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.
Even taking into account the risk of sounding defensive, the truth is that we work diligently and humanely to take care of our patients. Unlike 40 years 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 quality dialysis care, feel OK on dialysis, and stay alive.
Nephrologists are a part of a team that includes payors, dialysis providers, nurses, and technicians who provide care. Rather than focusing one’s anger on one group of people (the nephrologist) I suggest that we look at dialysis as a whole to see how we could improve.
For starters, we should modify the metrics for quality outcomes. Patient-centric outcomes: quality of life, depression, rate of hospitalization, and yes, even mortality should be measured and reported. In a previous article I discuss in more detail some of my issues with the Medicare QIP. Don’t you think that it is laughable that one of the CMS measures for 2014 is “whether the facility administers a patient experience of care survey”? Who thought that one up? These measures focus on processes, but we need more and better patient outcome measures.
Some would have us dispense with trials to test whether more frequent dialysis and/or more time on dialysis improves outcomes, but funding these trials is important. Proving that a therapy is truly beneficial compared to current therapy is necessary for it to be accepted by patients, some of whom would rather settle for less time or less frequent dialysis. And, results drawn from a well designed trial showing that a therapy works is essential for a payor to approve reimbursement for it.
I agree that “nephrologists have to speak up for their patients” and stand-up and take responsibility. But should we be held responsible for all that is wrong with dialysis? We have limited influence on the inadequate measures for quality, the ongoing lack of trials, the lack of technological innovation, and the somewhat lax regulatory oversight.