Scapegoating Nephrologists? Or Instead Challenging them to Take Responsibility?

by Peter Laird, MD

My wife views some of the responses people make to my blog posts with quite a bit of disbelief at times. After all, she washes my dirty socks, tells me to make the bed since I usually get up last, tells me to brush my teeth in the morning when I wake up with what she calls "dialysis  ammonia breath," she gets impatient with my slow and prodigious and plodding approach to setting up my dialysis machine with meticulous care and she is completely puzzled why anyone would really want to read what the bumbling oaf she calls her husband has to say about these things. 

She has fired me as her doctor more times than I can count even for very simple issues and usually tells people that I am a quack that doesn't no anything about medicine since she can't concieve how the person that she lives  and cajoles into my own share of the housework could have any sensibility at all. I had the incredibly bad luck once to discover too late that Hycodin cough syrup makes her vomit, unfortunately, right after we had gone out for an expensive meal. Ah, the love of a woman who puts up with all of my warts, although I am starting to sprout a crop of skin tags that she keeps telling me to get rid of, but she also serves as a great barometer in my life when she gives me a little bit of credit from time to time with all of the critique. In such, I expect honest criticism from her. After all, I am her ongoing project.

On the other hand, no one appreciates criticism especially in a professional manner where our own ego's are at hand. I would suspect that many people have witnessed doctors tirades and temper tantrums in the hospital setting over the least little bit of discord displayed to them. Some of us can be outright tyrants which I have upon occasion, "only" in the very remote past been guilty of myself especially during my years in training with little sleep certainly as the cause of those outbursts. Appointments with the generals aide during my military training did modify my behavior greatly before my wife took over that full time job.

Recently, a respected colleague and fellow blogger criticized one of my comments on his blog, The Kidney Doctor by Dr. Ajay Singh:

Dialysis Unplugged: The Best is Yet to Come Part III

In a comment to The Best is Yet to Come Part II,  Dr.Peter Laird writes:”How to improve dialysis is not a medical mystery, all of the other developed nations have extremely more reasonable approaches and outcomes than America that is dominated by profit and greed. The American nephrologist has left their first mandate to do no harm and instead filled their pockets with the wages of death from shortened and violent dialysis that they themselves would never submit to.”

Like almost every profession there may be some bad apples, but Dr. Laird’s comment is way off the mark in making the generalization that “The American nephrologist…[has] filled their pockets with the wages of death”. Scapegoating nephrologists may have shock value but it is neither accurate nor points to potential solutions.

I would first of all point out that I stand behind that comment and it indeed was not hyperbole as one commentator alleged. America has earned the dubious distinction of having the worst dialysis outcomes in the world. Dr. Singh feels that we are doing pretty good compared to outcomes in America's dialysis past:

Dialysis Unplugged: The Best is Yet to Come Part III

Even taking into account the risk of sounding defensive, the truth is that we work diligently and humaely to take care of our patients. Unlike 40 year ago when the majority of patients died, nearly 80% now survive. Could we do better? Sure. Are we doing badly? In the eyes of some yes, but for the most part, over 300,000 individuals receive good quality dialysis care, feel OK on dialysis and stay alive.

Dr Scribner had much to say about all of these issues long before I ever contemplated renal replacement therapy as a patient. First of all, it is Dr. Scribner, the father of chronic hemodialysis that accussed his colleagues publicly, openly and persistently of greed and profiteering at the expense of patient outcomes:

Belding Hibbard Scribner - Better Known as Scrib

Scrib's views were also a major influence on the Gottschalk Committee that looked at the potential role of government in 1967. He, among others, helped to get Congress to pass legislation for the Medicare End Stage Renal Disease Program in 1972, but later became disillusioned as he saw the large profits in the early years and the growth of for-profit dialysis organizations. He said that what he had regarded as “a noble experiment” had become a vehicle fueled by greed rather than concern for providing the best treatment for patients. He continued his interest in renal politics for the rest of his life.

Dr. Scribner also had something to state about mortality rates for patients on dialysis in the early days:

UW History with a Twist

Clyde Shields, a 39-year-old Boeing machinist dying from incurable kidney disease, was the first to receive the shunt on March 9, 1960, at the UW Medical Center. Shields lived for 11 years on intermittent dialysis. "Suddenly," Scribner says, "we took something that was 100 percent fatal and overnight turned it into 90 percent survival. To say the least, no one was prepared for it."

So, I can't blame Dr. Ajay Singh for not appreciating my medical opinions. He is not alone, but he is in good company considering my wife and her reputation which stands supreme among her family and friends. I gave up a long time ago worrying about what folks would think about my deliberately strong stance on dialysis related issues, but that is OK as well. I stand in good company following in the footsteps of Dr. Scribner who has had much harsher things to say about his colleagues than I did in my rather innocuous little comment that Dr. Singh took so much umbrage.  

I would hope that Dr. Singh and all of his nephrology colleagues would devote more time to solving our unique American dialysis issues instead of spending the time to write an entire post disparaging those of us that do not believe the current status quo is anything good. According to Dr. Scibner's legacy and many other well respected authorities, as of January 12, 2012, the best days are long since behind us for dialysis in America.  When and if Dr. Singh can prove my statement wrong with uncontrovertible evidence, I will be the first to stand up, applaud enthusiastically and turn my dialysis advocacy blog into a patient education blog.

I look forward to the day when my statement in Dr. Singh's blog has no more truth and America once again is the leader in dialysis solutions and not the laughing stock of the world as it is now. We can always hope as Dr. Scribner did by never letting go of the original intentions of his noble experiment gone wrong by profit and greed. We can only hope.

Comments

[MooseMom]

Dr. Laird, I have been following Dr. Singh's blog from the beginning, and to be fair, I don't think he is blind to what is wrong with American dialysis. He has long been an advocate of longer, slower treatment and has, on many occasions, decried the profit motive of the LDOs and how this damages patients.

But to be fair to you, when YOU are the patient, and when it is YOUR survival that's at stake, I'm not sure there IS such a thing as hyperbole. I suspect that if Dr. Singh suddenly found himself a victim of ESRD and a dialysis patient, he might sound a lot like you. At least, I'd like to think so.

You and he are on the same team. You both recognize the gaping deficiencies in SHD and want to prevent further suffering. And you both are generous enough with your time to blog about the subject... Very admirable of you both.

[Roberta Mikles BA RN]

A very interesting commentary--- Of course, when someone is a dialysis patient, or a loved one of a diaysis patient, they see care from a different view, at times. What is of great concern to me is the nephrologist's responsibility (noted in the ESRD Conditions) that is often put on the back burner. This is supported when you read a survey (inspection report) where there are identified deficiencies citing the medical director did not oversee properly, etc. When errors occur, or nephrologists are aware of various aspects of care, but do not intervene, for whatever reason, then I say '''' why have a medical director''. Some facilities have been cited for ongoing problems of the same nature,... Where is the nephrologist responsibility here? These are the physician's patients. Recently I had a few conversations with patient's family members who had problems with care, brought such to attention of their medical director, incenter, however, nothing was done.. Where is the responsibility.??
opinion of Roberta Mikles, Dialysis Patient Safety Advocate www.qualitysafepatientcare.com