by Gary Peterson
Everyone involved in dialysis care should be required to look at Tassin, France (1999 and 2006 articles). Patients lived exceptionally long lives with normal blood pressures without medications. All this occurred in the 1970s, 80s, and 90s. What did they do back then that was so successful? Nephrology has not yet cracked this mystery. One must be willing to think outside the internal medicine box in order to try to understand what is happening there.
They gave patients long nocturnal dialysis, three times a week. Patients enjoyed superior middle and large molecule clearances, no internal organ stunning, and essentially non-iatrogenic treatments. Tassin nephrologists never bought into the small molecule Kt/V theory that defines U.S. dialysis care today. Success did not require every-other-day dialysis. Long treatment times gave them a “reservoir of dialysance” that could easily tolerate the three-day dialysis weekend.
With longer treatment times, patients enjoyed mostly unrestricted diets. They did not have to be bombarded with educational material and restrictions. There was no need for becoming an “expert patient.”
Studies reproduced the long treatment times in other clinics, but were been unable to produce the same outcomes. So, what else did Tassin nephrologists do? Consider this.
Instead of just focusing on internal medicine and interventions, Tassin nephrologists also created an environment in which patients could thrive and live as normal lives as possible. The burden of dialysis care was minimized by requiring patients to give up only a few late evening hours of their normal lives three times a week. Adding dialysis time, especially during the business day, often proves to be psychosocially damaging and counterproductive.
Patients also shared group meals with wine and beer. (Ethnic, cultural, and religious diversity in the U.S. could make this difficult.) The environment not only sustained the meaning and purpose of patients’ lives, but also provided unique peer-to-peer educational and psychosocial support. They seem to have tapped into the power of a collective “joie de vivre” or “will/reason to live.” No one understands dialysis patients like other patients. The patients’ normal social circles (outside dialysis) can judge them harshly, often giving them bad advice/solutions that leave them feeling misunderstood, unsupported and discouraged. Tassin’s environment supported a collective psychosocial well-being that also allowed patients to reach their own truths and wisdom about life and dialysis care.
For those willing to think even further outside the internal medicine box, this environment also supports a human being’s innate ability to adapt and survive. Such an environment can help manifest beneficial adaptions and effects that are not recognized by traditional nephrology. When a patient’s body and/or psychosocial well-being are NOT being repeatedly harmed by dialysis treatments, patients seem to be able adjust – successfully and relatively easily -- to major organ replacement therapy with physiological, immune, epigenetic, and psychological adaptations that we do not yet fully understand. So, here’s a shocker for U.S. nephrologists to contemplate: Perhaps God is smarter than U.S. nephrologists.
New Directions for U.S. Nephrology
For the last 30 years, due largely to misaligned financial incentives, U.S. nephrologists have been using their internal medicine toolboxes to try and justify fast, cheap dialysis and the use of profit-making drugs.
Shame on nearly all of you for forgetting what they taught you on the first day of medical school. Stop harming patients.
Listen to patients. According to U.S. patient focus groups (1) (2), the patients’ biggest complaints are that they are not respected as human beings and that their individual needs and concerns are ignored by their caregivers. Quit being factory-line workers for guys like Kent Thiry and Rice Powell and their quality incentive programs (which appear now to be rife with fraud).
Instead, use your skills and internal medicine toolkit to complement the natural adaptative power of the body and mind. Stop trying to force interventions, especially short-time dialysis, that work against the power of nature and biology (or is it God you’re fighting?).
Be a physician that treats the whole patient. Try to move each patient as high up Maslow’s hierarchy of needs as possible through multiple pathways. Help your patients express their collective “joie de vivre” or “will/reason to live” that is appropriate for their community. (Unlike France, the U.S. is blessed/cursed with the Puritan work ethic as a basis of its cultural identity... and our food is too often 'fast food.')
Home dialysis obviously has many benefits. It can improve the patient’s environment and make increasing their dialysis time easier to bear. Perhaps with social media it can tap the power of the patient collective. Some patients do, however, find home dialysis socially isolating and it can create additional burdens on home and family life.
So much of dialysis care becomes easier when you give patients a lot of dialysis and support their individual and collective psychosocial health. Be excellent nephrologists and wise physicians… and change the U.S. financial incentives and leaders that (almost always) steer medicine wrong.