Ep2: Dr. Nathaniel C. Reisinger, MD, Cooper University Health Care, on Point-of-Care-Technologies in Nephrology

Hills and Valleys Podcast Ep 2: Dr. Nathaniel C. Reisinger on Point-of-Care-Technologies in Nephrology

Hills and Valleys is a podcast that uncovers stories from leaders in healthcare, tech, and everything in between. Straight from the heart of Silicon Valley, we give you a look at the good, the bad, and the future, one episode at a time. Brought to you by Potrero Medical.

About Dr. Nathaniel C. Reisinger, MD, Cooper University Health Care,

Nathaniel C. Reisinger, MD, is an Instructor in the Department of Emergency Medicine and Fellow in Clinical Ultrasound at the Perelman School of Medicine—Hospital of University of Pennsylvania in Philadelphia, Pennsylvania. After completing his MD at the University of Texas Southwestern Medical Center, he completed his residency in internal medicine at New York Presbyterian Hospital—Columbia University Medical Center, followed by his nephrology fellowship at Penn.

Dr. Reisinger’s clinical interests are focused on adapting novel technologies to enhance patient care and outcomes in nephrology. He was an educator long before venturing into medicine and is building a point-of-care ultrasound curriculum for nephrology fellows to help bring in the age of the ultrasound stethoscope.

Dr. Reisinger has a keen interest in the use of social media in nephrology. He is a 2017 intern in the Nephrology Social Media Collective . He is Editor-in-Chief of Kidney.Cloud (app available on iTunes & Google Play) and Jeff Berns’ chief social media strategist @Jeff_Berns_POTD. In addition, he works on the American Society of Nephrology’s joint quality improvement project with the CDC, Nephrologists Transforming Dialysis Safety, for preventing infections in the dialysis unit. He was recently named chief social media strategist for the Nephrology Business Leadership University. Dr. Reisinger has also been featured on DocTalk and is a recurring invited speaker with the Cardiorenal Society of America’s Cardiorenal University.

You can read his blogs here or follow him on Twitter @nephrothaniel

Listen to the podcast on any of the platforms below, watch the full video interview, or continue reading this blog to see the transcript.

Interview at the American Society of Nephrology on Point-of-Care-Ultrasound, Social Media for Nephrologists, and More.

Interviewer: Omar M. Khateeb, Director of Growth atPotrero Medical
Interviewee: Dr. Nathaniel C. Reisinger

Khateeb: Hi everyone, Omar Khateeb here at Potrero Medical. I’m joined by Dr. Nathaniel Reissinger here at Kidney Week 2018.

Dr. Nathaniel Reissinger, thank you for joining us; we appreciate it. So before we jump in and talk about the future of nephrologists, why don’t you tell me a little bit about yourself and your background. What got you into nephrology?

Reisinger: Sure. My name is Nathaniel Reisinger. I’m a nephrologist at Cooper University in Camden, New Jersey. I just graduated a fellowship not too long ago–about three months now in practice. I trained at Penn for my nephrology fellowship, and then I did a one-year ultrasound fellowship after that. I’d really have to say that what got me first into nephrology was just a love of the kidney, and the basic physiology that underlies electrolyte homeostasis. And I had wonderful mentors in my med school who really guided me every step of the way. It was that mentoring relationship and that love of physiology that first drew me to kidney diseases.

What Did Your Mentor Dr. Biff Palmer Teach You?

Courtesy of Southwestern Health Resources

Khateeb: That’s fantastic. And you know, that’s one thing that we hear quite often, that when you go into residency you end up picking things that you are most influenced by your mentors. And so… can you name some of the mentors that you know had the most influence on you in your career?

Reisinger: Sure. You know, I have to say number one would be Biff Palmer. He’s a genius of electrolyte and acid-base. I learned everything I know about potassium handling from him. He’s really an inspiration to his field both in basic science, but also in clinical research. Personally, he’s summited Everest recently.

Khateeb: Wow, that’s fantastic. I’m happy that we’re not in Everest right now. We’re in this beautiful warm weather here in San Diego. That’s pretty impressive. Very nice. And what were some key things that you could remember that he essentially taught you or some wisdom that he imparted on you back then.

Reisinger: I think the biggest thing in nephrology is really being able to bring a very complex and nuanced field down to some basic building blocks, and to make learning systematic and engaging for the learner. Nephrology is an incredibly complex field, especially electrolyte physiology, and to be able to make something as complex as potassium handling digestible to your average first-year medical students is a Herculean task.

What were Popular Topics at ASN Kidney Week?

Khateeb: Absolutely. And you know, here at the conference at Kidney Week there’s a lot of interesting topics that are being discussed. A lot of discussion around biomarkers, for example, and definitely your general courses such as around AKI. So what were some topics that you liked a lot?

Reisinger: I was particularly interested in the debate on the use of point-of-care ultrasound and guiding ultrafiltration in critically ill patients. Point-of-care ultrasound is a particular interest of mine, so I was on pins and needles during the debate.

Khateeb: Interesting. So what in particular got you “on pins and needles” with the debate?

Reisinger: Well, I thought it was particularly telling that ultimately both sides argued in favor of using ultrasound, but really only differed in terms of their semantics surrounding the questions.

I think it’s coming in to ubiquitous use among Critical Care providers. And I think really the debate is going to come down to the emergence and the development of a reliable database…a reliable track record of evidence…telling us one way or another. That just doesn’t exist yet for point-of-care ultrasound. So, it’s really an emerging field.

What are the Disadvantages of Point-of-Care-Ultrasound (POCUS)?

Khateeb: You know, the one double-edged sword of technology is that you kind of have a portal opened up to you whether you’re a physician or even a consumer–a portal of data and new insights, but a lot of times there’s a lot of overwhelming data; they’ve talked a lot about things such as alert fatigue and whatnot.

So as the technology gets introduced to nephrology, what are some concerns that you might have and maybe some things that you’re also excited about?

Reisinger: Sure, you know I think the biggest concern in adopting point-of-care ultrasound in the nephrology practice is what to do with that data overload.

So often you go to scan the patient and it’s not what you’re looking for that surprises you. Oftentimes, you’ll incidentally discover something that is totally unrelated to patient care or something altogether unexpected. So that presents a significant challenge in terms of point-of-care ultrasound, but ultimately you always have backup in terms of referral studies.

So if you see something, an “incidentaloma” or something that is potentially a false negative, you can always back up and ask for the radiologists to perform a referral study.

How will Nephrology Residents Train with POCUS?

Khateeb: Interesting. As mobile ultrasound evolves over time, what do you think some exciting applications or other things will be implemented in the training side for nephrologists as result of the evolution?

Reisinger: I think we’re moving towards, a fully integrated point-of-care ultrasound curriculum for nephrology fellows.

I think it’s not just the bladder and kidneys. It’s going to be of interest to the average practicing the nephrologist, but it’s going to be markers of volume status– things like quantitative lung, ultrasound, advanced cardiac techniques like VTI–supplementing traditional markers of fluid overload in point-of-care ultrasound like IVC measurements.

Then I think there’s a real potential to add value in the outpatient dialysis market by serial examinations of malfunctioning access, which is the lifeline for so many of our dialysis patients.

Nephrologists Will Focus More on Heart and Lungs

Khateeb: And it seems that over the years, at least in our perspective with these new and emerging technologies, a lot of the Kidney Week conferences are sort of getting split, not only focusing on dialysis technologies but all these other interesting technologies that are kind of opening up a new frontier for nephrologists.

And you mentioned earlier that it’s going to be more than just a focus on the bladder and kidneys. What are the other organs?

Reisinger: Without a doubt, I would have to say heart and lungs. You know, just look at your basic epidemiology. Patients with chronic kidney disease are really much more likely to die of cardiovascular events of heart disease–even more likely than they are to end up on dialysis. And the number one killer of dialysis patients, again, is cardiovascular disease.

So I think partnering with cardiologists in epidemiological studies and clinical trials is really the going to be the next frontier.

Khateeb: Are you excited about spending more time with the cardiologists? Are you guys going to be able to get along in the same room?

Reisinger: I think we can; I think we can build a shared vocabulary together. I think we speak the same language when it comes to fluid balance, but it’ll take a while for them to to fully appreciate what we do in the dialysis unit.

Khateeb: Absolutely. Well one thing for sure, they have a lot of heart, right?

Reisinger: That was good.

Khateeb: Right?

*joined laughter*

Reisinger: You got me… It takes two kidneys to make one heart!

Khateeb: Ah, that was pretty good. I have not heard that!

Social Media for Nephrologists

Khateeb:So you know, one thing we did notice here at ASN is the nephrologists on Twitter. You guys have such a vibrant and engaging group on there. I mean, I think I’ve learned more about nephrology in the last few days than from any graduate school course that I’ve taken. How do you feel that Twitter is serving as a tool not only for nephrologists, but also just to kind of get more engaged with each other and share information?

Reisinger: Oh, yeah. Absolutely without a doubt, that is our number one emerging trend in nephrology education. It is so valuable because of the dearth of internal medicine residents now going into nephrology.

So a few key players on Twitter in a short span of time really have created a vast network that brings in trainees, and really makes them makes them feel welcome and like they have a home. It gives them the resources that they need to succeed not only on the wards but in their career going forward. So there’s actually something called the Nephrology Social Media Collective. NSMC. It’s run by three nephrology Twitter celebrities: Joel Topf, Matt Sparks, and Swapnil Hiremath. “Kidney Boy”, Joel Topf, is the leader. You may have you may have heard of him.

Khateeb: Oh most definitely. He’s been trending. His Twitter handle, I think it was it was about “Urine is not the byproduct of the kidney but it is the product of it…”, or not the byproduct of it… See, I messed up that joke, but I think he said:

“Saying that the urine is a byproduct of the kidney is like saying that pollution is a byproduct of the factory. Urine is really the byproduct and homeostasis is the actual byproduct”.

Reisinger: Homeostasis the is the product of the kidney and urine is really the byproduct… exactly.

Khateeb: I’m still a novice so I’m getting up to speed…

Reisinger: I think you’re doing a great job.

Khateeb: I appreciate that. And you know, the nice thing is that it seems that this is a good resource also for medical students to kind of get engaged with nephrologists and see if this is an actual specialty they would like. And of course, it’s probably helped them with their step one’s and two’s.

Reisinger: Absolutely. I think nephrology can be extremely intimidating for trainees and it has a high barrier for entry.

But by bringing the foremost leaders in nephrology education onto social media, you’ve really made it accessible. And I think what we’re going to see in coming years is a sort of rebound as more people become engaged in nephrology as a result of this Free Open Access Medical Education (FOAM). It’s really a trend that transcends disciplines. You can go on Twitter now and learn everything. You can learn radiology. You can learn pathology. You name it.

Machine Learning and Nephrology

Khateeb: Very nice. On the topic of these emerging technologies that are really changing the culture of nephrology, one thing that’s been sort of trending up in a variety of different platforms and is being discussed in medicine is the use of artificial intelligence–predictive health technologies. How do you see that shaping the landscape of nephrology, say five/ten years from now?

Reisinger: Absolutely; I think machine learning is going to add another dimension.

Two are already a very versatile tool box in terms of clinical epidemiology. And I think what we’re going to discover is that the machines aren’t going to replace us, but rather supplement our own analyses.

In my own field and point-of-care ultrasound, machine learning has already been harnessed to start to interpret images generated by trainees. Certain ultrasound providers have used this actually to enhance image quality–image generation–at the point of care. You can see these ultrasounds now so they actually tell you how to rotate your probe how to improve your image quality. And that’s key if you’re going to be introducing point-of-care ultrasound to a lot of inexperienced nephrology trainees. You need someone there guiding them, and if that’s the computer, all the better.

Khateeb: Very nice. The other thing that we’ve noticed a lot of discussion around is these biomarkers and it seems that nephrologists are getting quite excited with the idea of having, you know, sensor technology in the urine, in the bladder, that can give you a portal into a new world and get streaming data from.

But there’s so many different biomarkers. Are there any in particular that you feel that are going to become more and more important as a research starts rolling out for nephrologists?

Reisinger: You know, Omar, what I think is most important in the biomarker world is really understanding on a molecular level what each of those markers represents.

I think we should take a step back and think about our original biomarker: creatinine. You know, creatinine is a byproduct of metabolism and it’s not always the be-all end-all of kidney function.

So, I think understanding that and ultimately translating these new biomarkers to clinical outcomes is going to be of critical importance.

Right now we have kind of a weak surrogate marker (creatinine) that we’re using to generate our outcomes. Compare that to cardiology, where they’re looking at hard clinical outcomes. You know, I think a rising creatinine really can’t serve any longer as our outcome of interest.

Khateeb: And of all the different technology… so, it sounds like aside from mobile ultrasound for nephrologist… anything else that’s come out, that you feel that nephrologists maybe should get get access to, that you see in other specialties?

Reisinger: So, you know, I would say that there’s a lot of technologies out there and the best approach to adopting new technology is to look for something that already stimulates your own knowledge of basic physiology.

Go with the new technologies that have a rationale in the already established evidence. So when you’re talking about, you know, these Foley devices with a sensor–as certainly, measurements of your output are extremely important–that may be more important than just your average run-of-the-mill nurse checking off the urine output.

How Wearables Are Changing the Healthcare.

Khateeb: And you know, it seems that especially in the last few years that patients side from really taking not only control but taking a very active part in their healthcare.

Now they have these wearable devices that are providing a variety of different biometric feedback and data and I’m sure that at some point they might be able to get more. Has that in any way influenced the practice of nephrology or at least with physicians? Is it a good thing or a bad thing that patients have all this data now?

Reisinger: Absolutely, you know, I think one of the bigger technologies that have come out of the past few years is these cardiac monitoring devices. As I said, cardiac or cardiovascular events are paramount for our vulnerable kidney population.

So now they have devices for remote monitoring of telemetry and we’re finding that atrial fibrillation and other arrhythmias are extremely prevalent– more prevalent than we ever thought. And this may actually be related to potassium fluxes on dialysis. There’s technology that’s coming out now to actually tell in real-time without a blood measurement what the serum potassium is for a dialysis patient just based on their EKG tracing.

Khateeb: Interesting. And you know, you mentioned earlier that with some of these different technologies you’re spending some time to create courses and trainings for medical students at this point. Correct?

Reisinger: That’s absolutely right. You know, I think whenever you’re starting to use a new technology you need a firm grounding in your trainees so that you’re establishing a reliable biomarker of disease. If you’re using point-of-care ultrasound without really assessing the quality of your trainees’ technique, then you could really be doing serious harm.

Khateeb: Well, doctor, we really appreciate you spending some time with us chatting. But before we let you go, I have one more, one last question. A lot of young fledgling nephrologists will be listening to this podcast and you know, probably look to someone like you as a thought leader to give some words of advice. Any advice to them in terms of really nurturing and developing themselves into thought leaders in the nephrology community?

How to Become a Great Physician

Reisinger: You know, I’d really have to say that the most important thing in my own career was following my interest , you need to be doing something that really speaks to you.

You can’t spend time, you know, micro pipetting in a lab if really your heart’s desire is clinical epidemiology. That’s how it was with me.

I was only in my second year of fellowship that I discovered my true passion was in point-of-care ultrasound. So you really need to take some time and use this fellowship as an opportunity to discover what really interests you.

And I think that’s where social media in nephrology can be so valuable because you have at your fingertips access to the world’s leading experts in a variety of subspecialties of nephrology. And literally you can just tweet at them now and gain access to their vast hordes of knowledge.

So I think I’d say engagement, really. You know, coming to kidney week, coming to our major meetings, and meeting people is the best thing you can do–just talk to people and hear what they have to say.

Khateeb: And now I gotta put you out there. So, how can we best find you online?

Reisinger: So, the best way to find me online is via Twitter. My screen name is @nephrothaniel.

Khateeb: Very nice. You know, nephrologists have a really good sense of humor. I gotta tell you. You can just tell that from the Twitter handles…

Reisinger: I think you can tell a lot about the about a nephrologist based on their Twitter handle.

Khateeb: Wonderful. Hey, we appreciate you spending the time and looking forward to seeing you next year at Kidney Week.

Reisinger: Wonderful. Thank you so much. Thanks for the opportunity to be interviewed.

Resource Type	Resource Link
Nephrology Social Media Collective Home	Nephrology Social Media Collective
Dr. Nathaniel Reisinger Twitter Handle	@nephrothaniel
Dr. Joel Topff Twitter Handle	@kidney_boy
Dr. Matt Sparks Twitter Handle	@Nephro_Sparks
Dr. Swapnil . Hiremath Twitter Handle	@hswapnil
What is Free Open Access Medical Education?	FOAM paper
Machine Learning in Nephrology	Article on Machine Learning in Nephrology
Creatinine as a biomarker	What is Creatinine?

biomarkers, POCUS, reisinger