Nephrology in 10 Steps

Andrew S. Bomback
Columbia University Medical Center, New York, United States (Spring 2015)

 

 
Photography by COMSALUD

1

I was seeing patients in clinic the morning my daughter was born. My wife called me to say that her contractions, relatively weak and infrequent when I had left home a few hours earlier, had suddenly picked up. She asked how quickly I could get home. I was about to see my last patient of the morning, so I told her I would leave right after seeing him. He was an elderly man with uncontrolled hypertension and worsening kidney failure. I had seen him four or five times before, and he had never looked worse. Under different circumstances, I would have spent an hour with him, trying to clear up why he was doing so poorly. I considered sending him to the emergency room but decided against it. Instead, I zoomed through the appointment, stopped a blood thinner that seemed to be causing an allergic reaction (I changed him over to full dose aspirin as a substitute), and asked him to see his primary care physician the following Monday. On my way to the car, my wife called me again. “Come home now!” she said. I thought about that patient, briefly – he was going to do well or do poorly regardless of what I did, and my actions could only hasten that outcome. This is one of my basic beliefs in medicine, which is why I often question whether I should have become a doctor. I saw him exactly four weeks after my daughter’s birth, and he looked great.

 

2

Eula Biss, in her book-length essay On Immunity, cites her physician-father’s joke about a two-sentence textbook for doctors: “Most problems will get better if left alone. Those problems that do not get better if left alone are likely to kill the patient no matter what you do.”

 

3

The last patient I saw before my son’s birth was a young woman referred to me for a hypertension evaluation. My job was easy because, it turned out, she did not have hypertension. Therefore, as a hypertension specialist, my input was not needed. She and her mother asked me if I could give an opinion about her heart rate, which jumped around from 60 to 180 beats per minute. Her heart rate fluctuations appeared to correlate with her position – highest when standing, lowest when supine. She had been to a number of doctors before me. In fact, she was wearing a Mayo Clinic fleece jacket as a souvenir from her five day stay in Minnesota, where she was diagnosed with POTS (postural orthostatic tachycardia syndrome). I told her and her mother that I had some theories about her heart rate, but, in truth, I did not have anything definitive to offer them about her heart rate other than referrals to two doctors (one a cardiologist, one a neurologist) whom I thought would be helpful in her case. “I don’t think you have high blood pressure,” I repeated. “That’s good, because you don’t need to be on medicines to lower your blood pressure.” Then, to soften their disappointment, because they had placed an inordinate amount of faith in their visit with me, unreasonably expecting that I could fix in one hour what a panel of doctors at the Mayo Clinic couldn’t decipher in five days (one of my theories was that she definitely did not have POTS), I said as sincerely as possible, “If one of my family members had your symptoms, these are the two doctors I would want her to see.” I may have been setting them up for similar disappointing visits with the two referrals, but, like them, I felt that a key diagnosis had been missed, was still missing. She was too young to be this sick. There was an answer that someone (I hoped, and I know they hoped, too) would uncover. This optimism (I think we can call it optimism) is why some of us choose to be doctors and why some of our patients put so much faith in us.

 

4

When I practice Spanish with my daughter, I ask her what my job is. “Daddy es un doctor,” she answers. And then I ask her what a doctor does. “Ayuda los enfermos!” she squeals excitedly.

 

5

One of our genetics researchers emailed me, asking if I could contact one of my patients who had a strong family history of kidney failure according to his database. The patient had given a sample for genetic testing and, in the accompanying questionnaire, had detailed a number of other family members with kidney disease. The genetics researcher now wanted to draw samples on as many of these family members that we could find. I had not seen the patient in almost three years. When I looked him up on our electronic medical records, to find a phone number, he was listed as deceased. He was only in his mid-thirties. I googled him to find an obituary, worried that he had died of kidney failure, although the last time I had seen him (just a few months before his date of death) his kidneys were still functioning adequately. He killed himself. A park in Brooklyn has been named after him.

 

6

I was always a bit uncomfortable with the way doctors were depicted in Seinfeld and Curb Your Enthusiasm.

 

7

In medical school, when I briefly experimented with growing out my hair and not shaving, a cardiothoracic surgeon suggested I get a haircut and shave. He did this in private; it was not a rebuke, rather a suggestion. He advised, “Your patients want you to look and act like the doctors on television.” Indeed, he looked and acted like a doctor on television. For the most part, I have followed his advice to this day. Every once in a while, I break the fourth wall (to borrow a term from television) and let the patients know that I am as frustrated and disappointed with the medical system as they are. Usually, this is when they see me on the phone with an insurance company or witness my struggle in trying to obtain their medical records from another hospital.

 

8

My most obvious example of breaking the fourth wall is with my patient, Linda. She has a rare form of kidney disease, fibrillary glomerulonephritis, about which we know very little. And because we know so little about its cause, we know very little about its treatments. She presented with moderate kidney failure and, in the first year of treating her, advanced to severe kidney failure. We had tried the only therapy that had been shown, in case reports, to work for her disease, a monoclonal antibody called rituximab, although the rationale for why this drug would work for this specific disease was at best speculative. She broke down in my office. She was in near hysterics. Two visiting nephrology fellows from Spain were shadowing me that day, and her crying was clearly making them uncomfortable. I handed Linda a box of tissues and told her we would re-dose the rituximab and that I thought a second round of therapy would help. I said, “You will get better,” which was not an outright lie, because if her kidneys failed, she would get a transplant, in which case she would technically get better. Linda stopped crying. “You really think so?” she said. “Yes,” I said, in my most television-doctor certainty. Later, when Linda left the office, the Spanish nephrology fellows asked me if I really thought she would get better. “No,” I said, “but she needs to have some hope right now.” They laughed, but Linda did get better. After it was clear that her recovery was going to be sustained, when she was stable and healthy and no longer suffering from kidney failure for over two years, I reminded Linda about that episode in my office, about her crying and my saying she would get better. She remembered it as clearly as I did. “I was bluffing,” I confessed with an awkward smile, but also in a way that a television doctor might say the line. So, I suppose I did not entirely break the fourth wall.

 

9

“We never say cure,” I admonished the patient. “We say remission. Your disease is in remission. It could always come back.” Sure enough, her disease relapsed four years later. “You responded before, so you should respond again,” I counseled her. “I have every reason to think we’ll get you back into remission.” I’ve stolen the lexicon of oncologists, as have all of my non-oncology colleagues. The terminologies cushion blows, dampen expectations, and, to some extent, force the patient to never lose contact with his or her doctor.

 

10

I can’t imagine what it must have been like to practice nephrology before the advent of hemodialysis, to advertise oneself as a kidney expert and then watch patients die as that organ failed.

 


 

ANDREW S. BOMBACK, MD, MPH, is Assistant Professor of Medicine at Columbia University Medical Center in New York. He is the author of over eighty peer-reviewed publications, primarily focusing on glomerular diseases and resistant hypertension. His non-fiction writing has appeared in Hobart, Harlequin, Essay Daily, Pharos, Journal of the American Medical Association, and New England Journal of Medicine. He is the recipient of the Alpha Omega Alpha Editor’s Prize for his writing on kidney disease.

 

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