« JASN Intensive Dialysis Series: More is Better | Main | Touch Cannulation: The Genius of Stuart Mott »

Thursday, February 23, 2012

Comments

Feed You can follow this conversation by subscribing to the comment feed for this post.

Anon

Dear Dr. Laird

Your blog is a constant source of information and study for me and I am truly grateful to you for writing it.

I thought about commenting on the post that you wrote "damned if you do damned if you don't" but things came in between so I will take this opportunity instead.

The art of medicine has for millennia been something of which few have knowledge but all have need. Its intricacies makes it a difficult to approach topic and hence its practitioners are seen as having special healing powers. The fact, as I am sure that you are aware is that medicine is a science and not a religion. More experience = more knowledge = better doctor (in very general terms of course)

The patient, up until recently, relies on the doctor to judge for him the best treatment for his/her ailment seeing that they do not have the knowledge necessary to do so themselves. This places a lot of power into the hands of the medical practitioner and his/her integrity needs to be beyond questioning or the whole system will fall apart.

And then came the internet.......

Now the patient has access to a horde of doctors, patient rights advocacy sites, bulletin boards and forums where he/she can ask questions or voice concerns.

So whether the doctor tells them of the mortality rates in their first year of dialysis or not you can be sure they will find out either way. In fact reading the post "damned if you do damned if you don't" will give you the information right there.

What used to be "get a second opinion" from another doctor is now "google it"

The internet has changed how we interact with information and nothing is sacred any more.

From a legal standpoint I am guessing this will turn into a hornets nest.....

"My doctor prescribed dialysis but according to a website in Germany...."

Thanks always for an interesting blog!


Peter Laird, MD

Dear Anon,

Thank you for your kind comments. Having nearly 20 years of clinical experience in medicine, the aspect of the art of medicine is one that is mainly based in many ways on individual personalities of the doctors. I found the most important aspect of the art of medicine was the foundation of honesty and trust. My patients knew that I would convey what I knew and what I didn't know to them in a forthright manner.

Many times, I have had to tell patients I knew and cared for that they had a terminal illness. The most difficult I can remember was telling a very young man in his 20's that his test for HIV was positive. It hit him like a brick wall. In any case, it was not only his right to know, but it was right to tell him. Being a doctor means knowing how to be compassionate with the truth. Not an easy task, but it is the first step for patients to begin dealing with very traumatic news.

One aspect of art of medicine is dealing with the fiduciary duties and legal requirements of our profession. For dialysis patients, the legal duties are spelled out in black and white in the Medicare Conditions for Coverage.

The ethics of medicine dovetails the art of medicine with respect for patient autonomy not only the prevailing ethical paradigm, but it is also the legal paradigm serving as the foundation for informed consent. Informed consent is also the foundation of many negligence definitions by virtue of failure to provide that requirement.

I have never seen any other specialty so ignore this aspect of medicine other than the American nephrology community. I listed a couple of studies that documented this objectively in my post. Given the alternative treatments for ESRD that have much different outcomes, informed consent is a mandatory requirement. To speak of the art of medicine by withholding information goes counter to legal and ethical standards. I simply cannot condone such a practice and I don't believe it has any part of the art of medicine today.

Just my own opinion.

God bless,

Peter

Sarah

Dear Dr. Laird,
Bravo! I just happened to read the article you mentioned by the physician who won't tell his ESRD patients about their mortality. I was also appalled. I deal with the effects of this kind of practice on an almost daily basis. You are absolutely correct. If the urgency and seriousness of the situation is not explained to patients, then you end up with a lot of "frequent fliers" in the ER who are hyperkalemic, and volume overloaded. Frequently their phosphorus levels are high and their albumin levels are low due to poor diet, missed HD treatments, and treatments cut short. Every time, I have to do an emergent treatment on a chronic patient for one of the aforementioned reasons, it means the patient is literally giving up measurable hours of his/her life. I have resorted to telling my emergent patients this and re-educating those that will listen on the importance of diet and HD treatments. I try to do this with a positive approach and not an angry or condemning style as I want them to be healthy and happy. But I don't shy away anymore from emphasizing to them that the "E" in ESRD stands for "END". Whether that "end" is 6 months from now or 5, 10,15 years from now is largely due to their diligence in taking care of themselves through diet, exercise and faithfully attending their dialysis treatments.
I hope many physicians listen to you and start informing their patients of the seriousness of their disease and the huge impact their personal choices will have on their prognosis. Also, I would like to see all the options presented to the patients. It seems to me that our docs just sort of pick HD for the patient. I don't seem to see a lot of peritoneal dialysis going on. Maybe it's just because I do acute HD. But in all my HD experience, I have only one time done acute HD on a patient who was waitng for the new tenkhoff site to heal and needed temporary HD till PD could be started. Keep up the good work! Sarah

Peter Laird, MD

Thank you Sarah, the failure of the America nephrology community to engage in true informed consent is just one area of concern over our unique American dialysis experience. WIthout telling patients the true nature of what to expect from conventional in-center hemodialysis and not relate the alternatives is a great disservice to the American dialysis patient. America's nephrologists have much to learn from their colleagues in Europe, Japan and Australia.

The comments to this entry are closed.

My Photo

October 2020

Sun Mon Tue Wed Thu Fri Sat
        1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 31