Distinguished Conversations (Full Text)

Sharon Moe, MD, FASN

/kidneynews/8_5/14/graphic/14f1.jpg

Sharon Anderson, MD, FASN

/kidneynews/8_5/14/graphic/14f2.jpg

Dr. Moe: How did you decide to go into nephrology? What was your runner-up in terms of specialties?

Dr. Anderson: My decision to go into nephrology was serendipitous. I had vague thoughts of being a primary care doctor when I started medical school.

The nephrology training I received as a medical student wasn’t very good, and I think this is an area we can improve on. So although I started my internship without a clear idea of what I wanted to do, I was lucky that my second rotation was on a renal ward. We had terrific patients on the ward—patients with glomerulonephritis, dialysis patients, and transplant recipients. I had an outstanding attending, Dr. Bill Bennett, a former ASN President. The combination of interesting patients and a dynamic attending made me fall in love with nephrology, and I never really considered anything else.

Dr. Moe: Many institutions now employ hospitalists and no longer have renal wards. How has the movement away from renal wards affected the practice of nephrology?

Dr. Anderson: I think we’ve lost a great opportunity for instilling interest in nephrology.

Many people, including me, were able to get medical students, interns, and residents excited about nephrology through the experiences on the renal ward. Hospitalists are now the role models on the wards, so we’ve lost this very important contact with our trainees.

The other issue that I think is of great concern is that fewer and fewer nephrologists attend on the general medicine wards. When I was a junior faculty member, everyone had to attend on the general medicine wards, whether they were good at it or not. With all the changes in the curriculum and training, nephrologists’ exposure, even to residents, is much less than it used to be. Our residents, for example, do renal consult rotations, but sometimes they last just a week or two. By not being front and center and right there with trainees, we are losing a huge opportunity to get them excited about nephrology.

Dr. Moe: How has your career in nephrology changed during your lifetime? What other aspects of nephrology have changed?

Dr. Anderson: I think careers in nephrology and nephrology itself have changed in dramatic ways. Sometimes when I’m talking to young people, I tell them that when I was in training, if you were an academic, there was sort of a clear path to follow. You did a research fellowship—it was all bench research in those days—and you wandered up the academic path. Then maybe you became a division head later on.

Now there are so many different paths people can follow. The career of being a clinician educator has blossomed in recent years, and deservedly has become a very viable and vibrant career path.

Obviously, the practice of nephrology has changed in that we have more novel therapeutics. We still don’t have a lot of great treatments for CKD, but at least for some of the glomerular nephridities, there are exciting treatments. I think the practice of dialysis will always be a huge part of what we do, but that seems to be evolving and changing too, with a greater emphasis on quality and perhaps more scrutiny of how we do things.

And then of course there’s everything beyond traditional nephrology. Many people have found successful careers in pharma, for example, or in other academic roles, such as my current role as chair of medicine.

Dr. Moe: As chair of medicine, how do you recruit top talent and balance academia, teaching, patient care, and your own research? How do you advise junior faculty to find their niche?

Dr. Anderson: I will start with my own career. I heard a great anecdote once: A young person went up to a senior academic and said, “You are a quadruple threat. You’ve done everything—you’re a great teacher, a great researcher, a great administrator, and a great clinician. How in the world can you do everything so well?” The answer was, “Not all at the same time.” I think that is the perfect answer.

Our careers have chapters. For much of my career, I was a basic scientist and spent much of my time in the lab, sometimes teaching and doing clinical work, sometimes a bit of administration. During the current chapter of my career as chair of medicine, I’m obviously spending a lot of time doing administration. So you can’t do it all at one time, but you can certainly do it all over the course of a career. For me, that keeps it fresh—there are new challenges with each chapter of my career.

I tell young people that they need to be proactive in deciding on their career path. When I was younger there was basically one career path, and nobody knew there were others. Now there are many different career paths, and young people need to actively seek the mentors they need and focus on their chosen path. To be outstanding clinicians and educators, they need to get training in how to apply modern concepts of teaching and perhaps try to not get too distracted participating in clinical trials, for example.

There is a short period of time when young people can begin their junior faculty career and dabble in all kinds of things. Here is my advice: Figure out what you want; go out and get the additional training you need, whether it’s an additional postdoc equivalent, educator training, or whatever; and keep your eye on where you’re going.

Dr. Moe: ASN is celebrating its 50th anniversary this year. As you think back to what you remember about ASN, what was your first encounter with the society?

Dr. Anderson: I was fortunate to encounter ASN very early in my career. As a medical resident, I decided I wanted to pursue nephrology and got involved in some research projects with David McCarron doing rat studies, partially as an elective but mostly on nights and weekends, which is how research seems to work when you’re a resident. I was fortunate to get a couple of projects done, and during my first year of fellowship I had a poster at the ASN meeting. I went to the ASN meeting early in my career and have gone every year since.

Most training programs are very proactive about getting their fellows involved with ASN, and as you know, ASN offers programs to bring residents and even medical students to the meeting. The earlier we can get young people to come to the meeting and see all the exciting things that are going on, the better.

Dr. Moe: How has the ASN meeting changed since your first meeting?

Dr. Anderson: In the good old days when it was held at the Omni Shoreham Hotel in Washington, DC, the ASN meeting was much smaller and more intimate, which was nice in its own way because you had a pretty good chance of running into everybody you knew. Now it has become much larger—as it should.

There was less clinical science at the early ASN meetings. Over time, it became clear that not only is clinical nephrology something we all continue to do, but we have a very large audience who are interested—perhaps more so than in the past—in clinical and translational science. Embracing clinical and translational science, by definition, helped to expand the society.

There are so many different things going on in nephrology now. All the efforts on quality and performance improvement, onco-nephrology, and many other subfields of nephrology did not exist 10 or 20 years ago.

The ASN meeting is the premier nephrology meeting in the world, and we are very fortunate to be able to attend.

Dr. Moe: What did it feel like to be the first woman president of ASN?

Dr. Anderson: I felt that it was about time, don’t you think?

I believe my time as the 46th president of ASN mirrored what was going on in the larger society. When I gave my presidential talk, I showed a picture of the founders of ASN, who were eight white men—they were the ones doing nephrology back in 1966. Obviously the field has greatly expanded in terms of not just gender, but ethnicity as well. I felt it was really a step forward for our society to have a woman as president.

Men outnumber women in nephrology today, although not nearly to the extent as when I was in training and coming up the ranks. But I think that the more the leadership as well as the membership of ASN can reflect the diversity in our profession, the better. I was honored and pleased to be the first woman president of ASN. And then of course my colleague, Dr. Moe, was the second ASN woman president, so we’re making progress.

Dr. Moe: Yes, and now we have our third and fourth Councilors (who will be president), Eleanor Lederer and Susan Quaggin, so things do change.

How did being ASN president help you look at the ASN in a different way, in terms of how we approach trainees and how we look at health care? Do you feel that being in that kind of position changed your view of ASN in general?

Dr. Anderson: I was pleased that I was able to be part of helping ASN move in the direction of greater diversity. As you know, increasing diversity was one of my crusades as ASN president. I felt it was extremely important that, for example, all of the committees and advisory groups not only have reasonable representation of women, but also that women be represented among the leadership of the groups.

The focus is not just gender diversity, but also experiential diversity. We need to get young people involved and active in leadership roles. The business world learned that diversity is good for business a long time ago, and it’s good for us as well. We need to understand the interests and needs of our constituents and tailor our programs and offerings to fit.

Dr. Moe: What do you think we should be doing over the next 50 years—or perhaps the next 5 or 10 years?

Dr. Anderson: We need to be continually attentive to trends that will affect not just patient care, but how we practice. For example, we are moving rapidly into the era of value-based care. It’s not going to be all relative value unit (RVU)–based, and I would love to see ASN take the lead in helping nephrologists figure out the best way to deliver that care.

You and I both work at the VA, so we know that the VA has advantages in this arena. We’ve been doing telemedicine and electronic consults at the VA for years. I can electronically answer the vast majority of the renal consults I receive without wasting the patient’s or my time in a 20-minute visit that isn’t needed. My university is just starting to pilot e-consults, so they’re learning.

All of medicine is struggling to figure out how best to deliver value-based care. Perhaps ASN, for example, could explore some sort of best practices in health care delivery—not just clinical guidelines or the best way to treat diabetic nephropathy—but innovative ways to deliver health care. There are some great experiments out there, such as the SCAN Echo project, which involves telehealth for people who live in remote locations, as do many CKD patients. We should always aim to improve the efficiency, patient centeredness, and quality of the care we deliver.

I was a training program director for a long time, and although I am not one now, I think nephrology training will be a challenge for the next several years. We need to rethink it. This might sound heretical, but one of the reasons hospital medicine is so popular is because it is shift work. To those of us of a certain age, the concept of shift work and the resulting discontinuity in patient care is anathema, yet shift work is what seems to be selling these days. I would love to see nephrology training programs continue to innovate and look at different ways to fashion the training experience, because training programs need to be perpetually attentive to what is going on in the practice world.

Dr. Moe: Do you think long work hours have driven a move to this so-called shift-training? In terms of general medical education, we’ve made a lot of changes in the past 5 or 10 years. Do you foresee any additional changes down the road? Will the 80-hour work week continue?

Dr. Anderson: It is hard to know. There has been a bit of a backlash to duty hour restrictions now. It is difficult to prove that duty hour restrictions actually improve patient safety, which was the original goal. The tradeoff for residents who aren’t so tired is endless handoffs of patients, so it is difficult to figure out who actually “owns” the patient or has been following the patient for more than a couple of days.

I do not think the concept of not wanting to work 100 hours a week is going away. Part of it is a generational thing. Millennials and younger people are better at demanding a better work–life balance than people ever were when I was their age. Whether or not you prescribe how many hours interns can work at a time, we will not again see the days when they were on every third night and stayed overnight in the hospital. We have to adapt as well. Maybe knowing that you are likely to be called in the middle of the night is distancing people from nephrology. I haven’t seen much in the way of, for example, nephrology fellow nocturnists, so to speak. Perhaps we could do what hospitalists, cardiologists, and ICU doctors do, and have someone whose job it is to be there at night for a whole week, with a day team coming in fresh each morning.

Again, I am not a training program director currently so there may be more going on than I’m aware of. But I think we have to do something to stem the diminishing attractiveness of nephrology to people looking at careers.

Dr. Moe: I think we have to think outside the box. We’ve been stuck in a rut with the same types of programs for a long time, and a lot of work is going on at ASN to think outside the box. But it will take time for us to come to whatever might be the new norm.

Dr. Anderson: Yes. ASN will be at the forefront of these efforts. The society’s very active Training Program Directors (TPD) group meets every year at the ASN meeting, and is also very active throughout the year. TPD is a great example of how ASN contributes to our profession by fostering and supporting an active group of very dedicated educators who want to figure out the right thing to do and how to do it.

Dr. Moe: Tell me about your professional accomplishments over the years. If you had to state the best three things you accomplished, what would they be?

Dr. Anderson: I was fortunate early in my research career as a fellow to be involved in some very important work. I was part of the group that originally looked at the use of ACE inhibitors in experimental progressive CKD. It worked very well in rats, and turned out to benefit patients as well. If I did not accomplish anything else in my career, I would be humbled and honored to be recognized for my involvement in this work that helped advance understanding and treatment of kidney disease. That work was exciting and will always remain with me.

Much of my career since then has been a bit accidental. So I am talking out of both sides of my mouth when I say that young people need to figure out exactly what they want to do very early on. I did not. I was moving along in my career and opportunities came my way. My first administrative role was a number of years ago. I was working at the Portland VA when my section chief walked into my office and said, “I’m leaving the VA, and I want you to be the interim section chief.” I started crying and said, “You can’t leave, I need you here. I can’t be the acting section chief.” But the opportunity was there and I took it, and really enjoyed it.

I think this makes an important point—that you need to keep your eyes open to opportunities that come your way. I’m a big fan of Sheryl Sandberg, COO of Facebook, and her book Lean In is an inspiration to me. She has a great anecdote: One of her friends wrote to her and said, “I was going to apply for this or that job with you, but then I realized everybody is asking you for a job, so let me do this. Let me ask you what you need.” Sandberg replied, “I really need help with HR.” Her friend said she would do it. Sandberg makes the point that your career may veer off in unexpected paths, but you need to be open and take the opportunities. I have done that too.

At one point, the Dean came to me and asked if I’d be the first ever Associate Dean for Faculty Affairs and Faculty Development. I said “Okay… what is that exactly?”

I’ve found my attention span, career wise, is about 6 or 7 years. By the time I’ve been in a job that long, I’m starting to think that maybe I should think about doing something else. I’ve been fortunate to be in places where those opportunities are there.

As you know, I did my training at the Beth Israel Hospital and Brigham and Women’s Hospital and was there for several years. Then I started looking for jobs. One of the reasons I chose Oregon Health & Science University, which is where I am now, is that I sensed it would be a place where multiple opportunities might arise, including things that I wasn’t even thinking about then. And that has happened. For me, career changes have been about keeping an open mind and taking a leap. As is often said, “Life begins when you step outside your comfort zone.”

Dr. Moe: I basically had the same situation. One thing led to another entirely different position. Sometimes, things come your way and provide an opportunity that changes your career trajectory. I think if you worry too much about what the future holds and try to plan too much, sometimes it might just hold you back.

Dr. Anderson: Exactly.

Dr. Moe: What about balancing career and personal life? As ASN’s first woman president, what would you tell the women in our profession who want to know how you managed and how it affected your personal life?

Dr. Anderson: Everyone needs to be able to prioritize, and everyone’s priorities are going to be different. I find it very helpful to compartmentalize. When I’m in work mode, I’m working. When I’m not, I’m not. Compartmentalizing requires developing some personal skills, and you have to figure out how to do that for yourself. I really love my job and always have, so it’s not a strain on me to put in the number of hours needed to do it well. But I have also realized that I need to carve out some time for myself. Some would argue I’m not as good at that as I should be, but I strive to do it.

You can think of your career in chapters. There are times when you will be able to put in more hours and energy into your work and other times when you cannot. And that’s okay. You just have to do what seems right at the time. Whether you are taking part-time work for child care—or whatever—you will see what the world looks like when you return.

Dr. Moe: I think one of the advantages of a career in medicine is that there are so many different ways to make it work. You can work in many different environments and locations and it can be part-time or full-time. When I speak with people thinking about medicine as a career and all the years of planning needed, I tell them, “Yes, but when you’re finished, you can do whatever you want to do and carve it out for yourself.”

Dr. Anderson: Absolutely. One of the reasons I decided to go into medicine was that I sensed (with a lot less knowledge than I have now) that there would be multiple opportunities out there. Nephrology is a great field. I hope it continues to be as vibrant as it is and that we get a little better about recruiting people into it.