Distinguished Conversations

Bill Bennett, MD, FASN

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William Couser, MD

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Dr. Bennett: Dr. Couser, would you introduce yourself briefly and describe a little bit about your current activities?

Dr. Couser: I am a nephrologist who was president of ASN 20 years ago and was Head of the Division of Nephrology at the University of Washington for 22 years, before retiring from clinical practice in 2004.

My life since then has been quite busy. I was Editor-in-Chief of JASN for 6 years from 2001 to 2007. I also held leadership positions with ISN from 2001 to 2013, which involved a great deal of time and travel. I’m still busy writing book chapters and review articles, and reviewing manuscripts for journals. I also continue to teach some fellows at the University of Washington and in courses elsewhere.

Dr. Bennett: How did you end up becoming a nephrologist?

Dr. Couser: It all began with a young man with Goodpasture’s syndrome I saw as an intern at UCSF in 1966, 50 years ago. The patient rapidly developed severe renal failure and was not considered eligible for a transplant because of his pulmonary disease. Dialysis in those days was only available to patients waiting for transplants, so I was instructed to inform the patient and his family there was nothing further we could do and to send him home to die.

I went to the library, looked up glomerulonephritis (GN) (there was no PubMed then!) and found a paper about a study from NYU in the 1950s in which several patients with severe GN were treated with infusions of nitrogen mustard and some responded. We treated this patient with nitrogen mustard, he had a dramatic response and was discharged free of pulmonary disease with a serum creatinine that had fallen from about 4 to 1.8 mg/dL, and he did well over the 2 years that I followed him. However, I formed a very negative opinion of nephrologists at the time because they seemed to know and care mostly about how normal kidneys worked and had little knowledge of, or interest in, kidney diseases.

Two years later as a senior resident on the Harvard Medical Service at Boston City Hospital (now Boston Medical Center), I met Ed Lewis, the new Chief of Nephrology, who had a particular interest in immunologically mediated renal diseases like Goodpasture’s. That reignited my interest in what caused Goodpasture’s syndrome in my patient at UCSF. So I entered nephrology training as a research fellow with Ed, funded by the National Kidney Foundation (NKF), started working on animal models of GN, and continued that work in my own laboratory with NIH funding for the next 3 decades.

Dr. Bennett: Dr. Couser, it is well known that during that time you contributed a great deal to the nephrology literature in the areas of immune-mediated kidney diseases. Looking ahead 25–30 years, how would you say the results of your work will translate into modern research? Where do you think it will all end up?

Dr. Couser: I am already gratified to see that happening. The experimental work I did around 1980, with David Salant as my fellow, on in situ immune deposit formation and the role of complement C5b-9 in membranous nephropathy, has now been brought to fruition in human disease by David with his recent discovery of anti-PLA2R antibody as the pathogenic antibody in human membranous nephropathy. That is a beautiful bench-to-bedside story and a major advance that already has an impact on the care of patients with this disease.

Clinically, it has also been rewarding to see the entity of crescentic GN without immune deposits that we first described in 1979 evolve into the whole ANCA-associated vasculitis story, and steroid pulse therapy for GN, which we first described in 1976, remains (somewhat to my embarrassment!) standard of care for crescentic, rapidly progressive GN. In a broader sense, that early work on membranous nephropathy helped change the prevailing thinking about immune complex nephritis from the older concept, that these diseases were like serum sickness induced by foreign antigens and circulating immune complex trapping, to a new view that most were autoimmune and involved in situ deposit formation due to antibody binding locally to antigens fixed or planted in the glomerulus. I think the ultimate significance of that work will come as advances in autoimmunity lead to identification of more nephritogenic antigens, clarification of the genetics of autoimmune responses, and then to ways of restoring tolerance to immunogenic proteins in autoimmune diseases like GN.

But research is like building a pyramid where each of us adds a few bricks to what has been laid down before and others then build on our work to eventually create a pyramid of knowledge that allows prevention or successful treatment of a disease.

Dr. Bennett: Well said. Having led a division and served as president of the two largest renal societies (ASN and ISN), what are your thoughts about the way we’re training people for the future? Are we doing it correctly? Also, why do you think nephrology is less popular with residents than it used to be, and how would you get it back on track if it is indeed off track?

Dr. Couser: The era you and I grew up in, the era of the physician-scientist, is coming to an end. During that era, those who went into academic medicine were expected to do research, take care of patients, and teach all at the same time and at the same level of excellence. It is still possible, but now much more difficult, to be that kind of physician. To successfully run a productive lab, secure research funding, and train research fellows is a full time job. The same is true of clinical care. If you want to be on top of the latest in clinical medicine and develop and maintain the necessary skill set to provide the services your patients expect and deserve, you have to do that almost full-time. So there likely will be increasing separation of physicians who are actively involved in research and those who are primarily involved in clinical practice. That requires the best training programs to offer a diversity of faculty and well developed options and pathways that can accommodate the different career goals of trainees.

Dr. Bennett: You were president of ASN in 1996–1997 and served on, or near, the Council for 13 years including your term as Editor-in-Chief of JASN. What do you consider your most important contributions to the society?

Dr. Couser: One of the accomplishments I am most proud of was leading the discussions with the NKF that led to NKF discontinuing its fall meeting, which took place for many years in the same venues in the three days preceding the ASN meeting. That agreement allowed ASN to control the venues, program events before the main meeting, and expand into “Renal Week,” a format that continues today as Kidney Week and has been essential to ASN’s meeting its overall goals.

Second, I emphasized public policy as a new priority for ASN. As president, I helped recruit the first full-time ASN public policy staff person (Jill Rathbun, a former House staffer). ASN public policy efforts have continued and become much more robust since then and have contributed to many legislative initiatives that have greatly benefited both research and patient care.

Finally, I had the good fortune to work with particularly visionary presidents of NKF (Alan Hull) and RPA (Rick Latos) to create the Council of American Kidney Societies (CAKS) to coordinate and streamline policy initiatives on behalf of kidney patients, and to serve as the first president of CAKS. Prior to CAKS, congressional testimony from the 3 major kidney societies on behalf of kidney patients was separately delivered, disjointed, overlapping, often in conflict, and consequently often counterproductive. Although CAKS itself has undergone several iterations since then and never totally fulfilled its initial promise, ASN does continue to work closely with the other sister renal societies in the US on issues of common interest.

It is very gratifying to me to see outgrowths of all three of my major initiatives as president still apparent in ASN policies and programs now 20 years later.

Dr. Bennett: How has the career and field of nephrology changed during your professional life?

Dr. Couser: Dramatically! Nephrology as a clinical discipline did not exist until the advent of hemodialysis in the 1960s, which gave nephrologists a real clinical tool for treating patients and thus created a whole new patient population with some of the most complex clinical problems in medicine. Thus the discipline was new, exciting, and had unlimited opportunity when I first entered it in the 1970s.

The research enterprise has changed dramatically too with the advent of cell and molecular biology tools, molecular immunology and genetics, and the capacity to generate big data and probe very large databases for new clues to etiology and pathogenesis of renal diseases. When I began attending ASN meetings in the 1970s, my own research area of pathogenesis of GN was allocated only one 2-hour session called “Immunology and Pathology.” Today that topic is covered in an entire theme with many sessions held on every day of the meeting. This change reflects in part the growth of research on renal diseases like GN in departments of medicine whereas it was previously done mostly by pathologists. I hope my own career choice as a clinical nephrologist to pursue basic research on mechanisms of GN played some role in stimulating that type of research within divisions of nephrology where research previously was almost entirely devoted to renal physiology.

Dr. Bennett: If a young resident came to you and said, “I’m interested in nephrology,” what would you tell them in 2016?

Dr. Couser: First, I would applaud and encourage them for selecting a field with the uniquely interesting and challenging clinical problems that nephrology presents. We are often told on consult services that nephrologists are the best clinicians and teachers in the hospital, and I think that has generally been true, although the current decrease in interest in nephrology as a career may imperil that status.

If you are interested in nephrology and want to become a clinician, you have to enjoy the challenges sick patients present and appreciate the rewards of being able to deliver long-term primary care to those patients. The training path is clear and can be provided by many programs.

If you want to pursue an academic career with a research component trying to understand and better treat kidney disease and be involved with clinical care primarily in a teaching and training capacity, you’re facing a longer path. You have to be willing to put in the extra research training time, which may be years, and maintain a focus on long-term goals before your work actually pays off in terms of discoveries that make a difference to patients. Most residents or fellows tell me: “Well, I love clinical care, but I think research is very interesting and I want to try it out for a while.” I can honestly say I don’t think I’ve seen anyone who just “tried it out” in the 30 years I’ve trained people in the laboratory who ultimately decided research was what they wanted to do and were successful at it. Most who excelled in research had prior experience with research as a college or medical student and already knew it was what they wanted to do before they began basic research training. I cannot over-emphasize the importance of early exposure to nephrology and research at the medical student level in influencing subsequent career choices. That is something we need to get much better at.

Dr. Bennett: What would you like to tell readers of Kidney News about ASN or your experience as an academic leader, research contributor, and physician-scientist regarding the future?

Dr. Couser: The top challenge ASN and the kidney community face today is addressing why nephrology is becoming less popular as a subspecialty. Multiple committees and learned bodies have examined this question, written papers about it, and made suggestions for changes, and all of them make important points. I think the bottom line is that nephrology is not as appealing a career as it once was because of perceptions that 1) the work is too hard because the patients are very sick, complex, and usually don’t get better, and increased government regulation (like G codes) make additional work without improving patient care, and 2) the job opportunities, especially locally, and income potential are too low. These two things play a big role in most peoples’ career choices today. They played less of a role when you and I were starting because career paths were chosen then based more on role models, people you respected and whose skills and careers you wanted to emulate.

Students today, and I doubt this is unique to medicine, have a much more personal perspective about life choices and look much more carefully than we did at the income they will make and the impact of their careers on their personal lives, their families, and the time they have available to do other things. Nephrology, when viewed in light of those priorities, does not look as attractive as some other less clinically intense options.

Salvaging nephrology is likely to involve more dramatic changes than just tinkering around the edges. ASN and other kidney organizations work hard to mitigate the clinical challenges and reimbursement issues for nephrologists, and a strong public policy effort is essential to keep these issues alive and under discussion. The workload problem can probably be improved if nephrologists become leaders in new care models where Advanced Practitioners take on a larger share of daily patient management, if reimbursement policies support that model. More telemedicine may also help. But because of ASN’s strong connection to training programs and research, it can play a major role in structuring the discipline in other ways. For example, it is possible we are trying to train too many nephrologists and thereby compromising job opportunities for graduates. ASN can certainly play an important role in defining the optimal size and structure of the nephrology workforce to meet current needs. I applaud ASN for its many committees and taskforces working on issues like the Match, better exposure of students and residents to nephrology, and other workforce-related issues.

Enhancing the attractiveness of an academic research career will require making successful physician-scientists more visible to students and house staff as role models, as the ASN Kidney TREKS program is starting to do. Then we need to increase the security of a research career by improving overall research funding and providing some bridge support by which people who successfully complete good research training programs are guaranteed initial research funding for the start-up phase of their careers. Recent increases in NIH funding are encouraging, but by providing inadequate funding for many years, we have been bleeding the physician-scientist workforce in the US for a long time, so there is a long way to go to rebuild it. And saving the renal physician-scientist from extinction will require that the earning potential of successful researchers compete better with the income earned by most clinicians than it does today.

I think the current status of nephrology as an “endangered subspecialty,” reflected by the low level of interest of US residents and difficulty in the past few years filling training program slots, justifies developing an “affirmative action” plan that addresses the major issues. For example, residents might be offered special incentives to enter nephrology training such as “sign-up” bonuses, loan forgiveness programs, help with visa waivers, guaranteed start-up research grants for good research fellows, and compensation packages that narrow the gap between those doing the research and training and those only providing patient care. When considered in light of the overall healthcare expenditures for kidney patients, the cost of steps like those would be trivial. And we have good data showing that care provided by well-trained nephrologists is both better and cheaper than care provided by non-nephrologists. It is not fair to assign ASN all of the responsibility for making nephrology more attractive to residents because there are many larger forces at play in the healthcare world, but ASN, both directly and through its public policy efforts, can have a significant impact in several of these areas. A giant step forward, which is unlikely to ever happen, would be if the US had the wisdom to initiate a national service requirement that physicians could satisfy by undertaking research training or entering endangered subspecialties like nephrology.

My message to readers would be the same as the major message of my ASN Presidential Address in 1997: If you want to see change, and we need it more now than we did then, get involved and contribute your time and voice to making things happen. And that is true not only at the national level where ASN operates, but particularly at the local level where nephrologists need to be much better organized and more active to prevent the discipline from being marginalized by forces constantly focused on the bottom line rather than improving care of sick patients.

Dr. Bennett: Dr. Couser, I’d like to officially congratulate you on a wonderful career, significant contributions to the discipline of nephrology, and very significant contributions to the workforce of nephrology by your many trainees, who are now following in your footsteps and leading many university nephrology programs all over the world.