Week 1: From the Beginning

Living in Manhattan has been a bit of a homecoming for me as I was born about 10 miles away from our current residence in Olin Hall. While I did not actually grow up in New York City, in many ways I feel like I am already accustomed to living here. I am very well acquainted with the local flavor, where "give me a square" is a perfectly acceptable way to order a Sicilian pizza slice, all distances are measured in blocks, and the customary response to being cutoff at an intersection is a one finger salute accompanied by a request to perform a biologically impossible feat. Having my room assignment switched four times between two different buildings in a span of three days due to some gender mismatches initially left me feeling unsettled, but I have definitely gotten into the swing of things. I feel like I have already been all over Manhattan from restaurants to breweries to underground fight clubs (well, a fighting video game club), but I am excited for whatever adventures come next, unless they involve 70 block walks in the middle of the night.

My clinical immersion experience has actually been fantastic so far. From Day 1, I have been thoroughly immersed in the work of the Transplantation Medicine and Nephrology team due in part to an existing collaboration between my lab and the clinical research lab here as well as the coordination efforts of my primary mentors, Dr. John Lee and Dr. Darshana Dadhania. A typical day for me starts out with inpatient rounds on the floor followed by seeing patients in the clinic. Afternoons have been a mix of work in the research lab, grand rounds, seminars, and consult meetings. With a full week under my belt, I have been able to see how patients have been progressing post renal transplantation (and in some cases simultaneous pancreas-kidney transplants) from just hours after surgery to days, as well as the many complications that can arise. Clinic duty has exposed me to more patients who are months to years post transplantation or are waiting for an available organ to have their transplantation.

From all my experiences so far, there are two C-words that stand out in my mind: communication and compliance. Communication has been absolutely crucial in providing patients with the best care possible and making sure that all people involved with their care are on the same page. The shear volume of people that actually make decisions regarding patient care is something that I never realized until I have been involved in the many discussions that take place throughout the day. Including the interns, residents, fellows, and attending physicians on the transplant team, the entire transplantation surgical team, and the nurses on the floor, over ten people at any one time provide input on care and must be completely up to date on patients' medical history, lab results, and changes throughout their hospital stay. Issues such as not having complete medical histories from other medical centers, contradicting answers from patients, and even typographical errors on patient charts all posed potential problems this week.

The doctor-patient consultations in the clinic showed me the wide range of compliance in patients that can further complicate patient outcomes. After transplantation, patients are given a regimen of medications for the rest of their lives, the most important of which are immunosuppressants that reduce the chance of the recipient's body rejecting the donor organ. These drugs tend have a very narrow therapeutic range, so proper dosage and time of administration is vital to their efficacy. A significant portion of the clinic visit is devoted to reviewing the medications the patient is taking including both how often and at what dosage. I found it remarkable how vastly different patients being treated for the same procedure could be in their adherence to these regimens and even just general concern regarding them. Some patients come prepared with stacks of lab results with certain numbers circled, expressing concerns over whether their serum creatinine is too high or if they need to have another procedure performed. Others cannot recall how often they take tacrolimus or even know which pill it is in the slew of daily medications. Still others purposefully go against the recommended regimen out of personal beliefs. At the end of the day, there is only so much a clinician can do to provide a patient with the best possible care. The patients themselves are ultimately the arbiters of their health decisions.

Looking forward, I will be beginning more work in the clinical research lab, where blood, urine, and stool samples from patients are currently being analyzed to develop better methods of predicting graft rejection and infection before clinical indication and without the need for highly-invasive renal biopsy.



New York Themed Music Selection of the Week: The Chainsmokers - New York City