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Advice for New Nephrologists

Nephrology can be a challenging practice, so it’s crucial for nephrologists to truly love what they do and explore the opportunities that make sense for them. As a mentor for nephrology fellows, I frequently share advice with new nephrologists beginning their careers. This advice often involves asking them two questions that have increasing relevance in today’s world—and these questions have yet to be answered correctly by anyone in the audience, in more than 20 years. I believe this is due to a true lack of understanding of what is important in their professional lives.

The following two questions and the answers have increased in relevance as we enter an age in which integrated care puts increased pressure on physicians and the health care system and puts increased focus on doing the right procedure for the right patient at the right time.

1. What is the most important thing for nephrologists to experience in medicine?

Answer: To have fun. Physicians have a gift. You can consider it God-given or otherwise, but it is a gift—a gift to be able to walk into the room of a patient (who can be a complete stranger) and have him or her share personal details about life with you. Our gift is no different than the gift a musician or an artist may have, creating music or art out of nothing. During residency and fellowship training programs, doctors hone their gift and hone their respect for patients. If they don’t understand that they have a gift and that this gift exists for their patients and their communities and not for themselves, then they will never be happy and they will never have fun. I contend that they should wake up every day with the passion and excitement to be able to use the gift they have, the gift that continues to grow: to care for patients and be a part of the health care system where they are being trained as leaders. If they lose their passion, if any of us lose the ability to have fun, what are we, after all? Just unhappy practitioners passively floating in the sea of change that flows all around us.

2. What is the hardest—yet often imperative—thing in all of medicine to do?

Answer: To do nothing. Why is doing nothing so hard? It’s hard because it takes time, and time is one of the most valuable commodities a doctor has. Also, there are expectations for action. Patients expect you to do something, such as prescribe a medication for their symptoms, even if the symptoms will resolve on their own. A senior resident or an attending physician can pressure you to do something, such as order a fourth CAT scan or an EEG, when the results to not add to the knowledge of the case.

Doing something can feel imperative, but that can have unnecessary financial and clinical costs.

Doing nothing is hard. It can be difficult to explain that your clinical observations justify waiting and watching, sometimes in an outpatient relationship, rather than pumping out test after test that adds little to patient care—and could even increase risk. Doing nothing is also a skill. It’s sitting down with the patient and taking a few extra minutes to explain why holding off on a test is more prudent than moving forward with it. It’s the time you spend helping an elderly patient better understand why just because something can be done doesn’t mean it should be done.

Come to think of it, these two questions help me better understand many aspects of today’s health care focus. I can only hope that as class after class of interns, residents and fellows pass through our institution we will build on the idea of finding a necessary balance between channeling their passion and the ability to do the right thing at the right time for their patients.

Robert Provenzano, MD, FACP, FASN

Robert Provenzano, MD, FACP, FASN

In addition to his roles as chief medical officer at Nephrology Practice Solutions and vice president of medical affairs at DaVita Kidney Care, Robert Provenzano, MD, is a clinical professor of medicine at Wayne State University School of Medicine in Detroit, where he earned his medical degree. He completed his fellowship training at Henry Ford Hospital and served as the chief of the nephrology, hypertension & transplantation section and director of nephrology research at St. John Hospital and Medical Center in Detroit. Dr. Provenzano is former president of the Renal Physicians Association and chair of the National Kidney Foundation of Michigan. He is also former CEO of St. Clair Specialty Physicians, PC, a multistate nephrology practice. He has published extensively on kidney care business models and is the chief medical officer of Nephrology Practice Solutions (NPS), a national kidney care management company affiliated with DaVita that oversees owned and managed practices. Twitter: @DrBobPro