The Art of Medicine: Let’s Not Lose It In Nephrology

The New York Times recently highlighted a new program being introduced as part of the evaluation of applicants for medical school.  A handful of medical schools are now assessing social skills, having the applicants interview nine “patients” with serious social or ethical problems.  Not only are social skills assessed, but also the ability of the applicants to work together in small teams.  As nephrologists, we know patients with chronic illnesses, including CKD/ESRD, are among the most needy in this regard, requiring physicians who listen and are able to work effectively in teams, whether within their practice, with other doctors, or with the interdisciplinary team in a dialysis facility.

A recent medical crisis with my Mother made me think hard about how physicians, patients and caregivers communicate nowadays in the world of technology-driven medicine and electronic communication.  Although my mother does not have CKD/ESRD, she does have significant chronic illnesses.  She is 85 years old and as mentally sharp and energetic as she was 50 years ago.  Over the years, she has developed diabetes, hypertension and, more recently, slowly progressive liver dysfunction (“cryptogenic cirrhosis”).  The latter has been the most problematic, leading to two hospitalizations over the past 3 years with hepatic encephalopathy.  Both of these hospitalizations were handled quickly and efficiently, poor control of blood sugar and blood pressure had pushed her over the metabolic edge, and she quickly recovered with appropriate attention to these issues.

A month ago, I got a call from my sister telling me Mom was admitted again, confused, agitated and disoriented.  This seemed like another one of her metabolic “episodes”, but the ER physician decided to order a brain MRI, EEG and neurology consult.  He did not pull up her medical records or listen to the history given by my sisters.  The MRI showed a small area of scarring (likely from a fall a few years ago) and the EEG was “abnormal”.  The neurologist could not interview my mom, who was still confused, and told my sisters that mom had status epilepticus based on the EEG and started her on high dose Keppra.  One could predict the result- extreme fatigue, inability to ambulate and growing depression.

When I got this news, I called the neurologist to get the direct information on what had happened.  The neurologist who made the diagnosis was not on hospital duty any longer and her associate was, but was not available.  I asked for an email address and was told, “his policy is not to provide email addresses to patients or families”.  The next day, I got a message that he also had spoken to my sisters and that, despite my being a physician, his policy was only to speak with a single family member.  I was finally able to contact the initial neurologist who was the “seizure specialist” of the group, who described why she made the diagnosis she did.

I asked if it was possible that the abnormal EEG was related to metabolic encephalopathy, since the clinical episode was so similar to previous episodes.  I also asked what the clinical manifestations of status epilepticus were- she could not answer either question but was adamant that the diagnosis was correct.  When I suggested tapering the Keppra to see if the now-corrected metabolic problems were the true precipitating cause, she stated that she would not consider that for at least a year.

I got a second opinion from a local academic institution- the chief of the epilepsy service interviewed my mom, reviewed the tests and immediately started tapering the Keppra.  He stated that the diagnosis was incorrect but an honest mistake, since the neurologist couldn’t interview my mom and did not have direct access to her previous records.  After 3 weeks of slowly tapering off the Keppra, my mom is back to her normal, ambulating, bubbly self.

The point?  Poor communication, over-reliance on high-tech procedures and inability or unwillingness to interact with the family – when the patient was unable to provide clear information – were at the root of the mistake.  Such situations occur daily with patients on dialysis and the increasing reliance of nephrologists on physician extenders further extends the gap between patient and doctor.  I hope that nephrologists will again reexamine the value of spending time with patients,  listening to them and better understanding what they want and need.  The technical aspects of dialysis are generally well performed but to truly deliver holistic care, we must all remember this is done one patient at a time, at the bedside, and it takes time and commitment.

As made famous in Cool Hand Luke:  “What we have here is a failure to communicate”.  That should never be the case in the practice of the art of medicine.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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