HemoDoc, From Doctor to Patient

The Lasting Scribner Legacy: "The Ideal Patient"

In 1960, Belding Scribner awoke after a revealing dream with the remedy to vascular access for chronic renal failure with his vision of a teflon shunt. This provided the first feasible dialysis access and ended over 17 years of researchers frustration to expand acute dialysis care to patients with no hope of renal function recovery that we now call End Stage Renal Disease (ESRD). However, Dr. Scribner's legacy is much more than simply finding a workable dialysis access. Belding Scribner not only found a solution to long-term access, but through clinical judgement and humanitarian benevolence, he not only gave his innovation away to the entire world, but then opened his clinic for all to learn the clinical care of chronic renal patients. All of this was tempered with his caring and compassion to relieve suffering and restore and rehabilitate each patient. 

One of the most interesting stories of these early pioneering days of early chronic dialysis care, is that of Nils Alwall, the noted renal pioneer from Sweden. Alwall entered clinical studies after first completely pharmaceutical studies with an interest in pulmonary edema and developing an "ultrafiltration" machine that could alleviate the excess fluids. In doing so, he became aware of the ability to also remove uremic toxins creating an effective dialysis machine that also had sophisticated ultrafiltration controls. The initial design made of metal was heavy and difficult to move, and had difficulties with leakage. But it was a prototype that brought forth care of acute renal failure. In the next two decades beginning in the early 1940's, Nils Alwall treated over 1000 patients which was more than all the other researchers in the world combined. 

As news of the Scribner Teflon Shunt reverberated throughout the early nephrology/dialysis community, Nil's Alwall eagerly instituted use of the Scribner shunt in his clinic in Lund, Sweden. However, his first attempts with the Scribner shunt and chronic hemodialysis failed in Sweden as it did in many other parts of the world due to lack of understanding of chronic renal failure treatments. Many researchers flocked to Seattle to learn the details of the Scribner protocols and how to use his shunt continuously with effective dialysis. In a biographical memoir by one of his students, Nils Alwall quietly traveled to Seattle to see what "magic" Scribner possessed not by his excellent outcomes.

Nils Alwall -  A Personal Appreciation: J Stewart Cameron

"At the end of his 1963 book (10), Alwall presented depressing data on his early attempts to use the arteriovenous shunt to treat end-stage renal failure. All 10 patients had died quite early after starting long-term dialysis. This surprise was part of an experience noted worldwide, and many wondered what "magic" Scribner and his colleagues had concealed. Nils thus quietly went off to Seattle to work for some months himself there, to learn on site how to do long-term dialysis and found that meticulous attention to detail, the use of humpless dialysis with long sessions (6-8hr) and meticulous control of weight, salt and water intake and blood pressure were the main components of the "magic" (6). He returned and re-started a now successful program of long-term dialysis in Lund in 1964."

Seattle became the destination for researchers wishing to understand the clinical determinants of Scribner's success that extended far beyond the vascular access issues. The Seattle success emerged as the stimulus for acceptance of dialysis worldwide becoming a reliable and viable treatment of chronic renal failure. But, what Scribner and his team in Seattle accomplished was unattainable to many of the other researchers until they evaluated his entire approach. I believe that the Scribner legacy of success stemming from his very first patient, Clyde Shields, is attributed to Scribner's empiric clinical judgment that was coupled with his humanitarian benevolence. Scribner's motivation for developing the shunt is found in the poignant story of a patient from Spokane WA.

In early 1960, Dr Scribner encountered a patient who initially responded exceptionally well to several rounds of dialysis. However, when Dr. Scribner determined that the cause of this patient's renal disease was incurable and irreversible, he had no choice but to release him to a slow and agonizing death over the next three weeks. 

Our Back Pages: UW History with a Twist - Insomnia, Teflon and Lifesavers

At the time, dialysis only took place in an operating room. It preserved the life of patients with temporary kidney failure, keeping them alive until their own kidneys returned to normal. Glass tubes and to be inserted into a patient to connect them to the artificial kidney, and were removed when dialysis was done. Patients whose kidney did not recover soon died.

Scribner was haunted by the death of a Spokane patient who briefly made a dramatic recovery while on dialysis, and thought about the case constantly. I literally woke up in the middle of the night with the idea of how we could save these people, he recalls.

His idea: insert a Teflon tube in the patient's artery and vein, and keep access open by hooking the tubes together to create a high blood flow. During dialysis, the “shunt” would be pulled out and replaced by lines to the artificial kidney machine.

As Nils Alwall summarized, Scribner's success was a combination of the attention to detail, the pumpless kidney, and further attention to weight management, fluid, sodium and BP that made Scribner's approach successful. In all this, Dr. Scribner altruistically spread the news of his protocols and his devices to all who sought a remedy to chronic renal failure. In the end, it was Scribner's clinical judgement coupled with his humanitarian benevolence that made a difference in 1960 and still is what makes a difference in 2023. While main in the rest of the world pursued increased urea removal with faster and less frequent treatments, Belding Scribner understood that long, slow and more frequent dialysis schedules coupled with ultrafiltration and sodium reduction to control BP was the foundation of his program.

The WA state Department of Vocation and Rehabilitation enthusiastically embraced funding the Seattle program after observing fully rehabilitated patients. By the time of the 1973 Federal ESRD program, Northwest Kidney Center was able to accommodate almost all the patients in need of care and did so with over 90% with overnight home hemodialysis. All this extended from Scribner's simple, but powerful definition of dialysis adequacy:

"If the treatment of chronic uremia cannot fully rehabilitate the patient, the treatment is inadequate."

Beginning with Willem Kolff's focus on rapid removal of urea with less TIME and frequency of sessions, America continues to stagger under the burden of a sickly, hypertensive and costly ESRD population. Scribner had again predicted this after observing the destruction of the treatment standards of care of longer, slower and more frequent treatments capable of fully rehabilitating the patient.  Further, the Seattle program did this at 1/3rd the cost of the in-center program.

Today, it is as if the legacy of Scribner was completely forgotten after 1973 and they began define dialysis adequacy by a non-toxic, or not very toxic, small, water soluble and easily diffusible molecule, urea. Patients were divorced from the clinical assessments utilized by Scribner and additional treatments added when needed, and instead became sickly, hypertensive and disabled. This became the new standard of care and the long, slow and frequent standard of care between 1960 and 1972 has since become "controversial," and widely maligned.

Yet, through all of this, anyone who studies how to do dialysis according to the  Scribner approach can reproduce the same physiologic benefits that occurred in the Scribner era of 1060-1972. His approach is reproducible and fruitful rendering the rehabilitated existence I know well myself. Willem Kolff described what he called "the ideal patient."

Guide for treating patients by chronic dialysis with the twin-coil artificial kidney 

"The ideal patient is one who does not require removal of fluid and sodium during dialysis because he limits his fluid and sodium intake. Thus, his predialsyis and his postdialysis weight and blood pressure will be respectively similar or the same. This avoids the great changes between pre dialysis hypertension and postdialsyis hypotension and ill health. The blood pressure and weight changes are aggravated by the use of antihypertensive agents, particularly before dialysis, which tends to cause a grater fall in blood pressure after dialysis. Thus, antihypertensive agents should not be used if it is at all possible to avoid them."

I am grateful for the legacy of Belding Scribner in my own care and management. Fortunately, I have learned how to tolerate a very low sodium diet and to lengthen my sessions as much as the provider will accommodate. Belding Scribner's legacy is alive and well and can never be destroyed despite the concerted efforts of many to confuse, obfuscate, mystify and perplex patients and nephrologists through endless academic studies which are contrary to the clear achievements of Scribner and many other early dialysis pioneers. Scribner's legacy lives on in Australia, New Zealand, Japan and Europe, but it mostly lives on in every long lived dialysis patient who took note of what Scribner wrought all the way back with his first patient. At the heart of his technical and medical approaches was a heart filled with compassion that led his humanitarian calling to simply relieve pain and suffering and death in patients otherwise doomed to die. Yes, Scribner's legacy is an enduring legacy that lives on today. The "ideal" patient was simply the normal, "rehabilitated" patient in the Seattle program of the 1960's molded into a survivor by one man, Belding Scribner. That is a true and lasting legacy.

To Spend or Not to Spend: That is the Question

By Peter Laird, MD

During the course of my career in internal medicine, I have observed the changing of the gaurd from the days of indepth investigation of all symptoms and abnormalities to the new ethics of today that calls for limited investigations and more focused treatments. Many of the new physicians growing up under this new fiscal restraint truncate their considerations of the causes of these symptoms in algorithmic precision. For the majority of patients, this approach will work since what is common is common. However, algorithms fail when patients presents with illnesses not considered within these cook book medical recipes.

The only antidote for those patients is old fashioned, Oslerian methods of investigation of clinical inquiry and focus on the patient as a clinician-scholar making close observations and developing clinical hypothesis from these observations.  There are no short cuts nor cook book medical rhymes that can replace the trained clinician applying the Oslerian medical precepts. Sadly, with the high tech, specialized clinical practice of today, the art of medicine is often overlooked often to the detriment of our patients.

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Sir William Osler

What is lacking today in many ways is the connection between doctor and patient that technology and fiscal policies dictate to the young clinicians beginning their practices. I observed many new physicians more concerned about getting home by 5:00 than taking the time to observe, collect data, hypothesize and produce a combination of effective diagnostic testing and treatment alternatives. And at the same time instructed the patient to feel comfortable engaging these plans.

Such an approach is not only time consuming but at times expensive. An in depth analysis always generates more questions needed answering than the cook book algorithmic methods of today that usually covers the top 90% of cases, but over looks the 10% that are rare and uncommon. Once again, the new methods work in a cost containing society but fail in the real world of individual patients.

Interestingly, a recent study supports the concepts of the Oslerian method of medicine more so than this new medical ethics focused on cost containment first and foremost. The common denominator speculated by one commentator was that of the pursuit of academic excellence at the bedside in teaching hospitals. The teacher-clinician model of medicine exemplifies the Oslerian method.

Best Care may Be at Hospitals That Spend Most

"Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," they wrote.

In an accompanying editorial, Karen Joynt, MD, MPH, and Ashish Jha, MD, MPH, of the Harvard School of Public Health in Boston, added that the nature of a hospital's mission could also influence outcomes.

"Features that make a hospital high cost, such as a teaching mission or research mission, may actually be related to better outcomes," they wrote. "Thus, it is possible that it was not spending per se that improved outcomes but rather the teaching intensity or academic expertise more common at high-cost hospitals."

The idealistic aspects of medical training quickly fall to the constraints of time and limited resources for the majority of physicians in daily practice. During my training, one of the aphorisms I heard many times over was the the best medicine in the long run was the cheapest. Preventing complications and further hospital admissions and associated treatment costs is best approached by gettting the diagnosis and treatment alternatives correct the first time around.

I am at times appalled when witnessing the cost containing methods of home dialysis programs that skimp on medically needed supplies such as giving me one roll of tape for an entire month while over looking the tremendous cost savings of a home dialysis program after higher upfront costs are considered. The penney wise and pound foolish approach to medical care in America appears to be the new mantra in the health care industry, and especially for dialysis patients.  Early in my career, I would ponder the consequences of the cost of the evaluation on my own ratings, but I soon put that aside and focused only on the patient. Needless to say, many times over I was less than popular with the bean counters.

The intensity and thoroughness of evaluations and therapies are the most important aspect of high quality medical care as taught by Sir William Osler over a hundred years ago. It all begins with a doctor that can listen and observe. It is time to return to the rudimentary traditions that gave us the most effective health care system ever known.  There is a time to spend and prevent and repair  instead of dealing with the inevitable costs of failing to seek the highest care for each patient that presents to a doctors office. In the end, the best care is the cheapest.

"I Need to have Control In my Life" - Celebrating Five Years of Borrowed Time

by Peter Laird, MD

On February 1, 2007, I entered into a new life that was difficult and wonderful all at the same time. I developed IgA nephropathy diagnosed by one of my colleagues in 1998 when I failed an insurance physical exam. They found protein in my urine. I found protein and blood. After consultation with my nephrology colleague, the diagnosis of IgA nephropathy became the prime suspect which was confirmed later by renal biopsy.

My first experience with dialysis was rather benign with a shortened session at low blood flow rates. My dialysis tech happened to be my own patient who I had know for several years. Krystal knew her trade well and I am grateful for her compassionate care in my early months on dialysis.  I learned many aspects of dialysis from her that I still use in my own self care practice. Recently, a friend forwarded the story of man in Sweden who insisted on learning self care to help avoid many of the symptoms of dialysis because he wanted to have control of his life. Interestingly, his example proved the inspiration for 60% of the current patients in his unit who likewise do their own self care HD and PD:

A Patient Directs His Own Care

Farman received a kidney transplant, but in 2005 he was back on dialysis. On the first day of treatment, he spoke with Britt-Mari Banck, a nurse in the Ryhov County Hospital hemodialysis clinic in Jönköping, Sweden. Farman said to her, “You have to help me treat myself. I need to have control in my life.” He had researched self dialysis and became convinced that if he could manage his own treatment, the side effects would disappear.

In many dialysis centers, the story would have ended there. But Farman’s unusual request was met with an unusual response. “I said, ‘Yes, how shall we start?’” recalls Banck, now acting head nurse for the hospital’s self-care dialysis unit.

Banck showed Farman how to use the dialysis machine, read and interpret lab results, and document his care in his chart. Within five weeks, Farman was managing his dialysis independently. He discovered that self-dialysis resulted in fewer side effects.

Christian Farman's hospital based unit now plans to push their goal of self care patients to 75%. American has paid even les attention to self care dialysis practices than even home dialysis options. For patients who do not have the option to do self care at home, self care in-center is a viable option. I did self care in my dialysis unit for nearly two years before going to the NxStage System One and the Laird hemodialysis unit came into existence. 

I am thankful to Dr. Belding Scribner for his vision of hope and life from a machine. I am grateful to NxStage for opening up the home hemodialysis  market where several others had toiled and failed. My five years of borrowed life have been some of the most production, perhaps not by shear volume, but in quality. The clear facts are that without dialysis, I would never have met my youngest granddaughter or the many friends and colleagues I have come to know in these last five years. I could not imagine the journey I started on that day in 2007, but I would not trade these last five years for anything. Having control of your life through self care, home hemodialysis fulfills the vision that Dr. Scribner brought to life all those years ago. There are many people to thank for my added five years of borrowed time, but of them all, the vision and perseverance of Dr. Scribner is the one that I continually am most grateful

I would hope all those that "hate dialysis" could one day have the opportunity that Christian Farman and I have had to regain control of our lives. Dialysis need not be a procedure filled with discomfort and dread, but instead in celebration of life. To all those that have labored to keep people like me and Christian alive, my heart felt gratitude is beyond words. 

The Slippery Slope of Shared Decision-Making

By Peter Laird, MD

The NY Times article titled When Ailments Pile Up, Asking Patients to Rethink Free Dialysis explores the ethical boundaries of shared decision-making, a new twist on the long held ethics of patient autonomy. (See prior Hemodoc post here, Bill Peckham's Comment from DSEN here)During the entire course of my professional career in medicine, my underlying ethical framework was that of patient autonomy. My understanding of my role in difficult cases was that of an educator giving informed consent of all available treatment options. Indeed, informed consent follows the accepted ethics of patient autonomy wherein patients make their own informed decisions, not the doctor.

In such, the medical community rejected the previous medical ethics known widely as paternalism where the doctor made decisions for the patient often without full consent or information. In my nearly 20 years of practice, I cannot recall at any time where the ethical platform of patient autonomy failed. Yes, there were difficult cases and at times continued support of a patient in dire straights with essentially no chance of recovery presented itself. Yet, in all that time, those that truly were beyond our help ended just that way, beyond our help no matter what the family desired. Nature took it's course.

There were other cases where the medical team was simply wrong in their assessment of the patient's prognosis. The most noted case that comes to memory is that of a teenage girl who became comatose for an undisclosed reason leaving her without oxygen for an undetermined amount of time. She had a suspected chemical abuse, but it was never documented or proved conclusively. As she lay motionless in the ICU day after day, the physician team approached her family several times with the bleakest of prognosis, yet the family remained faithful and never gave up. After about two weeks of the patient laying in a coma with no measurable responsiveness, her mother reported to us that she had moved her fingers. I didn't believe her.  The next day, the nurses began to tell us that she was moving her fingers and responding, yet on our examinations, she appeared completely comatose. It wasn't until the patient actually woke up the next day that we abandoned our opposition to continued treatment. 

Three months later, I was fortunate to meet this bright girl who did suffer permanent brain damage leaving her totally blind, but she was perhaps the most grateful patient I have ever encountered. Unfortunately, her gratitude towards her medical team was sorely misplaced, we had many meetings and consultations on how we could convince the family to withdraw care and let her die "in dignity." Never once did we question whether we were correct. We were flat out wrong even with all of our high tech assessments, high paid specialists, MRI's, CT's and brain wave tests.

The NY TImes article could truly be the poster child of a new medical ethic that the Renal Physicians Association (RPA ) calls shared decision-making. The NY Times article links to an outdated version of this RPA treatise from 1999, but RPA has several updated versions including the latest from October 2010.

Shared decision-making is now called the accepted method of ethical decision making by the RPA, but it is not in the least similar to the ethics of patient autonomy where the doctors fiduciary duty is to educate to the point of understanding so that the patient and his family or legal representative can make an informed decision. Instead, in my opinion, it is truly the basis for taking a step backwards in time to when doctors made all of the decisions themselves. 

Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis

Clinical Practice Guideline, Second Edition

Recommendation No. 8 

Establish a systematic due process approach for conflict resolution if there is disagreement about what decision should be made with regard to dialysis. Conflicts may occur between the patient/legal agent and the renal care team about whether dialysis will benefit the patient. Conflicts also may occur within the renal care team or between the renal care team and other health care providers. In sitting down and talking with the patient/legal agent, the nephrologist should try to understand their views, provide data to support his/her recommendation, and correct misunderstandings. In the process of shared decision-making, the following potential sources of conflict have been recognized: 1) miscommunication or misunderstanding about prognosis; 2) intrapersonal or interpersonal issues; or 3) special values. If dialysis is indicated emergently, it should be provided while pursuing conflict resolution, provided the patient or legal agent requests it.

On the surface, this sounds like a reasonable approach, however, the term "due process" introduces a term outside of medical ethics, this is a legal term. Am I simply injecting my own personal bias into their statements? Perhaps, but unfortunately, there is a dance between ethics and the legal world that is always in a state of evolution. Often the legal world follows the lead of the ethics world. If the due process in place that has criteria set by the state or other legal authorities for delivery of health care, then that due process over time could set up situations where care is requested, opposed by the health care team and denied by the paying authority whether private or state run. Granted we are not there today, but again, we are talking about slippery slopes that lead to inevitable outcomes. In a world today filled with many differing health care and legal systems, we need go no further than last  months news to see where the ethics of "shared decision-making" coupled together with specific "legal" criteria set in due process could lead here in America:

An Update on Baby Joseph: Expected to Leave Hospital soon for Pediatric Specialty Hospital

Baby Joseph was the center of an intense legal battle sparked by the decision of physicians at London Health Sciences Centre in Ontario, to ignore the parents’  wishes for a tracheotomy to make it possible to take their child home to be with his family for whatever time he had left.

Physicians at London Health Sciences Centre diagnosed the child as being in a persistent vegetative state (PVS) and said a tracheotomy would be invasive and futile treatment. Their plan was to take Baby Joseph off a ventilator and feeding tube. In the culmination of a lengthy series of legal maneuvers, the parents, Moe Maraachl and Sana Nader, moved their son on March 13 to SSM Cardinal Glennon Children’s Medical Center with the assistance of lawyers and Priests for Life.

When I first heard of the sketchy details of this case, I thought to myself that the parents were simply unreasonable and in denial. But then some of the details did emerge that the parents request was to simply have a tracheostomy tube placed so that they could take their child home to die. The cold hearted, in my opinion, medical team refused this very reasonable request and set up the entire confrontation. Simply put, if the medical team had listened to the heart felt request to allow the family the means of removing the child from the ventilator and place on hospice in the home, we never would have heard of this entire event. Instead, the medical ethics in place in Canada today is such that the autonomous decision making of parents of a terminal patient hoping only to correctly in my mind take their child home to die in the arms of his parents was soundly refused and openly opposed by his medical team who deemed a simple tracheostomy that takes only a few minutes to perform as futile. 

Sorry, to sound personal, but that was an erroneous decision made by doctors in Canada who usurped their authority in denying a commonly performed procedure for many terminally ill patients on a ventilator.  Palliative tracheostomies are often used as a means to allow patients to enter hospice in their own home. I am appalled by this entire episode of Baby Joseph and saddened that the RPA has actually laid the ethical framework for the same type of events to happen some day here in America. Baby Joseph's case inspires checks and balances against that old ethics called physician paternalism, it was wrong 30 years ago, it is still wrong today. Perhaps the RPA's commitment to shared decision-making in part explains the general lack of attention to informed consent by the American nephrology community. In other words, they are already making those decisions for us today.

This is all just my own opinion and commentary on the article in question and my own opinion of the RPA's Shared Decision-Making ethical position papers.

Do Doctors Need a Chaperon?

By Peter Laird, MD

I read an article in New York Times titled: Do Patients need a Chaperon? which brought me back to one of the important aspects of my own practice in medicine.  I trained at an Army Medical Center where one of my colleagues in surgery residency was accused of improprieties simply for conducting an abdominal exam on a young female in the ER with symptoms suggestive of appendicitis.  The difficulty attendant for any physician is that once a complaint of this nature is placed, there is truly no defence for that physician since it becomes the patient's word against yours.  In most cases, the doctor is held guilty with no recourse of defense.

To answer this issue, the commanding general of our medical center imposed mandatory chaperons for all female exams including history and physical exams not involving pelvic exams, perhaps a little overboard, but then again, the physician in the surgery residency carried that accusation against him the rest of his career.  

As a male physician, I have utilized this for all of my patients needing pelvic or breast exams.  I supervised several nurse practitioners over the years who I also advised to utilize chaperons even though they were female practitioners with female patients.  The wisdom of this came to roost when one of those nurse practitioners had a complaint lodged against her from doing a routine pap smear. Pap smears as all women know are intrusive and quite personal events outside of their ordinary daily activities.  It consists of both a speculum exam and what is referred to as a bi-manual exam where the uterus is palpated between a hand on the abdomen, and one internally. That is the standard of care for such an exam.

The New York Times article took a unique twist I had not expected by calling the presence of the chaperon themselves intrusive.  I hadn't expected that outlook given the intrusive nature of the examination itself.

DO Patients Need a Chaperon?

What’s more, it is not clear that having a chaperon in the room actually makes patients feel more comfortable, either.

Studies tend to show remarkably similar results: most female patients want a chaperon present during an intimate exam by a male physician. But if the doctor is a woman, that number is extremely low. In fact, many female patients distinctly do not want a chaperon present when they are being examined by a woman.

This attitude is mirrored by male patients, who overwhelmingly do not want any third party in the room, regardless of the sex of the doctor. For many patients, it turns out, a chaperon can make them feel uncomfortable.

So then we have to wonder whether chaperon policies are protecting the patient or protecting the doctor. If it is harming some of our patients by making an awkward situation even more uncomfortable, then we need to rethink blanket rules that mandate chaperons. On the other hand, we need to ensure our patients feel secure during these more sensitive areas of the physical exam.

The article asks an interesting question - are chaperon policies protecting the patient or protecting the doctor?  The answer is unfortunately both.  There are too many well documented cases of sexual misconduct by physicians whereby the patients do indeed need this protection from a small number of practitioners.  Likewise, there are a small number of litigious patients that make false allegations against physicians that without a chaperon to document the interaction leave the physician completely defenseless against that accusation.  

Unfortunately, some patients don't understand the nature of the legal requirements of these examinations and misinterpret the actual procedure done purely on medical standards of care, believing incorrectly that something untoward just happened when in reality it was the standard and required examination.  The article thus takes only a one sided argument on the patient's side of this issue without at all considering the devastating effects on a physician of even one sexual impropriety accusation ending an otherwise promising and rewarding career.  My response is to give the other side of the issue from a doctor's perspective that was not represented at all in the NYT article.

Nevertheless, I underwent a cystoscopy as part of my evaluation for renal transplant several years ago since my underlying renal disease sheds blood cells from the kidney itself.  I have known the urologist professionally for several years, but I didn't expect him to have a female nurse assistant for the procedure.  The indignity of having the exam before his female assistant bothered me more than the invasive examination itself.  

Many men and women avoid much of this issue by simply selecting male physicians for male exams and female physicians for female exams.  Perhaps that can't always be arranged, but that is the best solution in my opinion for many patients and physicians.  But the issue of the medical legal nature of these sort of exams shall not diminish at all the need for chaperons in the exam rooms for certain procedures and tests. It is simply a sign of the times we live in today and the risk of losing a career over one patient complaint is a reality of practicing medicine today as too many physicians found out too late.  Chaperons, love them or hate them are a medical-legal reality not soon to depart for the protection of BOTH the doctor and the patient.

The Caring Physician

By Peter Laird, MD

When I first entered the arena of dialysis care in February 2007, it didn't take long to realize that being a patient is not as much fun as being a doctor, well at least the fun of the old days of medicine before government regulations and corporate greed changed our profession for the worse. I wish I had a dollar for every time I heard one of my professors during my training retort, it is always better to be the doctor than the patient.  

Being in the presence of death and human misery is much more tolerable when you can "objectively" distance yourself from the suffering of a fellow human being.  Doctors become quite facile at distancing themselves from their patients which is a necessity when quick actions dictate survival in life and death situations, yet it can also leave us hardened and callous towards our own patients who trust us to not only be competent but caring as well.

My journey through the American dialysis industry in the last 4 years is filled with many caring and competent healthcare practitioners, but I have also seen my share of healthcare professionals that in my opinion are turning a blind eye towards the plight of their patients.  Most of us in the medical field do start our journey through the rigors of training with the highest ideals of altruism.  I remember reading through a long biography of Albert Schweitzer when I was first contemplating a career in medicine.  Not only was Albert Schweitzer a Christian missionary, accomplished organist, honored scholar as well as a skillful surgeon and physician, but unlike many in my profession, he
never lost the love of his fellow man suffering in need.  In 1952, Albert Schweitzer received the Nobel Peace prize for his work in Africa:

Albert Schweitzer (14 January 1875 – 4 September 1965) was a Franco-German (Alsatian) theologian, organist, philosopher, and physician. He was born in Kaysersberg in the province of Alsace-Lorraine, in the German Empire. Schweitzer challenged both the secular view of Jesus as depicted by historical-critical methodology current at his time in certain academic circles, as well as the traditional Christian view, depicting a Jesus Christ who expected and predicted the imminent end of the world. He received the 1952 Nobel Peace Prize for his philosophy of "Reverence for Life",^[1] expressed in many ways, but most famously in founding and sustaining the Albert Schweitzer Hospital in Lambaréné, now in Gabon, west central Africa (then French Equatorial Africa).

I am quite sure that Albert Schweitzer was not only aware of the words of the Bible, but yet again with his actions lived by the Bible and its teachings. One verse that has always motivated me is found in the gospel of Matthew and is also known universally as the "golden rule."  Therefore all things whatsoever ye would that men should do to you, do ye even so to them.  The majority of nephrologists surveyed would never opt for what they routinely prescribe to over 90% of their own dialysis patients. How many of my fellow colleagues have further forgotten the simple pledges and altruistic protestations we espoused during our medical school interviews.  I can think of no greater reminder of the classical teachings on the art of the doctor patient relationship than that of Dr. Francis W. Peabody in his essay -  The Care of the Patient.

The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine – or, to put it more bluntly, they are too “scientific” and do not know how to take care of patients. . .

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. 

It is time that sympathy, time, understanding and caring are once again lavishly dispensed and nowhere so needfully as in the modern open wards we call dialysis units where suffering and death call upon thousands of patients daily while too many nephrologists blindly turn their eyes from their patients as if they are little more than another chair to be filled for the shift to be full.

Welcome to HemoDoc, From Doctor to Patient

By Peter Laird, MD

HemoDoc, From Doctor to Patient is a doctor's blog from a patients perspective exploring both sides of the doctor-patient relationship as a source of information and communication between these two distinct groups of people that are nevertheless entwined together in one of histories most interesting human relationships.  As a young physician just out of medical school in the 1990's, I witnessed firsthand the transformation of this time honored relationship into one of less trust and increased antagonism.  Yet, no matter how many barriers are erected between the doctor and their patients in today's new medical paradigms, the interactions between an individual patient and his individual doctor in the confines of an exam room remain largely unchanged and the skills of a physician gaining trust and confidence from their patients is a time honored skill crafted through the ages.

For a new medical student eager to learn the art and practice of medicine, remembering the pioneers of modern medicine is essential to navigating the new medical ethics and practice styles of today. For patients, the need to find a caring and compassionate physician dedicated to their individual needs is an essential component of survival when faced with life threatening illnesses. Often today, the basic tenants of medicine to relieve suffering and promote individual well being is overshadowed by cost containment principles of treating the physician's entire patient population as a whole and not focusing solely on the individual.  This new medical ethics emphasizes the patient population more so than the individual suffocating centuries of advancement in the doctor-patient relationship. Indeed, now in every exam room is the foreign presence of the finance officer as well as the doctor and patient in all diagnostic and treatment decisions.  

Understanding the science of medicine as well as the rights of the patient in this atmosphere falls largely upon the individual patient to act as their own advocate.  The role of patient advocate that the physician has traditionally assumed is now mitigated by cost containment strategies for the entire patient population or patient panel cared for by the physician.  Physicians are compared openly to their peers through statistical analysis of all aspects of their practice.  Those physicians that spend the least are heralded as the champions of practice management though often at the expense of the individual patient. Respect for patient autonomy is falling to the ethics of distributive justice that fails to account for the simple truth that the best medicine is most often the cheapest medicine. 

Examples abound of medical practices deemed too expensive at the onset for general use having been in secondary analysis proved cost effective by their reduction in disease burden and associated treatment costs.  Colon cancer screening initially utilized the stool guaiac as the gold standard, yet when Medicare began reimbursing for screening colonoscopies, colon cancer chemotherapy costs fell dramatically, in part due to the reduction of colon cancer cases and the rising costs of modern colon cancer chemotherapy.  Yet, for the individual patient, the burden of suffering and death likewise fell dramatically. Furthermore, the more expensive upfront costs of percutaneous coronary intervention (PCI) with angioplasty and stent is more cost effective in long terms than the less expensive upfront costs of thrombolytic therapy.  In these instances, and many others, the best therapy turned out to be the cheapest and most cost effective by the reduction in disease burden and patient suffering.  

In all of this, the message from the ages is the truth that the best medicine is also the cheapest by prevention of disease burden, but I fear it is lost on the newest generation of practitioners who are taught to truncate their diagnostic and treatment protocols to only the most likely causes and the least expensive options.  It is a new mindset that flies in the face of the wisdom of men such as Sir William Osler, the father of modern internal medicine where the uncommon and rare hoof beats of the zebra were given credence with the considerations of the common.  

 Sir William Osler 1849-1919        

"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."

I have diagnosed only one patient in my entire career with parvovirus when she presented with symptoms seemingly the same as the flu, yet different, I spent an extra few minutes reviewing the patients symptoms and ordered the test to confirm that it was parvovirus and not influenza.  The results in many ways were purely academic, since the treatment for both pathogens is supportive care, yet my training in the traditional practices of internal medicine lead me to investigate further. However, the patients son who presented to another physician with the same precise symptoms as her mother never knew of his parvovirus infection since his physician trained in the modern cost effective methods of diagnosing and treatment never considered this as a possible cause of his viral illness.  

There are times where looking for the needle in the haystack makes a difference for the patient and in secondary analysis early diagnosis is also cost effective.  It is time for the patients to learn of these new medical ethics to push their physicians to stay focussed on the wisdom of the ages past from Sir William Osler and those that established the practices of modern medicine in the first place.  Taking short cuts in any profession leads to the demise of that profession and medicine is not protected from that outcome.

HemoDoc, Doctor to Patient will explore the general issues of medicine today from both the perspective of a patient and a doctor with special focus on renal disease and its treatments since that is the malady I bear.  The "Hemo" part of my avatar is that of the hemodialysis that sustains my life and how the doctor in me is attenuated by the role of being a patient suffering from a disease with worse outcomes than many cancers.  It is not a role that I have chosen in life.  It is however a role that teaches me much about the need to always keep the patient and their individual needs at the forefront of all discussions on health care.  The Oath of Maimonides spoke of this unique relationship hundreds of years ago. May we always be humbled by it:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

Never forget to advocate for your patient

By Peter Laird, MD

KevinMD has a wonderful post on a doctor following his instinct and advocating for his patient who was "too young" to have a heart attack, but nevertheless, he was.  The forceful actions of the physician in charge of his initial care in assembling a team and advocating for further and complete evaluation saved this young man's life:

Never forget to advocate for your patient

I encountered a young patient recently, just at the cusp of adolescence and adulthood, who had undergone a procedure related to a sports injury. Other people had been responsible for his care during surgery; I was coming on duty for the night and was part of the team watching over him in the recovery room.

Someone came to me and said, “His T-waves are flipped on the monitor. Do you want to do anything?”. . .

. . . Throughout this entire incident my beeper was going off non-stop for other things – OB wanted an epidural, there was an O.R. case to start that I had to postpone, I needed to speak to Joey’s parents who were completely blind-sided by it all. But we ultimately kept our focus on Joey and were able to get him the help he needed. I learned so much from his recovery room course – things I had learned before, but which are always good to learn again.

• Listen to your “gut.”
• Pay attention to the clues.
• Listen to your team.
• Don’t be afraid to call for help.
• and Stick to your guns when advocating for your patient.

I remember one elderly patient who presented to my clinic late in the afternoon.  His daughter was an ICU nurse that I knew from the local hospital.  He had the acute onset of dizzyness with no other related symptoms.  At first, I thought it would be a very common inner ear disorder we see in internal medicine outpatient clinics frequently.  However, when I did his examination including a specific trigger of vertigo in the exam room called a Dix-Hallpike test, it was negative leaving the benign condition of vertigo not likely.  

I immediately called the local ER and transferred the patient.  I gave explicit instructions to the daughter not to let any ER doc discharge her father with the diagnosis of benign positional vertigo. I didn't know what was causing his symptoms at the time, but I had a suspician it was more serious than a simple self limited inner ear disorder.  Sure enough, that is exactly what the ER doc did on initial evaluation.  But because of my instructions to the daughter, she insisted on further studies.  It turns out that her father had a dissecting aortic aneurysm partially blocking the posterior circulation to the brain which caused the acute onset of dizziness.  The patient was evaluated by a cardiologist who discovered the cause of his symptoms and immediately intervened.  After an extended stay in the ICU, he recovered completely. It was only a return hospital follow up visit that I learned of all that transpired in the ER.

I was trained well for my medical career as a patient advocate, BY MY MOTHER, an RN and also the person solely responsible for saving my oldest brother's life at the age of 12. He developed Hepatitis A after helping my father with flood victims in Fairbanks Alaska in 1967 I believe.  However, his condition contined to worsen until he ended up admitted to the local hospital in Nome Alaska.  It was a small hospital with only one doctor, a surgeon whose children and I were friends, often snow shoeing in the fields and streams around Nome.

My father came home early one morning and bluntly told my mother, you had better go say good-bye to your son, he doesn't look like he will last long.  My mother awoke and said, "like hell I will." It turns out that she had been asking the doctor to consider concommitent diabetes on top of the hepatitis since she had been suspicious of this for some time before he developed the hepatitis. However, these were the days before automated labs and the doctor refused to consider this as a possible cause of his decline.  My mother wakened the lab technician at 4am and demanded she perform a simple blood glucose test which showed my brother was in diabetic keto-acidosis as well as hepatitis A.

She awoke the doctor abruptly and asked him if he wanted to give the first dose of insulin or if she would.  After an extended recovery in an Anchorage hospital, my brother now owes his last 44 years of his life to my mother's tenacity.  I learned my lessons well as a doctor early on, from my mother. It was my pleasure to work side by side her for one year when I was only 19 years old and working as an orderly at a small country hospital in Brookeville, PA where I learned the real art of practicing medicine, always advocate for your patient. Patients trying to survive in this day and age are adrift at sea if they don't have a doctor that is an advocate for them.