Saturday, February 7, 2009

"13 Things I Hate about Nephrology" (by Nephrogirl)

Simplified hemodialysis circuitImage via Wikipedia

In a recent post, "nephrogirl" — who is either a nephrology fellow or younger nephrologist — listed the "13 things [she hates] about nephrology." I appreciate that she took the time to vent her unhappiness. And while her experiences with nephrology aren't mine — which might have to do with differences in our patient populations and many other factors — I understand her perspective. Here's the list, along with my comments.
1) The incessant checking of labs, powerlessly watching the kidney function slowly deteriorate. [I'd say the ratio of patients for whom I make a significant difference to patients that I feel powerless to help is well over 50:1.]
2) Sending patients for the critical intervention which you feel is going to make the difference, only to see them suffer a devastating complication from the procedure itself which was worse than the actual disease. [Interventions for renal artery stenosis and coronary artery disease might fall into this category. I've rarely seen catastrophic outcomes from either of these interventions, and the number of patients that I've seen helped far outweighs any of the complications I've seen.]
3) The self-deception involved in thinking you might be slowing the progression of their kidney disease, when their main problem is the cardiovascular death that’s waiting for them in the next 6-24 months. [Interventions to slow the progression of kidney disease, like improving control of hypertension and diabetes, also have the potential to also prevent or delay cardiovascular disease.]
4) The rampant noncompliance of so many patients. [Agreed, this is frustrating. But I've also seen many patients stop smoking, lose weight, begin taking their medications, and change their lifestyles.]
5) Reassuring the dialysis patient that his labs look better, when he’ll be dead in a year. [Again with the fatalism and therapeutic nihilism, which is difficult to argue against, because the prognosis for many dialysis patients is so dismal. Then again, I've seen plenty of patients survive many years on dialysis and eventually get transplanted.]
6) Relying on the creatinine to determine kidney function, a wildly imprecise measure at best. [Agreed, but the MDRD formula is now mainstream and is a more sensitive — though not a specific — measure of kidney disease.]
7) Watching the diabetic dialysis patient slowly losing his eyes, feet, kidneys, heart, and brain…knowing the outcome will not change despite everything that you try to do…watching the health care system spend tens of thousands of dollars on him in his last year of life. [I agree, this happens, and is frustrating, and many nephrologists feel powerless.]
8) Trying to explain kidney disease to patients and to other doctors – it’s a wild mystery to most people that they usually equate with death. [A cardiologist once said, half-jokingly, that "Everyone understands the heart, and no one understands the kidney." The mysteriousness and non-intuitiveness of the kidney is what gets many nephrologists into the field in the first place.]
9) The joylessness of a nephrologist’s life, especially one who feels it is her duty to try to make a difference, despite constant evidence that her efforts are most likely futile. [Most days, I'm very satisfied with my work, and I don't feel this way at all.]
10) The realization that it is easier and more financially rewarding to put a patient on dialysis than to try to preserve their kidney function. [I've suspected this phenomenon might occur, but I don't practice this way.]
11) Knowing that the promise of a kidney transplant is what dialysis patients live for…and knowing that a transplant can in some cases be worse than dialysis, especially when the post-transplant care is handled by an erratic system more interested in doing surgery than in practicing medicine. [In general, it's better to get a kidney transplant than to be on dialysis, even taking into account transplant patients who do poorly.]
12) Not being able to let go…for fear you’ll miss the acute renal failure, the rapid correction of hyponatremia, the diagnosis of RPGN…then when your back is turned, an unexpected catastrophe happens. [Many medical specialties require a high level of vigilance, nephrology perhaps more than most.]
13) The realization that the bill of goods you were sold when you chose this field is far different than the reality. [Personally, more than five years into practice, I still wouldn't choose any other field.]
Thanks again for taking the time to leave your comments.

1 comment:

pilgram said...

It was interesting to hear from the doctors point of view. I am the spouse of a dialysis patient and I hate dialysis. It tore my marriage apart. I put a gap so wide in our family that will never be repaired