. Ravi Mehta. Ravi gave an amazing talk on fluids as drugs and there’s been a lot of literature on that in the past couple of years and so it was great to hear his perspectives on what were some of the key points and best practices that we should be adopting.
One particular area that I’m interested in is the problems that develop with fluid overload. After resuscitating, we know we should resuscitate people but how quickly do we switch from that resuscitation phase into a de-resuscitation or de-escalation phase?
There’s still more to be determined in that area, but I think the recognition that we can’t just keep giving these patients fluid. So we have to think about when we deescalate to start to even pull fluid off to help our patients really recover.
People can check out the hashtag #CritCareNeph on Twitter and see a lot of the highlights including pictures of slides and things like that, which are speakers are sharing.
What is the future of Nephrology?
Khateeb: There are a lot of the new and interesting technologies are coming out now for physicians that augment their skills and gives access to things that traditionally you never had access to in medicine.
If you put the futurist hat on right now, What is the future of nephrology look like?
Heung: I think there are a few things that I would think about and actually several of these things did come out in for discussion at the Critical Care Nephrology pre-course.
One is the concept of alert systems and associated clinical decision support systems for Acute Kidney Injury.
At this point, I think that we all feel like we do a pretty good job recognizing acute kidney injury, identifying it, but the reality is a lot of times we’re fairly late in the game.
A lot of people are working on different Predictive Analytics type of work, especially with using the electronic medical record to try to predict which patients are at highest risk for acute kidney injury and in particular which patients may be already developing acute kidney injury.
We do know that alerts alone are not going to be enough. There’s the concept of alert fatigue, unfortunately.
Physicians get overloaded with the alerts that come up from the electronic medical record, but it seems to be at least in some studies, that when those alerts are associated with some specific recommendations, what we call a clinical decision support, that does seem to result in a change in behavior, which can potentially result in decreasing the risk for acute kidney injury and over the past couple years there have been a couple of studies that have really suggested that’s possible.
So that I think is pretty exciting. In the future, I expect that we will see more and more of these kinds of alerts with clinical decision support modules.
Probably not just an acute kidney injury, but I think acute kidney injury is a key area for that.
Point-of-Care-Ultrasound (POCUS) for Nephrologists
Another area I think is the use of point-of-care-ultrasound (POCUS).
This is not a new technology per se, but using its application in the ICU and for nephrologist is a relatively new pursuit. I believe here at ASN they have a brief course for that and certainly, at some of the other meetings around, nephrologists are starting to get training in point-of-care ultrasound use and it could be an interesting way to guide fluid removal and fluid administration in the future.
I think there’s a little bit more work that needs to go into that but it’s certainly coming our way.
The speaker, Dr. Nathaniel Reisinger, in our course even made the analogy that it’s the modern stethoscope, these portable, handheld, point-of-care ultrasound. So I could see technologies like that coming along and enhancing our ability to assess patients
Subtype Identification for Acute Kidney Injury
There’s a third area that I’m particularly excited is trying to better identify different subtypes of patients with acute kidney injury to better guide our therapy of them. So the concept of precision medicine basically.
When you think about it, acute kidney injury is a syndrome. All it describes is a decline in somebody’s kidney function that happens pretty quickly, just like the name sounds.
But the different causes for it are numerous, innumerable really. So why do we call the whole umbrella acute kidney injury and try to treat all acute kidney injury?
We should be thinking more about “this is the acute kidney injury subtype associated with this,” maybe it’s because of “this genetic predisposition,” or maybe it’s “this enzyme defect,” etc etc. That’s a future I think could be very exciting.
We’ve of course seen this in the field of oncology. Lung cancer is not just lung cancer anymore. Breast cancer is certainly not just breast cancer. We’re talking about what types of receptors, what kind of genetic mutations there may be, and that’s guiding what type of therapy is offered because we know that the different types of, say breast cancer, will respond differently to different treatments.
We don’t have that yet in Nephrology and certainly not in acute kidney injury, but I’m very excited because there’s a lot of work going on in that.
I’m hopeful that in the future we will have some more of what we’re calling Precision Medicine. We cannot just take a patient and say “this patient has acute kidney injury” and we’re focusing on this heterogeneous syndrome of acute kidney injury, but applying it to one person.
Hopefully there will be a day and not in the not too far future where we can look at these patients like “okay their syndrome is acute kidney injury, but these are their characteristics, this is a particularly pro-inflammatory subtype” or “they have this genetic predisposition” or something else like that where we can then use that information to provide more targeted therapy that will be beneficial to them and not use therapy that won’t be beneficial to them that might have side effects.
How Will Predictive Health and Precision Medicine Be Used For Acute Kidney Injury?
Khateeb: As a nephrologist between having Predictive Health technologies where you can see an event like an acute kidney injury (AKI) occurring in the future versus patients who come in with AKI and Precision Medicine is used for more targeted therapies, which of those two do you see coming faster for nephrologists? Do you feel like they go hand in hand or one will precede the other?
Heung: I think they will go hand-in-hand to some degree.
You have to be able to identify ways to even define different subtypes and then you need to look at those subtypes and do clinical trials to show that it does matter having the different subtypes. So I think it’s an iterative thing.
The clinical trials will inform further subtypes, using those subtypes, will inform the design of future clinical trials that are needed ultimately to show that something makes a difference in patients. In acute kidney injury, we have a ton of unfortunately negative clinical trials, meaning that they did not show significant benefit in mortality, which is of course what one of the big things that were working on.
One of the thoughts is that well, maybe we didn’t show a benefit because we’re treating everybody the same way, but they’re not all the same, and maybe there are patients that will respond to this therapy and there are some that won’t.
If we can pick the ones that will, that’s where we’re going to get the biggest bang for our buck. And again limit the risk from exposure to something a patient’s not going to respond to.
How To Be A Great Medical Resident
Khateeb: It seems that medical training still involves watching your attendings take pieces of a puzzle and make a full picture, almost like magicians. As technology comes out it sort of evens the playing field and standardizes these things.
There are a lot of young nephrologists out there trying to learn how to improve their intuition when it comes to this and I think that technology and intuition need to go hand-in-hand.
Any advice to younger nephrologists who are trying to improve their skills and essentially become more like clinical magicians while the technology catches up?
Heung: Yeah. I mean I medicine is still very much an apprenticeship and there’s a reason we call it “practicing medicine.”
You know, I certainly don’t think I have all the answers. One of my joys is coming to work every day and knowing that I’m going to learn something new, and I’ve certainly be been humbled many times.
The advice I give my fellows is that-
the day you think you know it all is definitely the day you should hang up your stethoscope and call it quits.
You should be humble and recognize that medicine is humbling. Patients don’t follow textbooks because patients are complicated systems. Ultimately, I think it’s getting as much exposure practicing and being exposed to different things then reading up on what you’re seeing.
Doing some research and have an open mind to things. I do think there will be things that can help with that in the future just because there’s so much information out there.
So, having some new technologies to help streamline the way information is processed or even interpreted could be helpful.
But at the end of the day, because patients don’t follow every rule. I always say medicine is not engineering. It’s just not as precise right now.
If you look at the fact that any lab value, there’s not one normal level. It’s always a range. So that alone tells you that there’s a lot of fluidity and variability. That’s why I don’t see computers or even AI taking over a physician’s intuition. That intuition has to be developed over time by seeing many patients, practicing learning, speaking to others.
That’s one reason that I really enjoy being in academics as because I’m a better doc when I go to the bedside and I have to explain my thought process not just to the patient of course, but also to my learners, to my fellows, and the students on rounds and I have to be able to demonstrate that there was a thought process in this, I did think through these things, and this is how we got to that point. So, it keeps me on my game and again
Khateeb: I guess it goes with that attitude “he or she who teaches learns”? It sounds like your big takeaway to younger nephrologists that to always stay curious and intellectually driven.
How Will Artificial Intelligence Change Healthcare?
Khateeb: It’s interesting that you mentioned the idea about AI and computers not replacing doctors and we absolutely agree.
I think there’s a big misnomer out there that that’s what was driving Silicon Valley, but as you know, the AI has to learn from something or someone, and usually, that’s the human being.
It sounds like the way that medicine is moving forward is that AI is not necessarily a replacement but more of an augmenting of skills so that physicians can go back to the patient’s bedside instead of spending more time with technology. So that does that sound correct?
Heung: Yeah, I think that would be great. Ultimately medicine is very much a human interaction specialty. At the end of the day, that’s my favorite thing. I love my toys, I love my technology, my labs, and all that stuff, but ultimately I like being able to sit down one-on-one with a patient or with their family and to explain what’s going on.
There’s nothing intuitive about kidney disease and especially with what I do in Critical Care Nephrology. These patients are often very sick, and I’m glad that I’m able to sit down, take some time, and explain it to them. Hopefully, we make sense of it for them and guide them through that journey.
Khateeb: Couple of quick, rapid-fire questions and we’re going to wrap up.
You mentioned #CritCareNeph on Twitter.
The beauty of the internet is that you can get so much information. Any other additional resources, Twitter handles, etc? What do you follow? Where do you go for information?
Heung: Well certainly related to kidney disease, one of the exciting things has been #NephJC, the JC is for Journal club. And so they do an online journal club a couple times a month. They pick an article and spread it out. Actually, they even made it easier.
They will do a summary of visual abstract and there will be a blog giving some opinions, a quick summary of it, and then there will be a Twitter discussion using that hashtag where people can comment.
There’s a moderator who will ask questions based on the article and often times they’re able to get the authors of the article to come in as well. So, it’s a great way to keep up on the literature, to get opinions from the author’s potentially, and certain experts in the field and seasoned clinicians, and it’s a great way to feel part of the community and learn so, you know, I’m representing here.
Khateeb: Obviously, you’re repping it. Look at that. JC pin and very nice.
So does it get a little competitive or is it is it mainly an open public forum?
Heung: It’s amazingly collaborative and friendly. Yeah, it’s fantastic
Nephrologists are generally very friendly people. I noticed this has been a very friendly and nice meeting. Everyone’s happy. Everyone’s getting along well.
So what about offline, if you have to recommend a few books. You’re a teacher and a leader in your field, so any books that are really good for self-development and leadership?
Heung: I mean, there’s a variety of books out there. I always think that Malcolm Gladwell books are very interesting just in terms of understanding different thought processes.
You know, you mentioned leadership and one thing that I actually teach is a course at the University of Michigan Medical School called leadership and that’s a medical student required course.
It’s pretty exciting. We developed this leadership curriculum starting a few years ago and this is our fourth year. We’re one of the few and first medical schools in the country to develop leadership really into the curriculum. It’s part of every business school, but I think it definitely has a role in medicine.
One of the things that I feel like I have really benefited from in terms of leadership training is doing some of these online strength finders kind of thing. One thing that comes to mind is like the Gallup Strengths Finder and really understanding a little bit more about myself and what my strengths are.
Understanding what your strengths are means you understand what your non-strengths or weaknesses are and honestly that’s helped me quite a bit in my professional interactions working with teams and things like that just to know a little bit more about myself.
I wouldn’t have necessarily guessed that before I did it, but it I have found that to be really helpful. So, people that have an opportunity to participate in those kinds of things, learn a little bit more about themselves. There are many different ones other than the Gallup strengths finder, but it just gives you a perspective on your leadership style, your learning style, your teaching style potentially, and your team interaction style, and those of others and how they can be hopefully complementary as opposed to
Khateeb: Fantastic. So, it sounds like the big theme here and
Heung: Yeah. My Twitter handle is @KeepingItRenal.
Khateeb: Oh, that’s that’s very punny. That’s nice. We really appreciate you taking time with us and that nephrologists like you exist to spend
Thank you very much.
|Resource Type||Resource Link|
|Dr. Heung Twitter Handle||@KeepingItRenal. ?|
|Online Strength Finders||Gallup Strengths Finder|
|Critical Care Nephrology Twitter Community||#CritCareNeph|
|Nephrology Journal Club on Twitter||#NephJC|