Nephrology and "The Big Fundamental"

Jay Koyner, MD, Associate Professor of Medicine at the University of Chicago, is Director of ICU Nephrology and Medical Director of Acute Dialysis. He is Co-Director of ASN's Critical Care Nephrology Kidney Week 2016  early program. His research centers on critical care nephrology with a primary focus on acute kidney injury. 

Jay Koyner, MD, Associate Professor of Medicine at the University of Chicago, is Director of ICU Nephrology and Medical Director of Acute Dialysis. He is Co-Director of ASN's Critical Care Nephrology Kidney Week 2016  early program. His research centers on critical care nephrology with a primary focus on acute kidney injury. 

Dr. Koyner plays in a weekly pick up basketball game every Sunday and prefers the team-focused approach of mid-major division I college basketball over the NBA. Follow Dr. Koyner on Twitter: @jaykoyner.


Being a life-long basketball junkie and a nephrologist, these worlds collided last week when Tim Duncan announced his retirement from the National Basketball Association after 19 hall of fame seasons with the San Antonio Spurs. For non-basketball aficionados Mr. Duncan is leaving the game as the best player to have ever played one of the 5 basketball positions, power forward. He retires as one of the 10 greatest players in league history, with numerous accolades including 5 NBA championships, 2 NBA Most Valuable Player (MVP) awards and perhaps the greatest nickname in sports, “The Big Fundamental.” As I read a handful of articles and blog-posts summarizing the career of this all-time great, I saw several parallels between Duncan’s career and the current state of nephrology.

Unlike contemporary all-time greats Kobe Bryant and LeBron James, Duncan worked in relative anonymity in a small media market with limited endorsements, and was all too often overlooked compared to other superstars. To me, this is reminiscent of nephrology: trainees only receive prolonged renal exposure if they specifically rotate on the inpatients consult service. While some programs offer dedicated nephrology-based inpatient services, this is not a universal rotation/requirement.  Other branches of the internal medicine offer exposure to their superstar faculty to all internal medicine trainees on dedicated inpatient services (e.g., cardiology, hematology-oncology or pulmonary critical care).  Nephrologists are more often relegated to serve as Duncan-esque players who appear only when a consult is called by the primary service.

Duncan spent his entire career playing with several other great players, including future hall of famer Tony Parker and retired hall of famer David Robinson. This ability to play well with others without seeking the limelight again reminds me of both inpatient and outpatient nephrology. Over his career, Duncan often deferred to his colleagues and often knew when to step aside and let them “take over the game” and guide the team to victory. This is not to say that Duncan was passive or a non-participant. In fact, Duncan retires having played the 11th most minutes in NBA history and ranks in the top 10 all time for rebounds and blocked shots as well as in the top 20 for total points scored. It is this longevity combined with him being the consummate professional teammate, which allowed him to be the only starting player on 3 distinct championship teams over 3 decades. For some critics it was always a flaw in Duncan’s career that he relied on others to help secure his championships; however just like in modern medicine, in the NBA it is impossible for a single star to achieve greatness and win championships without the help of their colleagues. In inpatient nephrology, we are often shifting roles on a day-to-day basis to care for hospitalized patients. To the trainee’s eyes, serving predominantly as a consultant may be seen as nephrology taking a back seat to others who are “leading” the charge. This aspect of nephrology, as a team sport, is unattractive to some, as they may feel that after many years of training they don't want to dedicate their career to a specialty built in part on collaboration.

Duncan has long-been known for his quiet workman-like demeanor; he played hard and consistently, delivering results without flare or bravado. Duncan was not flashy on the court, nor he was known for long-distance 3-point shots or high-flying 360-degree slam-dunks. His low post game was predicated on the “bank shot”- arcing the ball high above your opponent’s reach and using the glass backboard to angle the ball through the hoop. In a world where his colleagues are pushing boundaries; shooting the ball from further and further away (with increased accuracy) or providing increasingly athletic maneuvers to get to the basket quicker and with great agility, Duncan’s game was based on mathematics, physics and techniques that have been unchanged for decades. This is the quintessential comparison to nephrology.  Duncan’s bank shot is the functional equivalent of counter current exchange or calculating the rate of hypertonic saline supplementation in the setting of hyponatremia. Unglamorous and unsexy yet rooted in the fundamentals of medicine.  It is this physiologic foundation that first drew me to nephrology

As I see it, nephrologists exist in a world where their subject matter, grounded in human physiology, is labeled as complex and difficult to understand.  Our two most widely used diagnostic and therapeutic tools, serum creatinine and dialysis, are relatively unchanged over the last several decades. Many of the aforementioned articles and blogs referred to Duncan as a “throwback player” in a reverent manner;  to some medical students and trainees “throwback” connotes “old-fashioned” or even “antiquated” but that misses “the Big Fundamental” – that enduring aspects of nephrology enable us to contribute a classic and profound understanding to science and medicine.

Duncan retained the fundamental aspect of play and stayed at the top of an ever-changing game during his entire career. I see several promising and exciting areas that may move us beyond the incomplete view of nephrology to capture the excitement of our field of study and practice, including increased understanding of glomerular disease on the molecular level and novel biomarkers of acute kidney injury, among others.

Nephrology does have an image problem, and it is incumbent on all of us to look at our field and move it forward, to demonstrate to trainees and colleagues how exciting and dynamic nephrology can be. Nephrologists excel at collaborative medicine, and we should model that excellence as team-based care gains in importance. That does not preclude showcasing individual talents in field.

I suggest we embrace the myriad talents, tools and skillsets that nephrologists possess and ride them all the way to the Hall of Fame like Tim Duncan. Along the way we will adapt our game to ever-changing landscape of modern medicine, while continuing to cultivate those “big fundamentals” that are essential to advancing research, patient care, and professional satisfaction. 

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