Jessica Dominguez Rieg, PhD
Department of Molecular Pharmacology and Physiology
University of South Florida Morsani College of Medicine

Recently, I spent some time reflecting on the way we teach physiology at my institution. One thing that kept coming to my mind- why does renal physiology get such a bad reputation? We often hear medical students commenting that renal physiology was the hardest topic of the first year, that there’s too much math involved, and concepts like acid-base and electrolyte disorders are too difficult to grasp. Does a negative attitude about renal physiology really matter in the long run? If the students can successfully pass USMLE Step 1, can I rest easy knowing they are competent in understanding how the kidneys function? Or can I, a basic science faculty, make a bigger impact on how these students view the renal system?

Chronic kidney disease is a growing public health concern in the United States, affecting roughly 40 million adults. Given the increasing burden of disease, an aging population, and modern medicine that is keeping patients with end-stage kidney disease alive longer, we need a robust workforce in nephrology. However, the field of nephrology is in the middle of a major crisis, and there is significant concern that there will not be an adequate workforce to meet the healthcare needs of patients afflicted with kidney disease. Only 62% of available nephrology fellowship positions were filled in the 2019 National Resident Matching Program match and less than 45% of positions were filled by U.S. MD graduates, making nephrology one of the least competitive subspecialties¹. When does the waning interest in nephrology begin? Many think it starts early in a medical student’s academic journey.

I recently surveyed our medical students at the University of South Florida Morsani College of Medicine (250 respondents) and found that 60% of students agreed or strongly agreed that the topic of nephrology is interesting and yet close to one-third of them agreed or strongly agreed that renal pathophysiology is too complex and challenging for them. When asked what makes the biggest impact on their future career choice, 60% indicated that having role models and mentors in the specialty field was high impact; however, less than half of the students felt they had been exposed to encouraging role models or mentors in nephrology. Students ranked rotations during clerkships as having the highest impact in career choice; and yet our students are first exposed to nephrology during their Internal Medicine clerkship in their 3^rd year, which only last 8 weeks. Not surprisingly, students ranked didactics in the preclinical years as having the lowest impact on career choice. What if we can change that? Perhaps there is too little done too late- and we just can’t get enough momentum going to gain a critical mass of students interested in nephrology. Is there anything that we, as medical physiology educators, can do to help? We can light the spark!

1. Make it matter. The complexity of renal physiology must be taught with meaningful clinical context. Students need to understand the clinical importance of what they are learning or there is a high chance they will get turned off from the very beginning. One of the best ways I have found to make it matter, is to work closely with my clinical colleagues. Not only can they provide (and co-teach) examples of how to

2. Make it digestible. Students often get overwhelmed by the level of detail that is expected in the renal block. We must ensure we are giving them the important content in bite-sized pieces so they have time to think about it, apply it, and understand it. I give our students a blank nephron map² at the beginning of the renal block and ask that they work together to fill it out. On the last day of the renal block, we go through the maps together as a summary of renal function. Students like having all the transporters, hormones and key characteristics about each region of the nephron in one place. It helps them organize their knowledge and also gives them something to refer to in Year 2 and beyond.

3. Make it relatable. At our institution, students get renal physiology at the end of Year 1, so they’ve had all other organ systems besides reproductive physiology. I use many analogies throughout the renal system and always to try to highlight the similarities with the intestinal tract, which they are more familiar with at that point in time. After all, the nephron is like a “mini-intestine”, with similar histological features and transporter profiles. By relating the new renal content to something they’ve seen before, it can help make it a little easier to understand (and allows them to make systemic connections).

4. Make it stick. Students struggle with grasping acid-base disturbances. Consistent repetition and practice problems is key! Many times, students learn multiple ways to approach interpreting acid-base disturbances (different formulas, different values for expected compensatory responses, etc.) depending on who is teaching. This can be frustrating and confusing for students. We have found that having all faculty that teach some aspect of acid-base balance use a single resource, a step-by-step guide to interpreting acid-base disturbances³, has been very helpful in ensuring consistency in what we teach. Students also work through many practice problems in interpretation of arterial blood gases, starting in Year 1, again in Year 2, and again during the clerkships. The result is that students have gone from scoring less than 50% on NBME acid-base questions, to close to 90%- it’s sticking!

5. Make it fun! One of the notoriously challenging lectures in our preclinical years is integration of acid-base, volume, and electrolyte disorders. Traditionally, it was a lecture given by a nephrologist and was very technical and clinically oriented. However, students were lost and overwhelmed. So, I partnered with an internal medicine physician and we revamped the session into a fun, interactive series of cases where we co-facilitated discussion. Students were introduced to the 14^th book of Lemony Snicket’s A Series of Unfortunate Events: The Hazardous Hospital, where they were asked to investigate the mysterious health issues of Sir Cornelius. The cases we presented were challenging and framed with very relevant basic science concepts, and students loved it! Not only did they have fun while learning, but they really appreciated having a basic scientist and clinician teaching together.

In conclusion, renal physiology is challenging and may be contributing to a lack of interest in a career in nephrology. As medical physiology educators, we have the ability to work with our clinical colleagues and revamp how we teach the renal system. We can get students engaged and excited about renal physiology by making the content clinically relevant, digestible, relatable and fun. After all, there needs to be a spark to light the fire!

References:

1. National Resident Matching Program, Results and Data: Specialties Matching Service 2019 Appointment Year. National Resident Matching Program, Washington, DC. 2019
2. Robinson PG, Newman D, Reitz CL, Vaynberg LZ, Bahga DK, Levitt MH. A large drawing of a nephron for teaching medical students renal physiology, histology, and pharmacology. Advances in Physiology Education. 42:2, 192-199, 2018.
3. DeWaay D, Gordon J. The ABC’s of ABGs: teaching arterial blood gases to adult learners. MedEdPORTAL. 2011;7:9038.