Yoshitsugu Obi, MD, PhD, FJIM, FASN
Advisor, Obi Clinic
I am a PGY-16 board-certified nephrologist and have done my clinical and epidemiological research at University of California Irvine between 2014-2018. While studying there, I have become intrigued with the US clinical practice, which I was not able to get familiar with just reading articles or analyzing data. I do need to do clinical practice by myself for this purpose, and I started preparing to become a US-certified physician even though it may seem ridiculous to start over my career at the age of 40’s. Therefore, it was very fortunate for me to obtain an opportunity for the 3-week externship at Division of Nephrology, University of Florida (UF). I learned a lot there, but here I would like to briefly summarize some of the most impressive experience.
Figure 1. South tower view from North tower
UF Shands hospital is a huge hospital with more than 800 beds (Figure 1), and health care is provided across four buildings including its associated Veterans Affairs medical center. The nephrology team divides into several groups into those physicians who cover the general wards and ICU, those who cover ER and the chronic care hospital, and those who cover kidney transplantation. Nephrology fellows rotate these locations throughout their training period. At Shands hospital, the primary care providers for inpatients are hospitalists and/or surgeons, and the main role of the nephrology team is consultation where they suggest treatment advice and provide dialysis treatments. They take care mainly of dialysis patients admitted for complications and those inpatients suffering from acute kidney injury and/or electrolyte abnormalities. Fellows see patients early in the morning and then meet the attending physicians to discuss treatment options. They start ward round after electric medical record review, which is very similar to what I have done in Japan.
One of the biggest differences to Japan was the socioeconomic backgrounds of patients. There were quite a few young patients with alcoholic cirrhosis complicated by hepatorenal syndrome and those IV drug users with infectious endocarditis complicated by acute kidney injury. I often encountered hemodialysis patients coming into ER for fluid overload after skipping their last treatment session for a variety of reasons. Also, I recall meeting an undocumented and uninsured immigrant patient with ESRD who presented to the ER in the middle of the night after driving all the way from Orlando, where he had been receiving regular hemodialysis care for many years, in the hopes of receiving a kidney transplant. Shands hospital, like most hospitals in the US, face challenges of taking care of uninsured and undocumented patients with chronic comorbidities such as CKD and heart failure. Some states, such as California and Illinois, are able to offer kidney transplantation to select undocumented ESRD patients, mainly because it is less costly than continuing regular hemodialysis. Nevertheless, I was deeply impressed to see that the nephrology physicians always made every effort to listen to patients, feel for them, and respect their will regardless of their social backgrounds.
I had been just certified by ECFMG when I started this externship, and now I am preparing to start my career as a physician in the US. Therefore, it was a highly valuable opportunity for me to observe real clinical practice at UF Shands hospital before I work as a nephrology fellow. I greatly thank the nephrology attendings Dr. Tantravahi and Dr. Ali (Figure 2) who gave me flexible learning opportunities and taught me US medicine through discussions during their busy working time. I also thank Dr. Mark Segal, the Chief of Nephrology, and all the staff including Kayla; they welcomed me with warm hospitality although I was a total stranger to them. My special thanks go to Dr. Gerald Stein and ACP Japan Chapter for providing such a unique program. My experience at UF Shands hospital will definitely help me pursue my ambition to become a physician-scientist in the US, and I will strive to make my best effort to achieve my goal.