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Lamentations and provocations
Perspectives on the evolution of nephrology as a discipline
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In formulating this cover story, we could have easily spent our allotted words expressing sorrow about the evolution of nephrology, even admitting our roles. We do that in part. Yet, as an expression of optimism, we also put forth opinions on the paths forward – ones that the architects of reform might consider. Many plants pollinate late in their development; some just before dying. Analogously, bit of sorrow and angst is often evident before re-growth commences.
This cover story is a look back and forward through the prism of personal journeys in nephrology. No in-depth literature review – just thoughts focused on trying to gain a clearer understanding of what has happened and what might make the future brighter. Our message is a simple call for action.
Why nephrology?
Nephrology as a discipline was conceived in the latter part of the first half of the 20th century and delivered to society in 1960, facilitated by epochal changes in the treatment of kidney failure. By the 1970s and 1980s, it was flourishing as an intellectual pursuit and producing many meaningful contributions. It was one of the most challenging and satisfying of internal medicine specialties – a premier, thinking person’s profession. The curious physician vied for much-sought-after fellowship openings. The opportunities in academia and clinical practice were without boundaries, creating the “doctor’s doctor.”
A foray into nephrology was an opportunity to encounter mentors of exceptional intellectual and professional prowess: Donald Seldin, MD, George E. Schreiner, MD, Belding H. Scribner, MD, Neal Bricker, Lou Welt, Frank Dixon, Floyd Rector and John P. Merrill, MD among them. The desire to understand basic physiology, pathophysiology and immunopathology was paramount. Gifted, inspirational teachers, like Seldin, took it even further, showing that an education in the humanities, history and philosophy was essential to becoming the complete physician.
In-depth understanding
The expectation and deliverables of training was the achievement of an in-depth understanding of metabolic disorders, glomerular and interstitial diseases, the complex balance of “effective arterial blood volume,” the intricacies of glomerular and tubular physiology, transplant immunobiology and the pathogenesis of “uremia.” One also had to fathom the details of cellular transport, membrane pumps, ion transfer and the biophysics of transmembrane dynamics. No one else in medicine was called upon to help with acid-base disorders, electrolyte derangements and complicated volume problems operating across intracellular, interstitial and intravascular spaces, plus other mineral based metabolic disorders. Disorders leading to complicated and uncontrolled hypertension, acute and chronic kidney injury and end-stage kidney disease requiring dialysis or transplantation were purely in their domain.
The paucity of fully successful therapeutics added more to the challenge of the young investigator and clinician. For renal diseases, there were special diets and withdrawal of other nutrients mixed with few partially effective pharmaceuticals such as azathioprine and corticosteroids. The available antihypertensive drugs were replete with adverse events. Outpatient dialysis centers were appearing in metropolitan, then rural areas, either owned by physician groups or hospitals with corporate ownership making gradual inroads. Transplantation centers, almost all in academic environs, had 40% to 60% 2-year graft survival.
These primitive offerings were to gradually change, improving yearly, through innovative ideas and well-designed experiments shared at international, national or regional specialty meetings and in new journals, emerging organizations, liberal research grant offerings, and engagements with pharmaceutical companies and equipment manufacturers. It was the best of times to be on the frontier of medicine. Fellowships were in high demand, the career opportunities abounded.
Early nephrological arena
The career pathways in the 1970s through late 1980s were either academic or clinical. Though exceptions could be found, the academic path led to teaching, grant writing, clinical studies, working in an established laboratory, writing papers and developing a career of advanced standing in the medical establishment, usually in university settings. These nephrologists were the foundation of the most sought-after fellowships.
The clinical pathway consisted of entering practice, one already established, or starting afresh. The usual pattern was having an outpatient office, a hospital practice, rounding in a dialysis facility and, for some, having a few renal transplant patients, with the occasional clinical study.
In 1973, Medicare provided payment for care of all eligible patients with end-stage renal disease (ESRD) and a proliferation of dialysis companies and facilities began in earnest, in a predicable capitalistic fashion. Dialysis facilities initial provided 5 to 6 hours or more of dialysis in the 1970s, with few quality metrics to assess the adequacy of the treatment provided or outcomes. A retrospective and later determined to be faulty analysis of the National Cooperative Dialysis Study provided a new metric, Kt/V, and the emphasis on therapy of ESRD by dialysis became solute removal de-facto and restoring euvolemia was relegated to an after-thought. Treatment times were shortened to 2.5 to 4 hours, averaging just more than 3 hours.
Kidney transplantation saw improved patient and graft survival statistics with better and safer immunosuppression protocols, but an ongoing organ shortage coupled with the emphasis on filling ever increasing dialysis facilities prevented universal emphasis on this modality. Peritoneal dialysis as a treatment modality only briefly exceeded 10% of patients in most facilities with most below that. Home hemodialysis was available in spotty geographical locations until recently, while still less than 5%.
Within the hospital, the nephrologist was the go-to physician for complicated critically ill patients with challenging metabolic disorders, post operative volume and acid-base disturbances, and acute or rapidly progressive kidney injury. Nephrology was a rigorous, busy but largely gratifying practice.
In addition to generating income through direct patient care, nephrologists received income from medical director fees provided by dialysis companies, mandated by Medicare, plus the monthly capitation payment (MCP) for dialysis. The MCP was intended to compensate the nephrologist for provision of comprehensive medical care for the dialysis patient. To some, the MCP was only to provide dialytic therapy although others took a more global approach. Whereas in the 1970s patients were most often seen on daily rounds during every treatment, the frequency and duration of contact between the nephrologist and patient on dialysis began a slow downward spiral. Due to these events and changes, average clinical nephrologists were stretched between the ever-increasing population of patients in the outpatient dialysis facilities, medical director and hospital responsibilities, clinic attending, consultations and the business of a practice, not to mention scientific and committee meetings, volunteer teaching rounds, perhaps a research project and journals to read. Fellowship programs were expanding and had plenty of highly qualified applicants. All was good, but not necessarily built to last. Change emerged from multiple directions.
Changes
We admit there are exceptions to what we are about to describe. We are painting with broad strokes and even run the risk of being inflammatory. That is not our intent. Without being apologists, we attempt to comprehend the events that led to the disruption of the previous patterns of gratifying nephrological life.
The projected prevalence of ESRD treated by dialysis made in the 1970s by the Gottschalk Commission was short by an order of magnitude. Whereas the original estimate of 35 persons per million population was calculated for Medicare budgetary purposes in 1973, the incidence rate of treated ESRD by dialysis by the 1990s was 300 to 400 persons per million population and higher in certain demographics. Renal transplantation also increased. Efficiently caring for this rapidly growing population of mostly elderly patients became an urgent problem requiring novel solutions.
The answer was an industrialization of the dialytic process, with a proliferation of for-profit and non-profit dialysis facilities throughout the United States. Facilities were owned entirely by large corporations, although some had joint ventures with nephrologists who shared the profits, and thereby introducing new conflict of interest issues. These same corporations began purchasing nephrology practices, such that many nephrologists became employees or partners in larger entities, which is another level of conflict. At the clinical level, industry embraced, even helped to fund the development of guidelines for metrics such as Kt/V, anemia, bone and mineral metabolism.
A new business model evolved in parallel with a rather bizarre system of payment. The responsibilities and duties for the medical director required that the designee spend a quarter of one’s time overseeing and being ultimately responsible for the care provided by the facility. Rarely was this monitored or performed. The MCP was provided to the nephrologist to take responsibility for the dialysis patient’s needs. The result was a mixture of care without universal consensus as to who ultimately was responsible for the patient with renal failure. Mortality on dialysis remained high. Encouraging signs appeared, showing that better survival can be attained in patients on dialysis,1 but it was still inadequate.
An over-riding emphasis on filling the dialysis facilities evolved over time. Peritoneal and home dialysis therapies declined. The nephrologist was now beginning to spend a disproportionate amount of time taking care of complicated chronically ill, mostly elderly, dialysis patients and less time in those arenas for which the original training embraced, such as consultation for renal metabolic disorders. The changes in dialysis facility ownership, with an emphasis on outpatient dialysis facilities, inaugurated new conflicts of interest for the physician. In some practices, the MCP, facility ownership and medical director’s fee constituted 60% of income or more of the nephrologist.
The nephrologist began to re-align responsibilities and tasks. Less time was devoted to hospital-based consultations, including the intensive care unit. The prominent position as the “go-to doctor,” the intensivist, was lost to hospitalists and other specialties. Many nephrologists were rarely seen in the hospital, and the patients they cared for (often assisted by internal medicine residents in teaching hospitals) were elderly, complex and chronically ill. Time-consuming, low-revenue producing procedures, such as renal biopsy, were off-loaded to other specialties.
Transplant programs emerged and began to manage pre-transplant evaluations, in-hospital care and post-transplant follow-up. The excitement of participating is this rapidly changing modality was lost to the average nephrologist. Another example of the movement was from being the ultimate pathophysiologic to one of a chronic care manager.
To maintain balance in the practice, nephrologists began an association with physician extenders. This enabled oversight for more chronic outpatient dialysis patients; however, it caused a further distance from the personal interaction with patients.
Not surprisingly, the discipline of nephrology experienced a gradual diminution of prestige. Attractiveness of the profession fell to new lows, as witnessed by the decrement in those applying for fellowships, with unfilled programs even at prestigious universities. Potential trainees were exposed only to the spectrum of chronic and ever-growing burden of care. The culmination of these factors has changed the way nephrology is practiced and is perceived by young physicians. It is now among the least sought-after specialties in the United States. One-quarter of fellowship offerings go unfilled each year. This once premier specialty had fallen upon difficult times.
Provocations
A provocation is something that incites, instigates, angers or irritates. We hope to provoke introspection and boldly suggest a road map for action. In the beginning of our thinking on this subject, the solutions to the modern dilemmas of nephrology seemed as simple and straightforward as realigning the specialty, thus creating specialties within a specialty. On deeper reflection, the complexities became more apparent and a more systematic overhaul seemed necessary to restore the wholesomeness and vitality of the specialty. This required a transformative initiative, engineered over time, to repair the easy-to-fix defects first while constructively contemplating the deep-seated, recalcitrant problems. The latter will require a significant involvement of all stakeholders, not nephrologists alone.
Restructuring the specialty and the required training deserves careful consideration and innovation. We believe enhancing diversity in choices for career pathway preparation is key. Consequentially, we suggest discrete routes and destinations for nephrology career choices. Differentiation within the specialty will make it more attractive. Here are some examples:
- Pathway A: Oversight of chronic care. The training and career of this nephrologist would largely entail management of patients with symptomatic or worsening renal disease with emphasis on primary and secondary prevention, comorbidity management, quality of life enhancement and transitions to renal replacement therapy including conservative management. The base would be the dialysis facility, having the time and resources to manage patients.
This nephrologist would interact with vendors, consultants and payers; manage home hemodialysis and peritoneal dialysis programs; develop algorithms to sustain and nurture quality of care; and oversee studies and data management. Achieving transformation would demand re-formatting of the curriculum of current training programs, with an infusion of new skills among the faculty.
This transformation would focus attention on volume removal vs. the archaic Kt/V model of quantification of dialysis therapy and better care of progressive CKD. Until there is better alignment of incentives through ever evolving financial models, a piecemeal approach to quality and improvement in care will only occur glacially and with resistance.
- Pathway B: Consultative outpatient and hospital care, including intensivist training. This pathway emphasizes a broad array of skills in the diagnosis and management of metabolic disorders, stone and bone diseases, intrinsic renal disease, cardio-renal syndromes, hypertension, diabetes, fluid and electrolyte disorders. There is further weight given to an in-depth understanding for care of patients in various acute settings in the hospital. This pathway would help the nephrologist regain some stature once held as the go-to physician for complex, seriously ill patients. This role becomes increasingly important in a capitated payment model, which is frequently misaligned when the hospitalist is interposed.
This nephrologist would form the necessary structure to enable highly coordinated care in the delivery systems which will develop from ACOs, ESRD Seamless Care Organizations and other integrated care models. These newer models of care will help solve many of the quality problems that have been noted but not approached in a systematic goal-directed fashion, such as prevention of unnecessary prior fee-for-service procedures and hospitalizations or re-hospitalizations.
- Pathway C: Transplantation. Transplantation will likely become increasingly complicated and demanding of special skills. Traditional pharmaceutical therapy will be augmented or even replaced by targeted biologicals. Traditional human-derived allografts may soon be displaced by genetically engineered xenografts. The catalogue of expertise expected for the transplant nephrologist will be exponentially expanding. This person will manage patients, clinics, protocols and the staff required for a rapidly expanding population of transplant candidates.
- Pathway D: Clinician-scientist-investigator. This traditional career pathway must be preserved at all costs. If it is lost or down-graded, it will lead to stagnation of the discipline and eventual demise as an intellectual undertaking. This pathway is extraordinarily diverse and highly rewarding in terms of personal satisfaction. It embraces fundamental sciences such as molecular and cell biology, genetics, physiology, biochemistry, immunology, informatics and biophysics, as well as emerging nanotechnology and synthetic biology. “Softer” sciences like clinical epidemiology, clinical trials, outcomes and cost-effectiveness research, can be added. The suggested curricula will require academic faculty to become versed in the emerging clinical realities to prepare trainees for what awaits when independence from a mentor emerges and not to lose sight of questions emerging from the bed side of patients.
Perspectives
The time for study and self-examination has expired. Inspired and energized leadership will be a key to success. To date, the American Society of Nephrology, Renal Physicians Association, National Kidney Foundation, nephrology section chiefs and internal medicine department chairpersons have studied the issues but have yet to articulate a cohesive, consensus-driven, plan of action. They each have their own possible solutions, but there is no extensive, effective collaborative effort to attack the problem.
The issues are complex. Some problems, such as financing of care, lie outside the domain of nephrology. However, changing the training milieu, bringing full-forward exhilarating role models, energizing innovation and re-instilling passion and personal satisfaction in the discipline are within the control of organized nephrology. Any change in expectations for delivery of care must directly and constructively involve the payees, payers and patients. Resistance to change is likely. There comes a time when the greater good transcends such obstacles.
The alterations proposed for training, however, do not have to await the larger structural change in financing and organization of care. In our opinion, the stakeholders have enough data now.
Toward a solution, we commend the ASN for having many programs to address the problems upon which this article cogitates. Sharon M. Moe, MD, FASN, issued a call to arms in her 2015 presidential address.2 Yet, our discipline has not yet achieved the sought-after outcomes articulated. We therefore propose a summit, possibly led by, either alone or collectively, the ASN, NKF, and Kidney Care Partners, including all stakeholders, with a mutual commitment aimed to change the training programs to align with the realities of practice and research. This gathering would be charged to assemble a list of deliverables and plan of action. It should be a sufficient duration to allow for a full airing of viewpoints. It is time for action. A few dedicated people can change our world. That is the way it has always been with change. Let’s unite and bring back pride and enthusiasm for our beloved discipline.
Acknowledgements: The authors are grateful to Ted Steinman, MD, Allan Collins, MD, and Ray Hakim, MD, who provided helpful insight to the preparation of this article.
- References:
- 1. Foster BJ, et al. Clin J Am Soc Nephrol. 2018;doi:10.2215/CJN.04330417.
- 2. Moe SM. Presidential address. Presented at: American Society of Nephrology Annual Meeting; Nov. 3-8, 2015; San Diego.
- For more information:
- Tom F. Parker III, MD, was a practicing nephrologist with Dallas Nephrology Associates and Baylor University Medical Center from 1984 to 2016. He lives in Asheville, North Carolina. Richard J. Glassock, MD, is formerly with the Geffen School of Medicine at UCLA and lives in Laguna Niguel, California.
- Disclosures: Parker and Glassock report no relevant financial disclosures.