Kenneth A. Liss, DO
Lessons from My Father
When I was thirteen or fourteen, I took an acquaintance’s side over my brother’s in an argument. Full of righteous indignation, I bragged to my father how I was sure I had the moral high ground and had done the right thing. That was ill advised at best. My father gave me a lengthy dissertation about the need to protect your siblings publicly even if privately you discuss otherwise. Needless to say, I regretted my decision for some time and it has stood as a powerful life lesson.
Recently a nephrologist used the pages of one of our most respected peer journals to question the motives of fellow nephrologists who participated in JV dialysis facility ownership. Let me be very transparent. I am part of just such an enterprise. I am also quite motivated by profits, and being able to earn an income that supports my lifestyle. In no way am I embarrassed by this fact. In fact, it is part of what made me study hard in school, go to medical school, and complete a renal fellowship. I now see an average of 20 to 30 patients daily while handling administrative details and teaching in a residency program. In addition, I have an active clinical research program and occasionally find time to opine in this editorial section. Paramount, however, is providing high quality compassionate care to my patients. Hopefully at the end of the day I can say that nothing stood in the way of this most solemn obligation.
Right now, there is a critical intellectual and political battle raging in America regarding the best path forward to provide quality care to all of our citizens. There is one school of thought that believes that profit needs to be removed from the delivery of this care. Nephrologists provide ESRD care for approximately one ninth of one percent of the US population, yet are responsible for eleven percent of Medicare costs. Certainly, we can provide invaluable insight into this debate.
I fear that the solutions are too complex, and they are definitely too varied, for this editorial section. I can assure you, however, that having our motivations and honesty questioned by one of our most respected thought leaders makes our task that much more difficult. Make no mistake, the purpose of that opinion piece was just that. Now I need to answer to my colleagues from other disciplines as to why I put my own avarice above the needs of the most vulnerable patients. Using a public forum to take one’s colleagues to task for doing their job is not only insulting but may be part of the reason why 40% of nephrology fellowship positions are not being filled.
The author of the same piece attacks ESRD seamless care organizations (ESCO) for the same conflict of interest issues. It is my understanding that those organizations profit when patients are best managed and avoid hospitalizations where a fee-for-service model is the major component of reimbursement. Those organizations profit when patients are managed efficiently and of course in a cost-effective manner. It is my opinion that an organization that does that successfully has every right to profit. Lastly we are led to believe that data comparing quality of care in joint venture facilities and non-joint venture facilities is nonexistent and furthermore impossible to accumulate. I welcome such a study and have extreme doubts that mortality in for profit and non-for profit facilities, even those that are a JV model, is dissimilar.
The truth is that most people choose their medical providers through recommendations from friends, relatives, or through word of mouth. This choice comes with some risk and as a medical practitioner I understand that this puts patients in a vulnerable position. I take quite seriously this responsibility and am therefore personally compelled to adhere to a certain code of conduct. Profit should be the end product of rigid standards, quality, and hard work whether you are a brain surgeon or a shoe cobbler. I would never work in any other system and I would never be so supercilious to publicly question anyone else’s motivation for doing the same. Perhaps take a lesson from my father next time.