We had a chance to sit down with Dr. Jason Cobb and ask him a few questions about his experiences at Emory.
Can you tell us a little bit about yourself?
My name is Jason Cobb. I am from Washington, Georgia, but I have been in Atlanta since 1998. I did my undergraduate at Morehouse college, medical school, residency, and fellowship all at Emory University. So, I trained at Emory from 2002 to 2011 and I have been a faculty member since 2011. I am now an associate professor of medicine in the Renal Medicine Division. I am a nephrologist which means I take care of patients with renal disease. Specifically, I am a general nephrologist, so I see patients in the hospital, the chronic kidney disease (CKD) clinic, and outpatient dialysis including home dialysis. I am based out of Emory Midtown Hospital. I have a research interest in education, particularly fellowship education, I am the associate program director for the nephrology fellowship program. I also have an interest in diversity, where I am part of the American Society of Nephrology’s Diversity and Inclusion committee. At Emory, I am also part of the department of medicine’s diversity, equity, and inclusion committee. And some of my other research interests include Glomerulonephritis (GN), Lupus Nephritis, and I have a Lupus Nephritis clinic at Emory Midtown Hospital (EMH). Right now, I am enrolling patients in a Focal segmental glomerulosclerosis (FSGS) study, particularly looking at African-Americans with the APOL1 genetic variants.
What is FSGS and why is the APOL1 variant important for study?
So, as we know in the United States, minorities progress with chronic kidney disease (CKD) to the point of needing dialysis or reaching end-stage kidney disease at higher rates compared to white patients. African American patients have the highest rate about three to four times that of white patients. You got multiple studies with African American patients, same amount of kidney disease, diabetes, or blood pressure. African Americans seem to progress more than other patients and the cause seems to be a genetic variant of the APOL1 gene. The genetic variant is seen most prevalently in people from West Africa and people that have migrated throughout the centuries with the African diaspora. Individuals with the G1 or G2 variant seem to have an increased risk of chronic kidney disease (CKD), end-stage kidney disease, FSGS, HIV-associated nephropathy, and lupus nephritis. We are at a point in medicine where we could be talking about the genetic underpinnings of pathology or the so-called precision medicine. This means that patients could potentially have a treatment that would be tailored to their specific genetic variant.
Why did you go into medicine and are there any experiences that led you to this career?
In college, I was at Morehouse in the dual degree program where I was supposed to do part of my time at Morehouse and then finish up at Georgia Tech. I was a NASA scholar, where I did internships each summer at NASA, and they all are engineering type-internships. I knew after the second summer that was not for me, and probably even after the first summer. I was interested in the science behind engineering, but I knew I needed more interaction with people. So, I ended up shadowing at the hospital at night after working long days in the internship. I fell in love with the profession during those shadowing hours at Cape Canaveral, Florida’s local hospital. I was a patient transporter, and I was also shadowing in the emergency room. And that’s when I knew that medicine was for me.
Why did you specifically choose nephrology as your medical specialty?
So, I got into medical school where I initially thought I was going to be a pediatrician. Quickly found out after doing my pediatric rotations at Hughes Spalding near Grady, that it was not quite for me. I knew I wanted to take care of the entire patient, and I was thinking that I was going to be a pediatrician and take care of kids, and there is a lot of work to do with children just to do a physical exam or take a history. So, then I went toward the adult side and decided that I wanted to do Internal Medicine. In medical school, I knew I was good when it came to physiology, pathophysiology, acid-base stuff. So, I was thinking about cardiology vs. nephrology because they both deal with a lot of physiology. I came into residency open-minded, but really that first year of residency or internship at Grady. I discovered HIV-associated nephropathy, lupus nephritis and how they tend to affect the kidney more than they do the heart, even though both systems are affected. So, my time at Grady during that first year of internship did it for me where I wanted to continue treating patients with HIV and Lupus-associated nephritis. Another thing was that growing up, my aunt had end-stage renal disease and was on dialysis and a lot of people in my community were on dialysis. That background definitely pushed me toward nephrology once I got into medical school.
What does the typical day of a nephrologist look like? Could you walk us through a day in your life?
So that is one of the reasons why I love nephrology, we are one of the specialties where you are not in one place. The average nephrologist will spend a lot of time at the hospital, taking care of patients in the ICU that develop kidney disease. People who already have kidney disease get admitted to the hospital at high rates. So, we spend a significant amount of time in the hospital. Then we all do clinic, most nephrologists will have a clinic that is geared toward kidney disease and taking care of patients or patients with diabetes and hypertension that develop chronic kidney disease and possibly need dialysis. But mine is a little different where I see a hybrid of patients with lupus nephritis and HIV. This is what is very interesting about the clinic which is the fact that you can tailor your clinic to what your research interests really are. A significant amount of my time is actually at the dialysis units where people do dialysis three days a week: Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. A lot of my patients do home dialysis as well. So, a typical month for me would be where I do hospital duty for a week where I only take care of patients in the hospital, be it ICU, general floors, or emergency room. These patients usually have kidney disease. The other three weeks of the month are in the clinics and with dialysis patients that either do dialysis at the center or home dialysis. Today I actually saw 50 dialysis patients where I got to the dialysis center around noon and finished around 6:30 PM.
What are the advantages of doing home dialysis over clinic dialysis?
Patients that do dialysis at home actually have better outcomes. Unfortunately, in the United States, only about 8-9% of patients are doing dialysis at home. At Emory, we are proud to be above the national number with 19% of dialysis patients doing home dialysis. Around 30-35% of my patients are doing dialysis at home. Home dialysis can be associated with better outcomes, fewer hospitalizations, less mortality. Also, patients who do home dialysis have the tendency to live a more productive life when it comes to things like work. When you do dialysis at a dialysis unit three times a week, there could be 3-4 hours just on the machine, you must also think about transportation, getting ready, and being in a waiting room. So, the whole process could take 6-7 hours out of your day, three times a week. The recovery process is better for home dialysis because they get dialyzed more often for home dialysis. A lot of my patients in-home dialysis work full-time jobs and have professional lives. I have a patient who is a lawyer and still an active attorney doing dialysis at home. For the healthcare system and economically speaking a year of dialysis at home costs the system $30,000 - $35,000 USD a year, whilst taking care of a patient in a dialysis center costs around $60,000 - $70,000 USD a year right now. So, it definitely is a lot cheaper. It is economically beneficial for the healthcare system and less impeding for the patient. The reason why there are still a lot of patients who opt for the center instead of home dialysis has to do with patient education. A lot of patients do not even know that they have that option. The other reason is physician education where not all physicians are trained to offer home dialysis. Thankfully, Emory nephrology fellows get well trained to provide home dialysis.
What is the aspect of your job that you enjoy the most?
I do not think you can beat the interactions that I have with my patients, especially for general nephrologists like myself. I see my hemodialysis patients in the center twice a month and I see my home dialysis patients once a month. I do not think there is another specialty where doctors get to see their patients that many times out of the year. I mean, I see my in-center dialysis patients 24 times a year and my home dialysis patients 12 times a year. So, the continuity of care that I get as a nephrologist is amazing. The ER patient in the middle of the night whom I had cared for in the past, I could know their medical history quite well without even opening the chart. The relationships that you build with the patients when you see them so often are amazing. A lot of physicians in family medicine talk about long-term care and how they see their patients 2-3 times a year, well in nephrology I see them once or twice a month, so I get to develop very long-lasting relationships with my patients. Another thing that I like about my job is teaching, and that is the reason why I love to be here at Emory in academics, where I am able to teach fellows. Nephrology trainees are almost always training with me either at the hospital or the dialysis units. The long-term relationships with patients are a fascinating thing about nephrology that is not very well known, our continuity of care is unparalleled. Unfortunately, a lot of times in our field, there is a lot of focus on the research side of things in nephrology and not enough exposure to the clinical side of things, especially in medical school. So hopefully we get to have more pre-med and med students with us in the hospital, clinics, and dialysis units. That kind of exposure will get people more interested in nephrology. Unfortunately, nephrology is one of the medical fields with the lowest amount of attention of doctors applying or training in that specialty. Unfortunately, in the United States right now less than 100 American medical graduates go into nephrology. We depend a lot on International Medical Graduates (IMG’s) to fill those spots.
In addition to dialysis patients, is there another kidney pathology where you get to build these long-term relationships as well?
Patients with the following conditions I also get to see a lot during the year: lupus nephritis, HIV-associated nephropathy, or CKD from diabetes or high blood pressure. My average patient even in the clinic I probably see every three to four months. There are 5 stages to Chronic Kidney Disease and when you get to 4 or 5, I probably start to see those patients close to every 1 or 2 months. So, I get to see those patients a lot as well. Also, in the Hospital, we do get our “frequent flyers”, with patients that come to the hospital very often.
What strategies do you follow to achieve a nice balance between work and life?
You must take a lot of vacations, but the pandemic has really gotten in the way of my vacation time. Between family and friends, it is also important to make sure to find the time to spend with them. I have had to work for certain holidays, but we work as a team in the renal division, and we all cover each other in multiple instances. Doctors are known for getting a certain amount of time allotted for vacation and not using that time. I have not used all of mine, but I definitely try to use them compared to when I got hired in 2011 where I was using less than 50% of my vacation time. I am now taking advantage of closer to 80 to 90% of my vacation time.
At work, some strategies include that now a lot of people on the renal team cover each other in the hospital. We have also changed the way that we do on-call and I think I had some influence on the way that we changed things. So now we cover each other more so that you don’t have to be on-call with your own patients so often. Hospital duty also used to be two weeks per month, and now it is one week per month. So, in short, find time to do what you find important, take time off for vacation, and at work trying to find ways to maximize free time through efficiency. Solo practitioners are not a thing anymore, and medicine is highly reliant on teamwork nowadays. I advise as well to find a group during training where you have a great fit. Fortunately for me here at Emory, we have a large kidney department, and we are kind of divided amongst the different hospitals and facilities. I am part of the Emory Midtown group and I have had a great time working there in a team.
What is something you wish you would have known as a pre-medical student?
So, I wasn’t 100% sure I was going into academia at the very beginning. I fell in love with teaching and with specific groups within nephrology. I did not take any time off, I did not take a gap year. I went straight through from college to medical school, to residency, and then did my fellowship. I wish I had done a master’s in clinical research or MPH; I think that would have helped my research career even more. Right now, I know I am great at developing relationships with patients, getting them into the clinical study, but when it comes to the whole clinical trial design and running a study from the very beginning, I just do not have those skills. I wish I had attained those skills in a master’s program that dealt with clinical research. I love my career and I love what I do, but at this point, I do not see myself going back into school for a 1- or 2-year master’s program. In order to become a nephrologist, the process is getting your undergraduate degree (4 years), then medical school (4 years), then internal medicine residency (3 years), and then a nephrology fellowship (2 years) for a total of 13 years of schooling. I like my current ratio of 80-90% clinical work and 20-10% research work.
What is a challenge you have faced during your career and what lessons did you take from that?
There have been some challenges associated with the academic ladder and when you are the younger person in the group or in the division and there are a lot of activities that you get assigned that do not always line up to your career trajectory and advancing in the academic ladder. So, you have to learn how to say no to certain things that do not fit your career path or trajectory. It is also important to find the right mentor and I only came across that person until I was a fellow. It is important how to identify which things will add to our CV and make it look better and which things do not. In academia, this is very important because it allows you to stand out. For me, I have been able to establish my lupus nephritis clinic and increase my understanding of HIV-associated nephropathy, as well as continuing to explore health disparities, diversity, and inclusion in healthcare.
Tell us about an interesting case in your medical field.
She is one of my patients who I have been following for quite some time. So, let’s talk about her for the last 8 years. She was seen by rheumatology at Grady, she had lupus and at that point, she was only 25-26 years old, and it was starting to affect her kidneys. The patient was referred to my lupus nephritis clinic at Midtown and I started her on oral medication treatment, and she did really well with her lupus nephritis. When you are young like that you want to usually develop families and have children when we had a consult, we talked about her possibilities for having a family, but after going into remission she ended up having a lupus flare and the oral medications were not working. We then had to start her on IV medications like Cytoxan and that is pretty much chemo therapy, but at lower doses. I talked to the patient about not getting pregnant and focusing on getting over the flare first. So, she is doing the treatment for like 6 months and half-way through she ends up becoming pregnant. Then we had many discussions about terminating pregnancy and continuing treatment or carrying on with the pregnancy and halting the treatment. She ended up wanting to continue with the pregnancy, her kidneys unfortunately ended up failing and she had to be put on dialysis but remained under my care in the dialysis clinic. Today, she is at home and has her kid who she is doing very well with. She was initially doing dialysis at the center, but this took too much time away from home and from the attention the child needed. So, we decided to put her on peritoneal dialysis (home dialysis) and she is able to spend the time she needs with her kid. This is an example of someone with chronic kidney disease who I have been following for a very long time and established a relationship with. She and I had the challenge together to lose weight during the pandemic. You cannot get a kidney transplant unless your BMI is under 35. We have been working on that with her, where her initial BMI was in the 40’s and now it is right at 35. So, we referred the patient to a kidney transplant around November, December. So, I hopefully will see her through that as well and continue the care. Succinctly, everyone in nephrology loves the continuity of care.
