Primary care management of chronic dialysis patients: emerging challenges

Amit Kumar Ghosh

Department of Internal Medicine Mayo Clinic Rochester USA Email: ghosh.amit{at}mayo.edu

Sir,

The article by Zimmerman et al. [1] on the diverging attitudes of patients towards their own primary care from their physicians adequately describes the challenges faced by the physician in an era of scientific uncertainty, with increasing need to see additional patients, delivering evidence-based health care, while being responsive to patients’ individual concerns. However, there could be several additional reasons to explain the variable pattern of physician behaviour (nephrologist vs family physicians) in delivering primary care to dialysis patients.

The widely variable rates of colon and breast cancer screening in patients, among nephrologists and family physicians (table 1) highlights the need for complementary efforts on the part of both group of physicians when it comes to taking care of these patients. Redelmeier et al. [2] have reported that clinicians often overestimate the risks of adverse drug reactions but may underestimate the risks of systemic disorders, and often fail to treat unrelated disorders in patients with chronic disease. There is also a difference in the approach of nephrologist and family physicians, as the former tends to feel comfortable with diagnostic certainty while the latter group of physicians often practice under circumstances of uncertainty. Stacey [3], using his certainty–agreement diagram, has masterfully described the response of most individuals and organizations in any complex decision process. Most decisions can be classified as simple (high certainty, high agreement), complex (intermediate certainty, intermediate agreement, one or both) and chaotic (low certainty, low agreement). It is conceivable that most of the speciality care often revolves around making decisions with high certainty and agreement.

Recent developments in medicine provide the physician with newer approaches to understanding the scope of the complex adaptive processes of medical decision making. In general, such decisions involve a collection of individuals free to act in ways that are not totally predictable, yet their actions are interlinked in such a way that one person’s actions change the context for the other [4]. It is widely recognized that using an analytically reductionist approach to medicine may not be easily applicable to several problems faced by the physician. Clinicians should have to be increasingly aware of their own inertia in treating patients with chronic disorders [5]. Among the recommendations to avoid clinical inertia are included continued emphasis on evidence-based guidelines and emphasis on improving clinical care and routine use of computerized or paper flowsheets to follow diagnostic tests and monitor therapy. I totally concur with the authors that better communication among physicians caring for chronic dialysis remains the first step in the co-management of chronic dialysis patients.

Conflict of interest statement. None declared.

References

  1. Zimmerman DL, Selick A, Singh R, Mendelssohn DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003; 18: 305–309[Free Full Text]
  2. Redelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med 1998; 338: 1516–1520[Abstract/Free Full Text]
  3. Stacey RD. Strategic Management and Organizational Dynamics. Pittman Publishing, London, UK; 1996
  4. Plsek P, Greenhalgh T. The challenges of complexity in health care. Br Med J 2001; 323: 625–628[Free Full Text]
  5. Phillips LS, Branch WT, Cook CB et al. Clinical inertia. Ann Intern Med 2001; 135: 825–834




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