Tension – nephrologists live in it. The tension between trying to delay chronic kidney disease (CKD) progression whilst also preparing a patient for dialysis. Tension with administrators who are targeting metric achievement when we know that patient-centered care must leave room for individualized plans. At times we also feel tension between ourselves and our colleagues.

All of us believe we are trying to do what is right, but with different backgrounds and goals, “what is right” doesn’t always translate into an identical strategy. As I sat and read a recent AJKD article by Clapp et al, I couldn’t help but relate to the situations – and the tensions – described. The work done by the authors takes a deep dive into the understudied world of how we interact with primary providers in the ICU setting; the resulting article is both fascinating and intensely relatable.

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The tension between nephrologists and ICU providers surfaces in a variety of ways. At times we advise a diagnostic plan to address the problem we think we were called for, and our plan goes unfollowed. Sometimes we grumble that we were consulted too late to properly prepare for impending dialysis. Sometimes we think it’s too early. We can get steely-eyed when called with the singular goal of initiating dialysis, and equally steely-eyed when we feel as though we have been called just to state that someone is “not a dialysis candidate.” Nowhere are these tensions more pronounced than in critical care settings, where things often move quickly and expectations of consultation may not be well-defined on the front end.

When the needs and expectations of those calling us and our reciprocal expectations differ, how do we reconcile them? How do we navigate the different opinions of the varied stakeholders? After a few years in practice, we have all developed a working approach – either explicitly devised or simply as a product of our experiences. How, though, do we help our trainees learn to navigate this landscape? These are all worthwhile questions, and Clapp et al go to great lengths to define some of the major themes around the tension between nephrology and ICU providers.

In the article, attendings and fellows from nephrology as well as nurses and providers from three different ICU settings were interviewed as well as observed in practice. Clapp et al identified five themes: 

Nephrology consultation in the academic intensive care unit (ICU). Figure 1 from Clapp et al, AJKD © National Kidney Foundation.

The authors appropriately draw no concrete conclusions about the relative contributions of these themes, nor do they offer clear solutions. That said, as a reader I can see how the themes – occasionally alone, more often conspiring together – have been the source of the friction that I have personally struggled through in the past. In chatting about this paper with some of my colleagues now practicing elsewhere, I strongly suspect that so will you.

I cannot do justice to the depth of the article, and – if only for that cathartic feeling of “I am not alone,” – I strongly recommend that you give it a full read. See, for example, the illustrative quotes below on the understandings of dialysis.

Illustrative Quotes Regarding Aggressiveness Discordance and Its Bases. Box 4 from Clapp et al, AJKD © National Kidney Foundation.

I will also add my own brief narrative to the chorus of interviews as an illustration. As a first-year fellow, it took me months to appreciate that the differences in my interactions with the medical ICU (MICU) and the cardiothoracic ICU (CTICU) were not just me. I spent far too much time frustrated with the differences. I could consult on a MICU patient and feel as though my input was valuable, instructive, even incisive at times. Moments later I could provide what I felt was the same level of service to a CTICU patient, and walk away feeling defeated. In the former case, I felt as though we were partners collaborating on aligned goals (for the sake of discussion we’ll say management of sepsis and avoidance of dialysis). In the latter instance, it was entirely lost on me that the goal was dialysis. Dialysis as a procedure here was a foregone conclusion that was reached well before the initial call.

As time has passed, I have come to understand and accept that the expectations of different providers vary, and in the CTICU, I am often consulted not for my cognitive insights, but for my capacity to deploy dialysis. I don’t know that I will ever truly be at ease with that, but I have at least come to understand the expectation. Although this sentiment runs the risk of stereotyping, and is certainly not universal, my feelings and angst are representative of what the authors observed in their institution; they note that within their work, “Discordance was most apparent in nephrology’s interactions with the surgical ICUs…” – which brings us to the question of why.

In their discussion, Clapp et al spend some time discussing the observed friction and discordance and offer some conjecture on its origins. I was previously unaware of the work done describing the tension between surgeons and those that manage surgical ICUs (anesthesia- or surgery-trained, typically). The authors note that studies have shown that surgeons’ “’covenantal ethic,’ an intense sense of personal accountability for patient outcomes, creating a tendency toward interventional aggressiveness…” can generate pressure on the surgical ICU provider to offer aggressive interventions quickly.

Meanwhile, we nephrologists who arrive on scene only after a need emerges, bring with us a new set of eyes that do not see the case from the same vantage point, often seeking diagnostic clarity before acting. Further, many of our backgrounds have trained us for a deliberately slower approach to problem-solving. We often do not see the same level of acuity that our surgical ICU colleagues might. Reconciling the varied approaches can be a significant contributor to the observed strain.

To be clear, the same issues observed in the surgical ICU settings were also seen in the MICU, though both to my read and as noted explicitly by Clapp et al, these issues seemed less obstructive in the MICU. This reflects my experience and may be a result of similar internal medicine training between providers; a common ground, of sorts. Exploring whether this surgical ICU-medical ICU difference plays out at other institutions will be an interesting and instructive step forward as this body of work further develops.

The authors and I hope that these cultural differences receive additional exploration. With the progressive sub-specialization in medicine and the rising number of providers required to provide highly technical support to complex patients, understanding our differences may help us to develop approaches that cultivate nephrology’s many interfaces with our colleagues. Regardless of how this work develops, I plan to have all of my fellows read this article. It is important to me that they know that it isn’t just them.

– Post prepared by Ed Gould, AJKDBlog Contributor. Follow him @paininthekidney.

To view Clapp et al (subscription required), please visit AJKD.org.

Title: Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration
Authors: Justin T. Clapp, Sushmitha P. Diraviam, Meghan B. Lane-Fall, Julia E. Szymczak, Madhavi Muralidharan, Jamison J. Chung, Jacob T. Gutsche, Martha A.Q. Curley, Jeffrey S. Berns, and Lee A. Fleisher
DOI: 10.1053/j.ajkd.2019.05.030