This is the time of year to reflect on the past 12 months, to be introspective and honestly assess where we have come and where we are going. As the themes of my blogs over the year have emphasized, patients with kidney disease are among the sickest of the sick, yet are embedded in a system of care that is largely dysfunctional. Uncoordinated care, inadequate focus on care transitions, lack of identification and management of co-morbid conditions, and too little preventive care all remain problems that must be overcome if we are to truly improve survival and quality of life for our patients.

Having said this, however, 2011 also showed us that there is clearly a growing momentum to do things differently, to restructure the way we think about and deliver care, and patients benefit. The one renal community initiative – PEAK, a program to lower incident patient mortality by 20% by the end of 2012 – is on track. The results of the CMS Global Capitation Demonstration Project are in and overall, with an intense focus on care coordination, survival improved, hospitalizations decreased and total costs of care were lower than in a matched group of Medicare fee-for-service population. Both DaVita and FMC identified the key drivers of poor outcomes and created customized programs including provision of nutritional supplements, use of biometric devices to control fluid overload, dramatic success with influenza and pneumococcal vaccination, and medication management therapy, among many others. These programs had one important characteristic in common – they were patient-centric, engaging patients in their own care and being sensitive to what each patient needed and wanted. Outside of the Demonstration, 2011 also saw a significant growth in home dialysis, particularly peritoneal dialysis, again demonstrating a sensitivity to patient needs and desires.

So why am I optimistic about 2012?  We now have a large number of approaches to improving outcomes that we know can work and are implementable. In addition, we are continuing discussions with the Center for Medicare and Medicaid Innovation (CMMI) and it looks more and more likely that a large-scale pilot program of integrated care management/care coordination will begin in the New Year. Finally, in mid-2011, a group of Chief Medical Officers from throughout the dialysis industry met together for the first time to discuss ways of substantially moving the quality needle for ESRD patients. This group is working closely with the KCP and KCC, ensuring alignment between business leaders and clinical leaders in the industry, along with policy makers. We have not seen this level of collaboration before and I am confident that 2012 will be just the beginning of new progress to improve the lives of patients with kidney disease. By working together, along with our patients, we can make this happen.

We would all do well to remember the words of Steve Jobs and try to live them as we start the new year:
“Everyone here has the sense that right now is one of those moments when we are influencing the future.”

I look forward to your comments, until next time.

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

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A recent editorial in the Clinical Journal of the American Society of Nephrology discusses the imperatives in the training of the future generation of nephrologists (1). In this insightful presentation Kohan notes five of the key forces that are driving what he calls a “perfect storm” in our discipline. The forces include increasing clinical workload, diminished interest in nephrology as a career choice, the changing nature of nephrology care, increased requirements for nephrology training programs from accreditation bodies and decreased funding for nephrology trainees and research. Mentioned as well is the excellent study by Berns published in 2010 demonstrating the dissatisfaction nephrologists had with the real-world preparation they received during their fellowship training (2).

Nearly seven years ago, we published a Special Article in Seminars in Dialysis following a preceptorship we organized for second-year nephrology fellows (3). This multi-day program, carried out by senior leaders in nephrology was attended by nearly 70 fellows, many from some of the most acclaimed nephrology training programs in the United States. As part of the experience we surveyed the participants to better understand the training programs from which they came. We were astonished by the responses, including:  50 percent of programs offered fewer than three months of experience in OP hemodialysis; 25 percent of programs offered no exposure to chronic peritoneal dialysis; 50 percent of programs offered fewer than three months of inpatient dialysis; and two-thirds of programs offered fewer than three months of transplantation. Faculty rounding during the OP dialysis rotation was “prn” in 25 percent of programs.

We made a series of recommendations to improve the fellowship experience and align what fellows are taught with what they need to know when they enter practice. These include: continuity experience in outpatient dialysis (minimum of three months, preferably 12 months); exposure to all available forms of RRT including HD, PD, HDF, and CRRT; exposure to daily and nocturnal dialysis as well as HHD; exposure to interventional nephrology; regular multidisciplinary rounds with faculty and other care team members on a regular basis; and regular didactic lectures on relevant topics related to dialysis and the management of ESRD and CKD patients.

This list is now incomplete, as pointed out in the excellent study by Lane and Brown published in the same issue of CJASN as the Kohan editorial. These authors from Australia point out that in order to truly be a world class nephrologist, one must have the content knowledge, as outlined in our recommendations above, but also must be trained in delivering holistic care, in developing the necessary skills to apply the knowledge, the be sympathetic/empathetic and to be a superior communicator.

So the challenge goes to our nephrology training program directors – how can they adequately deal with the external forces outlined by Kohan, provide the content knowledge that grows every day and develop a new generation of compassionate communicators?  Not an easy task, but unless we all dedicate ourselves to helping making this possible, it will not happen and one of the last remaining great medical subspecialties will be struggling for survival.

Do the words of the late John F. Kennedy apply to nephrology of the future?

“We have the power to make this the best generation of mankind in the history of the world or to make it the last.”

I look forward to your comments, until next time.

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

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References:

1.    Kohan DE. Training the next generation of nephrologists. Clin J Am Soc Nephrol 6:  2564-2566, 2011.
2.    Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 5:  490-496, 2010.
3.    Nissenson AR, Agarwal R, Allon M, Cheung AK, Clark W, Depner T, Diaz-Buxo JA, Kjellstrand C, Kliger A, Martin MJ, Norris K, Ward W, Wish J. Improving outcomes in CKD and ESRD patients:  Carrying the torch from training to practice. Seminars in Dialysis 17:  380-397, 2004.