Wednesday, May 13, 2009

the renal experience

the dumbest kidney
is smarter than the smartest doctor.

= a cute saying that is supposed to illustrate the amazing ability kidneys have to regulate electrolyte and water balance through an incredibly complex system of various channels and signals and feedback and all that. and it is pretty amazing, and i know i'm never going to get all of it straight. but i'm learning on this rotation that sometimes the saying is not actually true: some kidneys are pretty stupid and the result is that some poor kids end up on dialysis.

but most of the cases that i saw in renal clinic yesterday were not so sad. it was a lot of hypertension, some diabetes insipidus (and here i thought that was endocrine territory!), some proteinuria, and the like. then there was one classic 'i-don't-know-what's-wrong-with-my-kid-so-i'll-just-see-every-random-specialist-in-the-country' case, featuring an unfortunate autistic child with multiple medical problems but no known unifying diagnosis. mother of said patient came with the usual giant binder of records -- hundreds of pages worth of lab tests, imaging studies and treatments tried to no avail. she was a very nice woman and clearly did a wonderful job caring for her son, now well into his teens.

if i had to guess, i would bet that she is aware of the futility of her search at this point, but can't let go because feeling as if she is leaving no stone unturned helps her to deal with a very difficult situation. it's a very expensive coping mechanism, though.

after going through a review of systems that was literally positive for everything (example: does he have diarrhea? yes. constipation? yes. pain? everywhere. ), i did the best i could to focus on the RENAL side of things to answer the specific question of whether his kidneys were okay.

it turns out mom had made the appointment specifically because one of the patient's MRIs (performed for back pain) had a comment about a very mild finding (blunting of the calyces in case anyone cares) and she wanted to hear from a kidney specialist that nothing was wrong. so, after a long discussion of many things in which i tried to be as empathetic as possible, i brought the attending in, and we pulled up the scan on the computer and provided some reassurance.

she seemed cool with that.

i mention this case because as a future specialist, i know i will be dealing with a lot of patients like this. after the fact, i can't help but have some feelings of concern about the appropriate allocation of our health care dollars, but when the patient is in front of me i know the best thing i can do is just focus right there and imagine what it would be like to be that kid or that parent. i'm not sure there is an easy answer as to what is right, but i was glad our patient's mother left feeling satisfied.

back to the lab
well, not for a couple of years. but i have a meeting today with an investigator whose lab i may be interested in joining for the research portion of my fellowship (about 2 years). it's actually a lab i worked in for a (very) short stint during my research years. i remember really not liking the post-doc that i was paired with, but liking the overall atmosphere and the things that they studied.

i sort of can't believe that i'm going to be doing basic science again! it seems to far from what i'm doing now . . . but i sort of miss it in a way. i know that i still want patient care to be the main part of my peds endocrinology career, but i think it will be good for me to think about things in a different way for a while.

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5.12.09

workout: none. i think i'm better enough to try running this morning, though.

doin' time: not yet. but maybe today.

reading: about MODY (mature-onset diabetes of the young) + various metabolic disorders

flossing: no, because i ran out of floss! and my gums actually missed their nightly massage.

4 comments:

D10 said...Best Blogger Tips[Reply to comment]Best Blogger Templates

We have several doctors here that are in clinic 1-2 days and the rest of their time is spent on basic science. They all seem to like the balance it offers.

runsarah said...Best Blogger Tips[Reply to comment]Best Blogger Templates

I have heard that quote before, but thought that my lecturer made it up! What are you thinking of doing research in?

Claire said...Best Blogger Tips[Reply to comment]Best Blogger Templates

You know, when you said the mom brought in the typical larger BINDER, my brain was already on the renal system stuff and I read BLADDER! :-) Glad she accepted the kidneys-are-okay answer. I think the research is one of the things that deters me from a fellowship...of course, that may change if I find something I love next year!

atilla said...Best Blogger Tips[Reply to comment]Best Blogger Templates

one of my least favorite consults is " you have no surgical problem and I don't know what is wrong with you or how to help you" I read and reread the blog looking for dinner.

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