Wednesday, January 18, 2017

Nephrologist are Incrementalists and Superheros

Image result for incrementalistsDr. Atul Gawande recently wrote this amazing article on amazing heroism on incremental care. 

This article discusses the difference of episodic heroic medicine vs incremental care. Who cares of you when episodes of urgent care and then there is care of chronic illnesses.

Who are the physicians that take care of you "episodically"?- the Er doc, the cardiologist when you have chest pain, the surgeon when you need emergent surgery.  Who are the incrementalists-- the primary care docs, ID docs for HIV patients, family docs, pediatricians.etc...

He makes an amazing argument of payment to those docs as well. He says that the interventionists make most of their income on defined, minutes- hours long procedures such as hip replacements, endoscopies, cardiac procedures. etc.,and then move on.  Hence payment is high for those specialists. On the other hand, the lowest paid specialties such as pediatrics, endocrine, family medicine, ID, and I would add nephrology here as well are incrementalists and are not paid that well.  Almost certainly at the bottom are geriatricians and palliative care specialists. All are incrementalists, they produce value by improving lives long term and over time but not well compensated.

The article does an amazing job describing the two types of physicians and how each type make such an amazing impact on the patient's lives. While some are "acute" life savers; others are "long term" life maintainers.  Both are important to maintain balance in medicine. Nephrologists are not mentioned in the article but I would say they are both episodic care providers and incrementalist.  We have times were we are urgent life savers for taking care of the hyperkalemia and dialysis but then the long term care of the CKD patient, ESRD patient and transplant patient is incrementalist side of the nephrologist.  Yet, we fall in the bottom half of the payment model.  Incrementalists need to be rewarded as well. Being a surgeon, Gawande raises and brings an important issue to the forefront for us internists out there. Bravo for supporting and thinking of us and what we do. We make a difference in incremental ways and it matters!

Worth read in the New Yorker

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