In the News: Nephrologists take care of the most complex patients

As a nephrologist, I always wondered , “ too many med reconciliations, so many co morbidities and I feel like I am taking care of so many complex patients.”  A study from Canada confirmed my assumption. This study was a population-based retrospective cohort study of 2 597 127 residents of the Canadian province of Alberta aged 18 years and older with at least 1 physician visit between April 1, 2014 and March 31, 2015. Data were analyzed in September 2018. When types of physician were ranked according to patient complexity across all 9 markers, the order from most to least complex was nephrologist, infectious disease specialist, neurologist, pulmonologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician.

This study had some interesting findings:

1.      They used 2 different methods of sensitivity analysis making their discovery a strong finding, which were consistent with both methods

2.      In terms of mean number of comorbid conditions a specialists deals with, Nephrologists were the highest followed by Infectious diseases

3.      Nephrologists took care of sick patients with mental conditions as well- not a surprise to most of us ( followed by ID and Neurology in the lead)

4.      We also dealt with patients that were prescribed the most medications( not just by us but by all physicians they see). I can attest to that as doing a med recon on most takes a lot of time as there are many medications. As a result, med discrepancies are not uncommon in our patients

5.      Most patients referred to renal also had a higher mean of seeing other physicians, a close second to ID

6.      Mean number of days spent in hospital, we were also on top with ID, this is part of the fact that many have co morbid conditions such as CAD, CHF and access infections and so forth

7.      Strikingly, we also had the patients with the highest mortality( significantly higher than other fields)

What is more important is not where we stand in the ranking but that there is such a wide variation of types of complexities of patients all fields are seeing and taking care of. As authors suggest, this impacts education and health policy.

Should residents applying for ID and Nephrology be involved in learning about complex disease models? Is this perhaps a major reason why residents are scared to go into these fields? Complexity and curiosity drove me to Nephrology but for some – might scare them.

In addition, the reimbursement in the US doesn’t reflect complexity of the patient. There is no question that patient complexity requires time (including the time required to communicate with the multiple other doctors), expertise, and resources to optimize management. However, reimbursement of physicians and facilities in North America is most commonly based on

fee-for-service compensation. The complexity of medical decision making is addressed by assessing the number of diagnoses and management options that are considered, the medical risks, and the amount of data to be reviewed. Adjusting payments to encourage physicians to spend more time and resources caring for patients at highest risk of complications makes sense from a health care payer perspective. This is important in Nephrology as there is declining interest in this field and changes in reimbursement might help change that trend.

As ESRD and transplant physician, internal medicine is part of our core and most often, we are in charge of the medical management of these individuals. Due to the fact that we take care of the most complex patients, most nephrologists are good leaders. Leading the dialysis unit, dealing with multiple physicians, and communicating with all types of doctors makes us ideal in leading an administration. Hence, many Nephrologists also take on administrative roles and fit well in them. A recent ACKD series of articles highlight these non-traditional roles of the Nephrologist.

Nephrologists are in a very crossroads of a complex field in medicine, with high regards from many fields of medicine. We should take pride in this and allow for an ongoing dialogue with the payers that complexity takes time and dealing with complex sick patients is equally as hard as doing an interventional procedure.