The most recent article in the Core Curriculum series published by AJKD discusses general medical care in the dialysis patient. Dr. Jean Holley (JH) from University of Illinois authored this review, and discusses this important topic with Dr. Tejas Desai (eAJKD), eAJKD Advisory Board member.
eAJKD: Is this curriculum primarily for fellows in training or practicing nephrologists as well?
JH: The article is a summary that will be useful for fellows, practicing nephrologist, and midlevel providers working with dialysis units, including nurse practitioners and physician assistants. Over the years, less primary care seems to be done by nephrologists, with more midlevel providers rounding in dialysis units and handling the medical care issues of long-term dialysis patients. In addition, nephrologists are sometimes prompted to do preventive care for dialysis patients. As an example, USRDS tracks influenza vaccination of dialysis patients.
eAJKD: Is there a dearth of educational material for midlevel providers, and if so, how can we improve their understanding of the care they need to administer?
JH: I think there is a dearth of information in this area, not only for midlevel providers, but for nephrologists and nephrology fellows, too. It’s an area often neglected in dialysis care. For example, the Renal Physicians Association (RPA) has an advanced practitioner course offered yearly that covers various primary care topics. National conferences in nephrology are also making extra effort to cover these topics of primary care.
eAJKD: You focused this curriculum on primary care by nephrologists for CKD and ESRD patients. How about the corollary? How about educating primary care physicians on the CKD care of their patients referral to nephrology?
JH: We do need to share the responsibility of our patients with our primary care providers. A continued effort is needed to educate primary care physicians on CKD topics like bone disease and about anemia. The nephrology communities can perhaps do a bit more in terms of reaching out to primary care providers.
eAJKD: Does the amount of primary care that nephrologists administer vary geographically? Why might that be?
JH: I think it depends on the nephrology practices in the area. I work in a relatively small, rural community. There are two nephrology groups in town. One of the groups continues to have a primary care practice. They do a lot more primary care with their dialysis patients than my group. You have a choice; you either provide the primary care for your patients, or you align with a primary care practice to provide this care. It depends on how busy the nephrology practice is, if they spend more time caring for outpatients, or if they’re primarily an inpatient-focused practice. Those factors, along with the interest of the nephrologist, determine the model. Dialysis units have developed protocols to cover a lot of primary care issues. Diabetes management and foot care are common things that many of us encounter in the dialysis unit.
eAJKD: Have you noticed that the younger nephrologists are less likely to practice primary care medicine with their CKD and ESRD patients?
JH: I can’t think of any study that’s really looked at that particular question. I think younger nephrologists, or those who completed training more recently, are going to be less likely to provide primary care and more likely to focus on nephrology care. Although clearly, there are individuals who vary, depending upon their interest and comfort for addressing primary care issues. If one joins a practice as a young nephrologist and it’s been established that the practice is going to manage primary care issues, then you’re probably going to work in this model. If it’s not, then I think you’re less likely to do that.
eAJKD: Do you feel the relationship between primary care providers and nephrologists has changed now that nephrologists are taking on more of the primary care responsibilities for these patients? Are they appreciative or do they feel that we’re encroaching on their turf?
JH: I think it depends on the providers. A lot of primary care providers and other subspecialists are reluctant to take on the care of patients on dialysis. The unique medical issues and complex medication interactions in this population are feared by many. The community respects the nephrologists in taking care of those complex patients. I still think, ideally, I would have one or two terrific primary care providers who I knew well and shared all my patients. This would facilitate bidirectional communication. Many primary providers who have patients with CKD and ESRD are quite willing to let us manage the CKD issues, particularly with anemia and bone disease. On the other hand, many patients complain to me of cold symptoms or bronchitis during dialysis rounds. Do I treat that or not? If I do, the patient’s perception of who is their primary care doctor might change.