Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Sections by Topic
    • Archives
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Trainee of the Year
    • Author Resources
    • Reprint Information
  • Editorial Team
  • Subscriptions
  • More
    • Advertising
    • Reprint Information
    • Impact Factor
    • About CJASN
    • Feedback
    • CJASN Relaunch
  • Other
    • JASN
    • Kidney News Online
    • In the Loop
    • American Society of Nephrology

User menu

  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • JASN
    • Kidney News Online
    • In the Loop
    • American Society of Nephrology
  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Sections by Topic
    • Archives
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Trainee of the Year
    • Author Resources
    • Reprint Information
  • Editorial Team
  • Subscriptions
  • More
    • Advertising
    • Reprint Information
    • Impact Factor
    • About CJASN
    • Feedback
    • CJASN Relaunch
  • Visit ASN on Facebook
  • Follow CJASN on Twitter
  • CJASN RSS
  • Community Forum
Special Feature: Primary Care Issues for Nephrologists
You have accessRestricted Access

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

Jeffrey S. Berns and Lynda A. Szczech
CJASN May 2007, 2 (3) 601-603; DOI: https://doi.org/10.2215/CJN.01360307
Jeffrey S. Berns
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Lynda A. Szczech
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.

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).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Frequency of nephrologists’ responses regarding the provision of each type of primary care service.

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.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
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.

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.

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

  • Copyright © 2007 by the American Society of Nephrology

References

  1. ↵
    Kausz AT, Guo H, Pereira BJ, Collins AJ, Gilbertson DT: General medical care among patients with chronic kidney disease: Opportunities for improving outcomes. J Am Soc Nephrol16 :3092– 3101,2005
    OpenUrlAbstract/FREE Full Text
  2. 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 Transplant18 :305– 309,2003
    OpenUrlAbstract/FREE Full Text
  3. Bender FH, Holley JL: Most nephrologists are primary care providers for chronic dialysis patients: Results of a national survey. Am J Kidney Dis28 :67– 71,1996
    OpenUrlPubMed
  4. Flauto RP, Leon JB, Sehgal AR: The provision and outcomes of diabetic care of hemodialysis patients. Am J Kidney Dis41 :125– 131,2003
    OpenUrlCrossRefPubMed
  5. Holley JL: Nephrologists as primary care providers: A review of the issues. Am J Kidney Dis31 :574– 583,1998
    OpenUrlPubMed
  6. Holley JL, Nespor SL: Nephrologist-directed primary health care in chronic dialysis patients. Am J Kidney Dis21 :628– 631,1993
    OpenUrlPubMed
  7. ↵
    Nespor SL, Holley JL: Patients on hemodialysis rely on nephrologists and dialysis units for maintenance health care. ASAIO J38 :M279– M281,1992
    OpenUrlPubMed
  8. ↵
    Ajam M, Ramanujam LS, Gandhi VC, Leehey DJ, Ing TS, Schnell TG, Daugirdas JT: Colon-cancer screening in dialysis patients. Artif Organs14 :95– 97,1990
    OpenUrlPubMed
  9. Bargman JM: Neoplasia in dialysis patients: Pathophysiology, epidemiology, and screening. Adv Perit Dial16 :93– 96,2000
    OpenUrlPubMed
  10. Castellanos M, Varma S, Ahern K, Grosso SJ, Buchbinder S, D'Angelo D, Raia C, Kleiner M, Elsayegh S: Increased breast calcifications in women with ESRD on dialysis: Implications for breast cancer screening. Am J Kidney Dis48 :301– 306,2006
    OpenUrlCrossRefPubMed
  11. Holley JL: Preventive medical screening is not appropriate for many chronic dialysis patients. Semin Dial13 :369– 371,2000
    OpenUrlCrossRefPubMed
  12. Ishikawa I, Honda R, Yamada Y, Kakuma T: Renal cell carcinoma detected by screening shows better patient survival than that detected following symptoms in dialysis patients. Ther Apher Dial8 :468– 473,2004
    OpenUrlCrossRefPubMed
  13. Ito T, Tanaka I, Kadoya T, Kimura M, Ooshiro T, Ooishi K, Tanaka J, Yorioka N: Screening for gastroenterological malignancies in new and maintenance dialysis patients. J Gastroenterol34 :35– 40,1999
    OpenUrlCrossRefPubMed
  14. Walter LC, Lindquist K, O'Hare AM, Johansen KL: Targeting screening mammography according to life expectancy among women undergoing dialysis. Arch Intern Med166 :1203– 1208,2006
    OpenUrlCrossRefPubMed
  15. Chertow GM, Paltiel AD, Owen WF Jr, Lazarus JM: Cost-effectiveness of cancer screening in end-stage renal disease. Arch Intern Med156 :1345– 1350,1996
    OpenUrlCrossRefPubMed
  16. ↵
    Gornik HL, Lazarus JM, Chertow GM: Cancer screening and detection in patients with end-stage renal disease. Int J Artif Organs21 :495– 500,1998
    OpenUrlPubMed
  17. ↵
    Craven JL, Rodin GM, Johnson L, Kennedy SH: The diagnosis of major depression in renal dialysis patients. Psychosom Med49 :482– 492,1987
    OpenUrlAbstract/FREE Full Text
  18. Craven JL, Rodin GM, Littlefield C: The Beck Depression Inventory as a screening device for major depression in renal dialysis patients. Int J Psychiatry Med18 :365– 374,1988
    OpenUrlPubMed
  19. Hong E, Bernardini J, Fried L, Samsonov M, Pirain B: The relationship between symptoms, depression, and quality of life in peritoneal dialysis patients. Adv Perit Dial22 :83– 87,2006
    OpenUrlPubMed
  20. Israel M: Depression in dialysis patients: A review of psychological factors. Can J Psychiatry31 :445– 451,1986
    OpenUrlPubMed
  21. Kutner NG, Fair PL, Kutner MH: Assessing depression and anxiety in chronic dialysis patients. J Psychosom Res29 :23– 31,1985
    OpenUrlCrossRefPubMed
  22. Watnick S, Wang PL, Demadura T, Ganzini L: Validation of two depression screening tools in dialysis patients. Am J Kidney Dis46 :919– 924,2005
    OpenUrlCrossRefPubMed
  23. Wuerth D, Finkelstein SH, Ciarcia J, Peterson R, Kliger AS, Finkelstein FO: Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis. Am J Kidney Dis37 :1011– 1017,2001
    OpenUrlPubMed
  24. Wuerth D, Finkelstein SH, Finkelstein FO: The identification and treatment of depression in patients maintained on dialysis. Semin Dial18 :142– 146,2005
    OpenUrlCrossRefPubMed
  25. ↵
    Yucedal C, Olmez N, Gezen G, Celik F, Altindag A, Yilmaz ME, Kara IH: Depression in dialysis patients. Edtna Erca J29 :151– 155,2003
    OpenUrlPubMed
  26. ↵
    Murphy SW, Parfrey PS: Screening for cardiovascular disease in dialysis patients. Curr Opin Nephrol Hypertens5 :532– 540,1996
    OpenUrlCrossRefPubMed
  27. ↵
    Richbourg MJ: Vision screening in older adults on dialysis: Do nephrology nurses have a role? Anna J24 :541– 544, 549: 555,1997
    OpenUrlPubMed
View Abstract
PreviousNext
Back to top

In this issue

Clinical Journal of the American Society of Nephrology
Vol. 2, Issue 3
May 2007
  • Table of Contents
  • Index by author
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article
Thank you for your help in sharing the high-quality science in CJASN.
Enter multiple addresses on separate lines or separate them with commas.
What is the Nephrologist's Role as a Primary Care Provider? We All Have Different Answers
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
Citation Tools
What is the Nephrologist's Role as a Primary Care Provider? We All Have Different Answers
Jeffrey S. Berns, Lynda A. Szczech
CJASN May 2007, 2 (3) 601-603; DOI: 10.2215/CJN.01360307

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
What is the Nephrologist's Role as a Primary Care Provider? We All Have Different Answers
Jeffrey S. Berns, Lynda A. Szczech
CJASN May 2007, 2 (3) 601-603; DOI: 10.2215/CJN.01360307
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Disclosures
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

More in this TOC Section

  • Screening, Diagnosis, and Treatment of Cancer in Long-Term Dialysis Patients
  • Coronary Artery Disease
Show more Special Feature: Primary Care Issues for Nephrologists

Cited By...

  • The Other Half of Informed Consent: Transplant Education Practices in Dialysis Centers
  • Scopus (9)
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • Scopus
  • PubMed
  • Google Scholar

About

  • ASN
  • CJASN
  • ASN Journals
  • ASN Podcasts
  • CJASN Relaunch

Author Information

  • Submit a Manuscript
  • Trainee of the Year
  • Author Resources
  • Reuse/Reprint Policy

More information

  • Advertise
  • Subscribe
  • Email Alerts
  • Sections by Topic

© 2019 American Society of Nephrology

Print ISSN - 1555-9041 Online ISSN - 1555-905X

Powered by HighWire