The New York Times published an article recently about the increasing trend of nurses getting advanced degrees. “[In 2010] 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates.”(1)   The concerns expressed by a variety of groups in organized medicine was over the use of the title “doctor” for the nurses who had earned a PhD, with possible confusion of patients over who was a “real” doctor. Clearly this is a smokescreen and the real concern is over control and concern over the slow “intrusion” of nurses into medical practice. This concern is curious since it is clear that there continues to be a significant workforce deficit in primary care and in medical subspecialties such as nephrology.

Recent data from the Renal Physicians Association confirms what all practicing nephrologists already know: The patient population with ESRD and CKD is growing and is increasingly medically complex; the ability to recruit new nephrologists into practices is decreasing, with stagnant training programs and large numbers of IMGs not remaining in practice in the U.S. following training; there is increasing demand on time for administrative activities, including fulfilling the requirements of the Conditions for Coverage to carry out Medical Director activities appropriately; continued pressure from hospitals and other organized care systems to become salaried physicians; and constant downward pressure on reimbursement for physician services. All in all, working harder for less. It is time we applied the age-old adage, work smarter, not harder, and embraced ways of doing this, like working in teams and expanding the use of our advanced nurse colleagues.

There is no area in medicine where the interdisciplinary team (IDT) is as critical to optimizing clinical outcomes as it is in ESRD. Most people, however, narrowly define the IDT as the physician and various teammates in the facility (nurse, technician, dietitian and social worker). This narrow paradigm is critical for driving outcomes, as we showed in a recent publication. (2) When we looked at process measures that significantly correlated with survival at a facility level, IDT meetings were critical, particularly following sentinel events like hospitalizations. That is fine as far as it goes, but it is now apparent that this is necessary, but not sufficient to get the best outcomes.

Focusing on the holistic needs of the ESRD patient is essential, as demonstrated in the recently completed CMS ESRD Demonstration project.(3)  Attention to preventative care, including immunizations, control of diabetes, fluid overload and aggressive medication management all lead to better overall outcomes. But who is going to relentless pursue these things? The nephrologist?  The dialysis facility core team? We need to expand the definition of the IDT to include additional members, such as advanced practice nurses who cannot replace the nephrologist, but can enhance the team by addressing these key areas of care. If we do, we will truly be walking the walk of team, and our patients will be far better off— withbetter clinical outcomes and higher satisfaction with their care.

If we as nephrologists are to fulfill our responsibilities as leaders of dialysis facilities and clinical care for our vulnerable patients we should remember what the organizations 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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The ESRD Networks have been an integral part of the quality oversight of the ESRD program for decades now. Originally 44 such organizations, now officially 18, cover the country and have a contractual relationship with CMS based on specific performance and deliverables. The most recent iteration of Network contracts holds these organizations accountable for some specific clinical outcomes of dialysis facilities, in particular the fraction of patients with AVFs.  This focus for CMS and the Networks is part of the Fistula First Initiative, an outstanding national quality improvement program designed  to increase the number of AVFs in U.S. hemodialysis patients—an area where we lagged significantly behind other parts of the world. And who could argue with this focus? Everyone knows that AVFs are associated with fewer infections and episodes of clotting than grafts or catheters and the latter in particular lead directly to increased hospitalizations, mortality and significant increases in the costs of care.

An intense focus on AVFs, however, has some unintended consequences, including multiple surgical procedures.  Poorly constructed AVFs do not function and may lead to significant morbidity. Until permanent access is functional, catheters are required for carrying out dialysis with all of the attendant risks these convey. Judicious use of grafts is a far better alternative. Ah, but there is the rub—dialysis facilities and now Networks are not “graded” on how few catheters their patients have, but only on how many fistulas, no matter what the cost.

The misalignment this state of affairs causes was clearly illustrated to me in a recent call I had with an ESRD Network MRB chair and Executive Director. They were very concerned because their Network was getting intense pressure from CMS because the facilities in their region had among the lowest AVF rates in the country.  As it turns out, however, this Network has the lowest catheter rate. As we have been able to show in DaVita facilities, the facility can clearly impact catheter rates after patients enter the facility, with clear process approaches that drive permanent access placement and catheter removal.  It is less clear, however, how facilities impact, and can be held accountable for, whether a patient gets an AVF or a graft.  That is the domain of the attending nephrologist and the vascular surgeon, who are the ones who should be held accountable.

So, should the Network in question be viewed by CMS as a poorly functioning one because of somewhat low AVF rates or one of the best because of great catheter rates? If we return to the old adage, Do No Harm, forcing placement of AVFs where surgeons are not skilled in their construction or patients may not be suitable, seems to be far less important than focusing on minimizing the use of catheters. In the ideal circumstance, there would be great surgical support and both goals—more AVFs and fewer catheters—would be possible, few real life situations fit that description. Making tough choices is a part of the Art of Medicine, and for me, intense focus on catheter removal should clearly take priority. Penalizing Networks and facilities focusing only on AVFs, Fistula First, rather than Catheter Last is the wrong policy approach.  It creates unproductive friction between components of the care system that should be working closely together.

As articulated in Wikipedia:  “The law of unintended consequences is an…idiomatic warning that an intervention in a complex system always creates unanticipated and often undesirable outcomes.  Akin to Murphy’s law, it is commonly used as a…humorous warning against the hubristic belief that humans can fully control the world around them.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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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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