Standing on the Shoulders of Giants: We Need More Giants in Nephrology

In October 1978, after a year on the faculty at UCLA, I was invited to participate in a panel discussion on peritoneal dialysis (PD) at the Western Dialysis and Transplant Society’s (WDTS) Ninth Annual Meeting at the Hilton Hawaiian Village in Honolulu. During my training in nephrology at Northwestern University in Chicago (and my internship and residency at Michael Reese Hospital in that same city) I had become a strong advocate for PD. At that time I was placing Tenckhoff catheters at the bedside and prescribing either manual PD using bottled dialysate, or PD using the Baxter Physio-Control system, a proportioning device. I learned at the side of one of the great unsung leaders in dialysis therapy (then working at Lakeside VA Hospital), Dr. Peter Ivanovich—he had a deep passion for the care of patients but also understood the value in clinicians and clinical researchers collaborating with industry to guide research and development. Peter instilled in me many of the values that I have held throughout my career, and I remain grateful to him for that and am thrilled that he is still at it, now at Northwestern, helping drive innovation for kidney patients.

When I moved from Chicago to Los Angeles in 1977, I again was surrounded by giants: Chuck Kleeman, Mort Maxwell, Jack Coburn and many others. It was amazing. I immediately began a PD program at UCLA—the first in the city outside the VA system—which rapidly grew to 60 patients when plastic bags of peritoneal dialysate were approved by the FDA in 1978. I was therefore thrilled to be invited to talk about my experience with continuous ambulatory peritoneal dialysis at the WDTS in a session moderated by Dr. Karl Nolph. As a young aspiring academic nephrologist I was well aware of Dr. Nolph and his accomplishments, but had never met him. What happened at that session, at that meeting, was transformative for me. Dr. Nolph gave a fantastic presentation about PD in his typical erudite, organized, balanced and scientific manner. When he finished and the Q&A began, an eminent nephrologist from France stood up and said that peritoneal dialysis is a second-class therapy for second-class patients, performed by second-class doctors. The audience, myself included, was horrified. But Dr. Nolph handled it perfectly, in his calm, thoughtful way. He merely said he disagreed, that this was an excellent therapy for the right patient, that more needed to be learned about how to optimize its value, that patients deserved options and nephrologists had an obligation to understand all possible ways to improve the lives of end stage renal disease patients. And the session and the meeting continued. The rest is history, with hundreds of thousands of patients worldwide having benefited not just from PD, but also from the work and wisdom of Dr. Nolph.

Dr. Nolph spent more than 44 years at the University of Missouri, including service as the chief of the division of nephrology for 25 years. He not only made seminal scientific contributions to the field of nephrology, particularly related to PD, but he trained many nephrologists who went on to distinguished academic and clinical careers. Although for me all of these things were important and influenced my career and me profoundly, Dr. Nolph was a role model, a true giant in an even more important way. He was a profoundly kind, humble and compassionate human being. It was a joy to see him at every scientific meeting with his wife, Georgia, an accomplished physician herself. His generosity with colleagues was legendary. He inspired many to try to do better, not only for patients but also as human beings. Dr. Nolph died peacefully at home on Friday, June 20. He will be greatly missed, and never forgotten.

As we all contemplate why nephrology seems to have lost its appeal for young doctors, we should not only look at externalities (“too much work,” “salaries too low”), but also look inward. Who have we inspired? Who can look at us and say, “I want to be like them”? Which of us will have others say, “I stand on his/her shoulders”?

We would all be wise to do some introspection and remember the words of Sir Isaac Newton:

“If I have seen further than others, it is by standing upon the shoulders of giants.”