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February 5, 2013

Pay for Performance (P4P): Will This Drive Better Outcomes for Kidney Patients?

A recent editorial in the New York Times described a move by the New York City public hospital system to “pay doctors based on how well they perform.” (1) Under this program, the more than 3,000 salaried doctors at the NYU School of Medicine, the Mount Sinai School of Medicine and the Physician Affiliate Group of New York will receive no cost-of-living increases for the next three years, but there will be annual bonuses tied to meeting quality-performance goals. In the same issue of the Times there is an important critique of the pay-for-performance (P4P) approach, describing what many policy experts have said for years: “If only it worked.” (2) Op-ed columnist Bill Keller points out that the real driver of costs in our healthcare system is not overutilization of services, but rather the high unit cost of each service. Others may debate this premise, but the reality is likely a bit of both—more units and higher cost for each. As Bill Clinton said during the 2012 Democratic National Convention, “it’s math, folks,” and P4P is unlikely to change these factors significantly. Read more…

January 9, 2013

We Can All Get Along: It’s the Patient, Stupid

My last blog used the infamous Rodney King episode in Los Angeles as the springboard for suggesting that integrating care—physicians, hospitals and patients working together—is essential to achieve the best clinical outcomes for the chronically ill while constraining the runaway costs of healthcare. A recent article in The New York Times (http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?_r=0) makes it clear that this is not a theoretical concept. Physicians at one of the great healthcare organizations in the country, the Cleveland Clinic, have been forming focused teams that can mobilize to efficiently diagnose and treat a variety of illnesses, including neurological, cardiovascular, oncologic, urologic and nephrologic. Read more…

October 5, 2012

NephLink: The Collaborative Advantage of Social Media

It seems that everywhere one looks in the healthcare media these days, there are stories about the competitive advantages of physicians using social media. For example, American Medical News recently published a very informative article entitled “Four Ways Social Media Can Improve Your Medical Practice,” which illustrates the ways in which physicians using social media as a listening tool can discover needed services, improve customer service, gather feedback on medications and compare and improve quality.

I don’t disagree that social media offers physicians a valuable listening tool that may well provide some competitive advantage. But I’m much more interested in the collaborative advantage social media offers as a community-building tool. Read more…

September 6, 2012

Comparing Outcomes for Dialysis Patients Around the World: The Debate Continues

DaVita is entering the world of international dialysis in a big way. We are partnering with doctors in Singapore, India, China, Malaysia, Saudi Arabia, Germany and other countries. As we embark on this exciting adventure, we again are faced with the nagging perception that dialysis outcomes in the United States are worse than those in other parts of the world. Two recent articles provide fascinating perspectives on this important issue. Read more…

August 16, 2012

There Is Light at the End of the Quality Tunnel: Physicians Are Starting to Drive the Bus

I am becoming more optimistic as I continue to understand and refine the programs of VillageHealth, the DaVita integrated care–management organization, and delve into the incredible success of HealthCare Partners, DaVita’s new partner. This optimism is driven by the belief that physician-led, physician-driven, patient-centric care can not only be accomplished, but such an approach optimizes clinical outcomes while responsibly controlling costs. Read more…

July 26, 2012

Nephrologists Need to Drive Clinical Quality Improvements: How Do We Re-Energize the Discipline?

This weekend my wife and I visited some friends in Santa Barbara who are supporters of The Music Academy of the West. The Academy was founded by a group of artists and patrons in 1947 to “…aid in the development of gifted young classical musicians through advanced study with accomplished faculty artists.…” The Academy has evolved and now has its own campus where each summer more than 130 fellows participate through a combination of personal instruction, educational programs and live performances before small or large audiences. Guest faculty includes some of the icons of the music world, such as vocalist Marilyn Horne, opera legend Kiri Te Kanawa, violinist Gil Shaham, pianist Ingrid Fliter, and percussionist Colin Currie. Underlying it all is a strong culture of mentoring, as there is in training for a professional music career even while in school.

Participating students are experiencing this incredible summer experience while on hiatus from New England Conservatory, Juilliard, The Cleveland Institute of Music, Manhattan School of Music, Eastman School of Music and many other prestigious institutions. As I read through each student biography, I was struck by the fact that not only was the person’s school listed, but the key teacher with whom each student worked was identified as well. Mentoring. I had a chance not only to listen to solo, ensemble and orchestra performances, but also to talk to some of the students about their dreams for the future. There was a sense of wonder, of anticipation, of passion about the career for which they were preparing that inspired me. But it also made me think about my own career and the future of nephrology.

This was not the first time I was introspective about the need to re-examine nephrology as a discipline; to rethink how we attract the best and the brightest to the specialty and create opportunities for young doctors to see why nephrology, and improving the lives of kidney patients, is a noble, desirable career. In 2004 my colleagues and I published the results of a survey we took of 67 fellows participating in an advanced perceptorship in nephrology.1 We found that exposure to hemodialysis and peritoneal dialysis was pathetic, with 50% of fellows reporting fewer than three months of exposure to in-center hemodialysis ICHD, often without didactic sessions or regular attending rounds) and 25% no exposure at all to peritoneal dialysis. This mirrored concerns expressed by many more than 10 years previously. 2-4

Well, here we are, another 8 years later and has the situation improved? Three recent articles address this issue. Merighi et al. attempted to study the relationship between nephrology training experience and subsequent clinical practice. 5 Using a national survey, data from 2010 provided insights into the experience of over 600 nephrologists. Nearly 40% of respondents answered they did not feel well prepared for the care of dialysis patients at the end of their fellowship. In addition, although over 90% of dialysis patients in the US utilize ICHD, only 6% of the nephrologists surveyed would choose this modality for themselves.

Is this just a problem with training programs or is it a problem with the expectations residents have as they consider nephrology as a career? Shah et al. have tried to address this question in a fascinating study published recently. 6 Over 50% of the time nephrology was chosen prior to the second year of medical residency training, in half of these individuals during medical school or before. While the majority chose nephrology because of the interesting subject material, only 65% reported that mentoring or a role model was influential in the decision. A disappointing 64% were extremely or very satisfied about their career choice; however, the most common reason for high levels of satisfaction was mentoring.

So, how can the torch of nephrology be brightened, enhancing interest in the specialty, attracting the best and the brightest who can drive innovation in outcomes for our patients? Jhaveri et al. have proposed an interesting elective experience for medical residents that is an important step in the right direction.7 While there are many creative components to this approach, enhanced mentoring is an important component.

The theme is inescapable: if we really want to attract the nephrologists we would like to care for our families and ourselves, we need to focus on role models and mentors who are passionate about nephrology, about service to patients and about innovating to improve outcomes. If we can instill these cultural values in young physicians early in their career decision-making process, we can perhaps begin to build the discipline of nephrology to new greatness.

As Robert Frost said,

“I am not a teacher, but an awakener.”

It is incumbent on all of use to awaken the passion in students and colleagues to build the discipline our patients deserve.

Plutarch, over 2000 years ago, said it best:

“The mind is not a vessel to be filled, but a fire to be kindled.”

 

Striving to bring quality to life,
Allen R. Nissenson, MD

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  1. Nissenson AR et al. Improving Outcomes in CKD and ESRD Patients: Carrying the Torch from Training to Practice. Semin in Dial 17:380, 2004.
  2. Fine LG. A Proposal to Improve the Attractiveness of Nephrology as a Subspecialty Choice for Residents in Internal Medicine. Am J Kidney Dis 15:302, 1990.
  3. Nissenson AR. Morbidity and Mortality of United States Dialysis Patients. The Legacy of Inadequate Nephrologist Training? Semin in Dial 5:277, 1992.
  4. Kimmel PL et al. Effectiveness of Renal Fellowship Training for Subsequent Clinical Practice. Am J Kidney Dis 18:249, 1991.
  5. Merighi JR et al. Insights into Nephrologist Training, Clinical Practice, and Dialysis Choice. Hemodial Internat 16:242, 2012.
  6. Shah HH et al. Career Choice Selection and Satisfaction among US Adult Nephrology Fellows. www.cjasn.org Vol 7 September, 2012.
  7. Jhaveri KD et al. Enhancing Interest in Nephrology Careers During Medical Residency, in press. http://dx.doi.org/10.1053/j.ajkd.2012.04.020.

 

 

June 20, 2012

Our Aging Population: What Is a Nephrologist to Do?

I am sitting here on Father’s Day and reminiscing about my father. He was born in 1919 into a struggling first-generation immigrant family in Chicago. Over the years he worked hard, as folks who lived through the Great Depression and World War II did in those days, and became a successful businessman. He taught me many things, but above all the importance of interpersonal relationships and the value, the imperative, of always treating everyone with respect and dignity—from your bosses to the housekeepers. This value serves me well, as it did him. He died in 1998 after a short but terrible battle with pancreatic cancer. My mother, to whom he had been married for 54 years, was devastated but eventually bounced back. She is now 86 and in an independent-living apartment—incredibly, totally cognitively intact, but with multiple medical issues, some of which I have previously mentioned in my blogs.

The recent Time Magazine article by Joe Klein, “The Long Goodbye,” (1)got me thinking about the issue of how we as a society approach the impending deaths of loved ones. Klein points out how lucky he and his parents were to get into the Geisinger system, where patient-centric, integrated and holistic care was provided and his parents were cared for, as he would like to be. He states, “Doctors are trained to do whatever they can to save a patient, even an elderly one, and that is an excellent thing. But that Hippocratic impulse has been subtly undermined by the rewards of fee-for-service medicine and by the threat of malpractice suits, which militate in favor of ordering the extra MRI or blood test or dialysis even for a patient who probably has only weeks to live.…” A few days later Austin Considine, writing in The New York Times, noted that Klein was only one of many who have recently written on this topic, with articles in New York magazine and The Atlantic Monthly in the past year articulating the same themes (2). The managing editor of Time, Richard Stengel, notes, “[this is] an issue that’s always on people’s minds…every day there are thousands and thousands of people making these agonizing life-and-death decisions.”

These musings by noted popular writers were brought into focus for me, not because of the frailty of my mother’s medical condition, but by an outstanding article in the recent American Journal of Kidney Disease by Jane Schell and colleagues: Discussions of the Kidney Disease Trajectory by Elderly Patients and Nephrologists: A Qualitative Study (3). The purpose of the article was to better understand with whom nephrologists and elderly patients interact and discuss the future at various stages of kidney disease. The results are fascinating and worth summarizing.

Schell developed a process map of the progress of kidney disease, from diagnosis to disease progression to treatment preparation to dialysis to end of life. She then was able to identify, through questionnaires and interviews, themes for patients and nephrologists at each of these steps. For patients, Schell’s process map indicated diagnosis leads to shock, and then, as treatment preparation begins, patients are quite uncertain about how the disease will progress. As dialysis and further clinical deterioration occur, patients express a lack of readiness for living with dialysis and facing death. For nephrologists, Schell noted there is a real struggle initially to explain how complex kidney disease is, and a real feeling of frustration with the lack of control over the progression of the disease. As dialysis is initiated and clinical deterioration occurs, nephrologists tend to avoid discussions of the future. So what is missing here? We have a failure to communicate! As Schell concludes, “This study shows key areas within nephrologist-patient communication amenable to interventions that address patient understanding and treatment decision making. Effective communication has been shown to enhance patient understanding, shared decision making, and implementation of care plans consistent with patient preferences and goals.… These data show the gaps that exist in how nephrologists and elderly patients discuss and understand the kidney disease course. Interventions that focus on addressing emotion, uncertainty, and understanding may improve patients’ experiences. Effective communication may enhance patient-centered care and promote greater shared decision making.”

It is no coincidence that the recent RPA Clinical Practice Guideline is titled “Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis.” In order to share, one must communicate. Seeing frail, elderly patients in the office quarterly or the dialysis facility only once monthly is insufficient to permit the relationship-building, the establishment of trust, that is essential for true, deep discussions of these personal but critical issues.

Francis Weld Peabody was a distinguished clinician and teacher, educated at Harvard and Johns Hopkins in the early 20th century. His words first published in JAMA nearly a century ago still ring true:

“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.… One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Striving to bring quality to life,

Allen R. Nissenson, MD
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  1. Klein J. Time Magazine, June 11, 2012.
  2. Considine A. The New York Times, June 13, 2012.
  3. Schell J.O., et al. AJKD 59:495, 2012.

 

 

April 18, 2012

Back to Basics: What Are the Leadership Qualities We Need in Nephrology??

I recently had a chance to round on some in-center dialysis patients at my facility at UCLA. It was incredibly heartwarming to see so many of my former patients still doing so well. It was a real homecoming for me. As I made rounds with Fellows and the entire interdisciplinary team, I started to reflect on what it meant to be a leader in a complex healthcare-delivery setting. There is no setting in medicine that better reflects the need for leadership than care in the dialysis facility. So what are the components of a true leader—things we never learned in medical school, but that are so critically important for our patients as we serve as leaders in dialysis facilities? Each person needs to determine what he or she truly believes struck a chord. Our leadership is based on our belief in truth, grace, growth and freedom. Beliefs determine behavior that defines performance as a leader.

Truth involves standards, honesty, discipline, integrity and clear expectations; grace is not a religious reference but includes showing others that you are on their side, that you have empathy, compassion and understanding; growth is characterized by demanding feedback, being self-aware, understanding others, and having humility and discipline; freedom means being encouraging and secure, and forgiving and empowering others—it leads to serving others, and true power comes from giving power to others.

You need to define what you believe as a leader, but these are right on for me. To be true to yourself, evaluate your leadership: 1) The gap: how far are you from where you want to be?; 2) The fit: how do I fit my role?; 3) Feedback: what do others say?; 4) Parallel context: how are others in similar roles doing?

Sound like a business-school exercise? Sound irrelevant to the day-to-day grind of a nephrologist/Medical Director? Think again. Leadership is demanded of nephrologists, and such leaders will not only have great dialysis facilities with incredible patient outcomes, but will also have successful practices and fulfilling lives.

One of the great things about DaVita is the incorporation of core values into everything that is done in the organization. As I made rounds I had a true epiphany—the way I conduct myself is exactly the articulation of the DaVita core values! I first and foremost am committed to enable high quality of care by serving my patients and delivering service excellence. To be a true leader and be trusted by colleagues and patients and their families, this service excellence must be delivered with the greatest integrity; we say what we believe and we do what we say. Delivering credible, excellent care cannot be done by one individual, but requires a team working together with a common vision to improve the lives of patients with kidney disease. We must, of course, never be satisfied with where we are, but rather must always strive for continuous improvement. We also must be humble and understand that none of us is always right, and we must be willing to ensure that accountability for one’s own actions is something we insist upon from our colleagues and our patients. If we can drive excellent service, in a transparent way with full integrity, working with a team, continuously improving and holding ourselves accountable, then we can experience true fulfillment while still having fun in the process. Is this an achievable vision? I would submit yes—I am living it!

So, stepping up and being a leader, while always anchored by fundamental core values, is for me the way to do the best I can for my patients and to live the most fulfilling life possible. Are you a leader? What are your core values? Take some time to answer those questions. It might just be the most valuable time you have spent in your hectic life as a nephrologist.

Remember what the great management guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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March 19, 2012

Getting Integrated Care Right for the Kidney Community

For more information on the future of Accountable Care Organizations visit www.AccountableKidneyCare.com

In this short video, Allen R. Nissenson, MD, FACP, Chief Medical Officer, DaVita, shares why taking the proper care of the kidney population is so important for Integrated Care Systems or ACOs.

Disclaimer: The views expressed in this presentation are the views of the speaker and do not necessarily reflect the views of DaVita, Inc. DaVita does not guarantee the accuracy of the data included in this presentation.

March 5, 2012

Happy Birthday, Medicare Kidney Amendments!

In 1972, during the term of President Richard Nixon, the House of Representatives was working on a revision of the 1965 Medicare and Medicaid programs. The work of the House was nearly completed when an amendment was proposed and passed, Section 299I of Public Law 92-603, titled: “Chronic Renal Disease Considered to Constitute Disability.” The amendment added the following short phrase to the list of eligibility criteria for Medicare entitlement: “[an individual who] is medically determined to have chronic renal disease and who requires hemodialysis or renal transplantation for such disease.” The bill was passed on October 30, 1972, and the program was enacted on July 1, 1973.

So, 2012 is the 40th anniversary of that historic amendment, which ensured access to kidney care for thousands of people. Although this is not the precise birthday, I was compelled to write this blog because of a front-page article in the Sunday New York Times on Feb. 18. The headline read: “60 Lives, 30 Kidneys, All Linked: Intricate Balancing Act Produces a Record Chain of Transplants.” In the article, the domino chain–transplantation approach is explained. It is truly remarkable how many lives have been changed by this approach, which is increasingly necessary because of the massive shortage of available donor organs.

What caught my eye in the article, however, were some characterizations of dialysis: “Since receiving a diagnosis of diabetes-related renal disease in his mid-40s, he had endured the burning and bloating and dismal tedium of dialysis for nearly a year”; “Only half of dialysis patients survive more than three years”; “Many of the 400,000 Americans who are tethered [italics mine] to dialysis”; “Dialysis … saps the productivity of caregivers as well as of patients.” OK, anyone who has cared for dialysis patients knows that being on dialysis is difficult, and none of us is satisfied with the clinical outcomes or quality of life of our patients, but how often do we or our patients reflect on how far we have come, not just on how long and difficult the road ahead remains?

Thomas Graham is generally regarded as the first pioneer of diffusion-based dialysis. Working as a chemist in Scotland in the 19th century, Graham separated substances using a semipermeable membrane. Over the next century, many innovators contributed to the development of modern dialysis, including John Abel, Leonard Rowntree and Benjamin Turner; Georg Haas; Willem Kolff; and of course Belding Scribner. It was the incredible work of Scribner’s Seattle team that made chronic dialysis possible and a reality.

Here we are in the early 21st century and have the shoulders of such giants on which to stand. The promise of continuously operating, wearable dialysis devices is no longer a dream but rapidly becoming a reality. Recent research suggests that more frequent and longer treatments offer the hope of enhanced survival, fewer hospitalizations and higher quality of life. Extensive research is underway on in vitro growth of functioning kidney tissue and on reaching the Holy Grail of transplantation — true tolerance. While we wait for such breakthroughs, we would do well as nephrologists to read the inspirational book written by Lori Hartwell, someone who has had a life filled with illness, dialysis and transplantation. Lori’s book is “Chronically Happy: Joyful Living in Spite of Chronic Illness.”

So, happy birthday, Medicare ESRD program. Had you never been born, countless millions would have died of kidney failure. The current dominant treatment, dialysis, is not perfect, but it is continually improving. Those of us entrusted with caring for this fragile group of patients must always remember that we are also treating families and caregivers. The responsibility is enormous, but by working together — doctors, nurses, social workers, dietitians, technicians, families, caregivers and researchers — we can continue to do what is the true calling of medicine: provide holistic, patient-centric care that considers all of the unique attributes of each patient and family and strives to enable all patients to live the life to which they aspire. After all, who won the race, the tortoise or the hare?

Kahlil Gibran provides poignant advice for all of us: “Advance, and never halt, for advancing is perfection. Advance and do not fear the thorns in the path, for they draw only corrupt blood.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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