By Peter Laird, MD
As humans, many offer advice and sometimes outright criticism which is a painful but necessary step in learning for all of us. I don't know anyone that enjoys criticism and most of us develop defensive mechanisms in dealing with it. Yet, at times it is the only way in which we can over come an individual flaw brought to our attention that we overlook in our own egocentric views of our personal worth.
Institutions and cultures are no less subject to learning from criticism and even more so when it comes from within the culture or institution itself. "Physician heal thyself" is a reminder for each of us to engage in introspection brought on often through external criticism. It is a painful process at times, but it does reap the rewards of overcoming our shortcomings when fully engaged and acted upon.
The American dialysphere as Bill coins it is in great need of introspection and learning from external sources. DOPPS is an interesting ongoing study of the different patterns in dialysis practices in the developed nations. We have learned much about dialysis practices through this large, multi-nation effort, yet little has changed or been applied directly to American dialysis practices to date./p>
One such example is the findings of a DOPPS study on fistula creation outcomes in America and how adverse complications are often related to lack of training among vascular surgeons in America who perform less than 25 total during their fellowship. I wrote a post on this very issue back in 2008 called: Fistula First, American Surgeons Still Last.RenalWeb posted a new article today from AJKD that brings into remembrance the DOPPS study on this issue:
Hemodialysis Vascular Access Training and Practices Are Key to Improved Access Outcomes
This article reviews major findings from these data sources, focusing on specific practices and characteristics associated with greater arteriovenous fistula use in dialysis facilities worldwide. Important and often overlooked characteristics that are discussed in detail include specific preferences of dialysis staff regarding access type and the emphasis placed on fistula primacy and the number of fistulas created during surgical training. For example, in the DOPPS, the risk of initial fistula failure was 34% lower when fistulas were placed by surgeons who had created at least 25 fistulas during training (P= 0.002). It is imperative that dialysis clinicians advocate actively for specific dialysis access types on behalf of individual patients. Vascular surgery teaching programs must supervise adequate numbers of fistula procedures for every trainee.
I am thankful for the many caring people who have bravely stepped forward in my life to speak of weaknesses and deficiencies that I need to overcome. It is never anything but difficult to look inward, but it is a profitable venture for those that do.
America is in great need of engaging in a long and meaningful evaluation of all of our dialysis practices. DOPPS is a good starting point for many of our dialysis related issues, yet, will America hear, or shall we put up our egocentric defenses and refuse to learn from the external criticisms that want nothing but to improve our outcomes and will be the first on the sidelines cheering if we ever do. The data is before us, what shall we do with it?