What is the Nephrologist's Role as a Primary Care Provider? We All Have Different Answers

Abstract

At the 2005 Annual Meeting of the American Society of Nephrology (ASN), the ASN Dialysis Advisory Group concluded after much discussion that the role of nephrologists as primary care providers to dialysis patients needed further study and discussion. Out of this discussion came an ASN membership survey, an extremely well-attended session at the 2006 Annual Meeting on Primary Care Issues for Nephrologists, and a series of articles to be published in CJASN, beginning with the current issue. The ASN membership survey, completed in March 2006, included responses from >300 ASN members, 97% certified in nephrology and 95% certified in internal medicine. About half of those responding were planning to recertify in Internal Medicine. Nearly two thirds of nephrologists provided most of the primary care to at least some of their dialysis patients, with the majority of this care being provided in the dialysis unit rather than in the physician's office. Only 15% of their dialysis units had written policies addressing the provision of primary care services to dialysis patients. The primary care services provided by nephrologists to dialysis patients included counseling regarding smoking, seat belts, safe sex, etc.; cancer screening, immunization (other than for hepatitis B); management of diabetes mellitus, cardiovascular disease, lipid disorders, and hypertension; management of anticoagulation, treatment of anxiety and depression, pain control; completion of disability and utility shut-off forms, handicapped driver permissions, home oxygen prescriptions, and so forth (Figure 1). When asked to comment on whether primary care physicians or nephrologists should provide primary care and which subspecialty is best able to provide care, respondents were evenly split on each question (Figure 2). This underscores the heterogeneity of opinions and practice patterns even in our small sample. When asked “How confident are you that the primary care services you provide for your dialysis patients are of high quality?”, 48% responded “extremely”, 42% responded “somewhat”, and 10% responded “have concerns”. Seventy five percent of respondents did not closely follow clinical practice guidelines in their dialysis patients, were not particularly familiar with these guidelines, or were aware that they existed but had not read them. The vast majority of respondents pursued continuing medical education related to primary care by reading general medical journals and through attending CME activities focused on general internal medicine and primary care, ACP or similar meetings, and local Department of Medicine general internal medicine conferences. When asked which primary care services they thought they could consistently do better than other primary care providers, nephrologists most commonly selected management of glucose control (34%), management of cardiovascular disease (54%), hypertension (84%), and lipid disorders (57%). When asked which primary care services other physicians should provide to dialysis patients, the most commonly cited services were counseling regarding smoking, drinking, safe sex, weight, etc, cancer screening, treatment of depression, insomnia and anxiety, pain control, and completion of various forms and prescriptions not related to dialysis. Most (69%) indicated that they thought that provision of primary care services to dialysis patients was different than nondialysis patients; of these 93% felt that they were only “somewhat” or “not very” confident that primary care physicians were able to meet the special primary care needs of dialysis patients. Finally, 49% responded that nephrologists should provide primary care to both hemodialysis patients and peritoneal dialysis patients, while 40% reported that nephrologists should not provide primary care services to these patients. The available literature addressing primary care provided to dialysis patients by nephrologists primary care physicians as well as that related to specific topics about primary care services directed at nephrologists is scant (1–7). Much of what has been written addresses screening for malignancies (8–16) and depression (17–25) among dialysis patients, with other aspects of preventive care much less frequently addressed (26,27). What does emerge from this literature is that many nephrologists provide much, if not most, of the primary care for dialysis patients in the US and Canada, spend substantial portion of time doing so, and many dialysis patients view their nephrologists as providers of at least some of their primary care services. It is not at all clear that either primary care physicians or nephrologists are providing comprehensive high-quality primary care services to these patients. It is clear, although, that the roles of nephrologists and primary care physicians are often ill-defined and that communication between these physicians is often limited. With this tremendous diversity of experience and attitudes of nephrologists as background, we are delighted that CJASN is publishing over this series of articles, some based on lectures given at the 2006 ASN Annual Meeting, on important aspects of primary care medicine and pediatrics that we hope will be practical and useful for nephrologists caring for adults and children on dialysis. These papers will address a general overview of adult medicine clinical practice guidelines; screening and prevention of peripheral vascular disease, coronary artery disease, and cerebrovascular disease; cancer screening; new treatments for diabetes mellitus; hormone replacement therapy; and pediatric issues of primary care. It is clear that “one size does not fit all” in the area of provision of primary care to ESRD patients. We also hope that this series opens new dialogue between nephrologists and primary care physicians who share in the care of dialysis patients to improve their communication related to their care of this expanding and aging patient population, and encourages nephrologists to maintain their knowledge base current regarding general medical issues outside the sphere of nephrology, perhaps through recertification in Internal Medicine or Pediatrics. The goal of this series is to provide the impetus to discuss who will rather than should do the primary care for a given group of patients and provide the tools to nephrologists if this is a responsibility that they decide to take on. Disclosures None.Figure 1: Frequency of nephrologists’ responses regarding the provision of each type of primary care service.Figure 2: Degree to which respondents agreed or disagreed with each statement regarding whether nephrologists or primary care physicians should or are better able to provide primary care.

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