How should the provision of dialysis change when the dialyzor has multimorbidity?

By Bill Peckham

Kevin MD has a post up on a New York Times article, Treating an Illness Is One Thing. What About a Patient With Many? that points to the lack of practice guidelines for those with multiple health problems - those with multimorbidity. The article and the 2005 paper it links to do not include chronic kidney disease among the conditions studied but the conclusions are just as applicable to people with CKD.

In the article, Fred Powledge who has multimorbidity says clearly what many dialyzors would say:

“But what’s missing is someone who can look at the big picture and see my health as a whole.  “That falls to me alone, with the help of my very wise wife and frequent visits to reliable Web sites,” he continued. “As our population ages, we need some kind of overseer to juggle all the diagnoses and prescriptions and look for conflicts and duplications. This would also help to counteract the notion in many people’s minds that the doctor knows best - because often the doctor doesn’t.”

Fred sounds like he is pretty far along the learning curve, and I'd say informed self management is ideal, however, many with multimorbidity are not going to be able to learn to self manage (in a timely way) particularly if the onset is sudden. Not to mention the trouble we all have trying to stay up to speed.

As the article notes there is no advocacy group or national institute for those with multimorbidity. In dialysis no one has looked at how dose of dialysis effects the management of those with additional health problems. There are case mix adjusters for reimbursement but where are the "treatment adjusters"?

Comments

[Peter Laird, MD]

It is interesting to see the perspective of the "new" docs describing how things should be without regard to what the old docs accomplished years ago. I must confess that the few times that I have read Kevin MD, I just have not been able to relate to his perspective. Perhaps I am just old, or have too much uremic frost, but there is a new breed of docs from when I went through my training. I suspect that is part of what this article is trying to address but fails to realize.

This article is another example of that for me. In it we are told that no one looks over complex medical patients in our system. Allegedy, no research is done on them. Yet, as a dinosaur of another medical age, I trained in internal medicine where we addressed EVERY problem in each patient in EVERY evaluation. We learned systems to rapidly keep track of active and inactive problems. We addressed drug interactions and were in routine consultation with pharmacists who often rounded with the team during residency and even more so since we have developed computerized drug interaction protocols alerting to problems.

We learned the language of our specialists and secured enduring relationships with them. The internal medicine specialist made his bread and butter by learning how to manage these complex patients in the outpatient setting all the way to the ICU.

Indeed, geriatrics goes even further into the multiplex elderly patient of which there is much research spilled over into general internal medicine. I am puzzled why other physcians seem to overlook the specialty that I have practiced and loved for over 2 decades. I know what my mentors taught me about all of the issues presented by Kevin MD in his article and his take on this is completely foreign to me.

I must confess that internal medicine has changed in the last 10 years and not for the better. When I went through my training, the primary focus was on inpatient care with a little bit of outpatient medicine thrown in. However, knowing the most severe outcomes from inpatient medical care secured clinical skills on when patients are stable or unstable and need further intervention. Today, residents choose either an inpatient track to become a "hospitalist," or focus on outpatient treatment exclusively. There is a significant split between these two camps today that did not exist when I became an internist. The two legs of internal medicine today have competing interests often leaving the patient in the lurch.

Hospitalists make their bread and butter on improved efficiencies and outcomes. Yet they achieved this in a large part by doing the minimum testing to rule out dangerous medical issues, but often did not seek to find the root cause before discharge. For instance, it was the standard of practice years ago to not discharge a patient with chest pain without an underlying etiology deduced. Today, chest pain patients often are discharged from the ER simply excluding myocardial infarction. I had many patients come to their hospital follow up visit with where I was able to diagnose such things as blood clots in the lungs after a negative rule out MI protocol because the hospitalist had too narrow a focus.

Today, the standard of care is whether the patient is stable for discharge instead of the standard we had of stability and prediction of future risk by an indepth evaluation leading to the etiology of the problem in the first place. Thus, when the hospitalist clears a patient for discharge today, the actual diagnosis is often left to the clinic physician to conclude. I personally don't see this as an advance in medicine. In fact, the complete dichotomy between the inpatient setting and the outpatient setting leads to the outcomes that Kevin MD is talking about.

Unfortunately, once dinosaurs like myself no longer practice, then the situation that Kevin MD talks about will be the standard practice.

As a patient often frustrated by my own need to self manage issues today with my renal disease, I readily understand how patients may feel that they are left to their own without a captain of the ship to guide them. I have no doubt that well informed patients taking center stage in their own care is critically important as I do for myself, yet what is missing is the old fashioned internist who did exactly what these MDs are stating no one can do. We are indeed in the process of throwing the baby out with the bath water in regards to internal medicine.

It is unfortunately a dying specialty since it is underpayed and overworked. During the glory years of internal medicine, complex medical patients including drug drug interactions and multiplex decisions was the staple of our calling. Yes, the captain of the ship today is often missing in action. I suspect that there are some old dinosaur patients out there that remember when internal medicine was at the helm. I sincerely miss those days of practice because they were exciting and rewarding for patient and physician. If you want to fix the problem of the missing captain of healthcare, then perhaps we should restore the glory days of internal medicine. Even the self managed patient needs the captain to return to his duty station.

The best medicine has to offer is a well informed patient working with a well informed and caring physician. I do not see any system that will supplant that simple and basic relationship for the better of the patient.

[Miriam Lippel Blum]

As someone who lives with a number of comorbidities (Type 1 diabetes, CKD5, and heart disease among others), I often laughingly say that I am alive today despite the medical establishment's best attempts to kill me. If my husband and I were not as knowledgeable about each of the issues I must deal with I would have been injured or killed from poor clinical judgements made by physicians who only look at the small picture, not the whole person. I gave up long ago trying to find a "captain" physician to really manage and coordinate the others. Sometimes getting doctors to even talk to each other is a hassle.

There are now so-called case manager nurses and even social workers but most are usually employees of the insurance industry and their agenda is less care coordination than financial coordination of Medicare compensation to maximize profits.

[Don]

BINGO!!! In our case, we're dealing with CKD5, its underlying cause (Primary Hyperoxaluria 1), Fibromylgia (chronic pain & fatigue), persistent annoying but benign (SVT) heart problems and full thyroid hormone replacement. We greatly appreciate the specialized knowledge that we work with and tap into from day to day but repeatedly feel frustration & difficulty keeping the overall patient picture painted for our docs.

[Tracy Lynn]

For years my GP was the overseer, but now I seldom see one, because I moved cross country. I don't have a relationship with the new guy, so it's easier for me to have my neph doc do some and me do the rest.

[Don]

I forgot to note another related challenge - management of a very diverse assortment of prescription meds from all the different MDs. The PCP doesn't get a chance to veto meds from the specialists. Thank God for Walgreens software which flags potential adverse interactions prior to dispensing new/changed meds.

[Rich Berkowitz]

I guess I'm lucky, or perhaps I've made my own luck. Becaue I used to see my internist a few times per year because of my hypertension, she got to know me quite well. Then as my co-morbitities arose, she was involved from the get go.

I have upteen specialists as part of my team. Being one who believes in self-advocacy and not afraid to email doctors, I basically force them to communicate with each other. When I email one, I usually copy the others. My internist is fully aware of the treatments I'm getting and is a much better position to oversee my total healthcare.