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Dr
Volker Nickeleit
Associate Professor in the Pathology Department and Associate Director of the Nephropathology Laboratory at the University of North Carolina at Chapel Hill Chapel Hill, NC, USA |
Dr Zoccali: You are an European investigator who started your career in Germany, had research experience in Switzerland and then moved to the USA where you are now an Associate Professor. Although academic medicine has an international connotation we remain interested in stories of colleagues who settle in a foreign countries.
Dr Nickeleit: I studied medicine in Germany, started my career in pathology in Switzerland, finished my training in anatomic pathology in the US with board certification, moved back to Switzerland for 5 years and subsequently to the US again. Currently, I am an Associate Professor in the Pathology Department and Associate Director of the Nephropathology Laboratory at the University of North Carolina in Chapel Hill. Therefore, my career has followed a path that is quite uncommon, more like that of a nomad. I have enjoyed every step of the way and always felt stimulated by new working environments that provided rather unique opportunities and experiences helping to broaden my horizons.
Dr Zoccali: What are the main differences in Nephrology training between
Germany and the USA?
Dr Nickeleit:
Since I am a pathologist by training, I cannot give detailed insights into fellowship
training in nephrology. However, let me make some general comments about medical
training in the US.
American medical students attend "medical schools" not "Universities".
Medical education is generally expensive and has to be financed, in most cases,
by the students themselves. This framework already characterizes the following
main differences: the US training is short, i.e. 4 years, and very structured.
Teaching is organized in classes and follows well-defined learning objectives.
Teachers and students co-operate closely and have to evaluate one another on
a regular basis. The environment is interactive, stimulating, therefore, learning
objectives can be accomplished rather quickly.
After graduation from medical school, which occurs in early summer, students
immediately join a resident training program, which starts in July. All residency
programs are officially certified and must fulfil certain requirements, such
as guaranteed adequate case/patient numbers to meet the training requirements
set forth by the governing medical specialty board. Resident training, such
as that in pathology, is again structured similarly to the medical school classes.
Often, residents share a large, open office space to enhance communication and
peer-based learning, the latter constitutes a crucial training aspect. Training
follows a specific timetable with regular teaching sessions. Residents are expected
to assume independent work responsibilities very early in training. The training
also includes extra, unpaid duties; in pathology, for example, on-call responsibilities
for off-hour frozen sections or weekend autopsies would be examples of unpaid
extra duties. "See one, do one, teach one" is the standard cliche
characterizing the American residency training approach.
In comparison, medical and resident training in Germany is often less structured
and takes, by far, too long.
Dr Zoccali: What do you miss most in Germany?
Dr Nickeleit: My friends and family.
Dr Zoccali: What do you miss least in Germany?
Dr Nickeleit: The rigid and sometimes narrow-minded academic system.
Dr Zoccali: Your main research interest is in renal pathology and in
renal transplantation. Do you believe that we still have much to learn about
the role of viruses in renal transplant dysfunction?
Dr Nickeleit: It is a very peculiar dichotomy - despite all the progress made - there is still much to be learned. New immunosuppressive drugs and treatment protocols come with new, formerly uncommon complications, such as viral infections. Epstein-Barr Virus infections and lymphoproliferative disorders as well as polyomavirus-induced nephropathies are only two prominent examples. Probably, also other viral infections will become clinically more relevant in the future, such as adenovirus infections. In this regard, pathologists play a pivotal role. They are often among the first clinicians identifying and diagnosing new "disease entities". Infectious complications seen in renal allografts often constitute major diagnostic problems with regard to properly identifying potential concurrent rejection episodes. In this regard, much has to be learned from adjunct immunohistochemical markers for rejection, such as the accumulation of the complement degradation product C4d or the tubular expression of MHC-class II (HLA-DR). We also have to learn more about latent viral loads in renal allografts and how potent new immunosuppressive drugs may lead to activation of latent viruses and viral disease.
Dr Zoccali: Do you believe that transplantation of transgenic or cloned
kidneys will be done in a near future?
Dr Nickeleit: No. The idea is great, but we know that "the devil is in the detail". Much remains to be learned. Ten years ago during my training at the Massachusetts General Hospital in Boston, my former mentors told me that "xenotransplantation" was around the corner. Well, a decade later we are still waiting…..
Dr Zoccali: I suppose that you also have clinical duties. For a clinical
investigator what is the best way to balance clinical and research duties?
Dr Nickeleit: I love to do clinical work that frequently gives me new ideas for future research projects. However, it can be very challenging to balance clinical responsibilities with research activities. Either clinical duties dominate and research fades into an after hour hobby-like activity - or - research turns dominant and clinical perspectives are lost. In my mind, American universities currently provide the best academic environment to balance clinical and research duties. Clinicians on staff, i.e. tenured or on tenure track, are typically provided with protected off-service time to pursue research/academic activities. Often, around 16 weeks per year are protected. If investigators succeed in getting substantial extramural grant and salary support, clinical duties may be further decreased or vice versa also increased again. Such a dynamic and flexible system is well suited to support individual needs and preferences. Overall, such a system produces better outcomes.
Dr Zoccali: Which is the research to you would start tomorrow if you
receive a 10 million grant as a start up?
Dr Nickeleit: Even 10 million US$ would not be an everlasting fortune, in particular, considering the substantial overhead expenses these days..…..I - as a renal transplant pathologist - would use this money to finance two multi-center studies: 1) Protocol renal allograft biopsies subsequent to anti-rejection therapy. Currently, very little is known about residual histological changes following aggressive therapy. How often is a rejection episode "clinically" cured but "histologically" still active? Could such a smoldering rejection episode contribute to chronic rejection? 2) Protocol renal allograft biopsies of grafts incorporating new adjunct markers, such as the detection of C4d and tubular HLA-DR, accompanied by close monitoring of donor specific antibody titers. How often do we find subclinical "humoral" rejection, how long does it last and what is the clinical significance?
Dr Zoccali: What advice would you give to a young nephrology trainee?
Dr Nickeleit: Be flexible! Take advantage of the new opportunities arising in the European Union with vanishing borders, and "hand-select" the most appropriate training and research environment that is best for you. Try to identify dynamic and stimulating work places in which a well- established group can "pull you along". Stay away from places where you have to "re-invent the wheel": this is frustrating and unrewarding.
Dr Zoccali: What are you favourite hobbies?
Dr Nickeleit:
Sailing, hiking and biking.