The Physician’s Role in a Successful Peritoneal Dialysis Program
Zipporah Krishnasami

Zipporah Krishnasami, MD, is Medical Director, Birmingham Gambro Home Training Unit, Birmingham, AL.

John Donne wrote, “No man is an island, entire of itself.” Although his observation serves as fodder for the philosopher’s appetite, it has a practical application for a peritoneal dialysis (PD) program. No single individual, including the physician, makes a PD program. Instead, the program is comprised of individuals – the physician, the home training unit (HTU) staff, and the patient – working and interacting with each other to ensure corporate success. Vince Lombardi, the revered coach of the Green Bay Packers, summed it up this way, “Individual commitment to a group effort – that is what makes a team work, a company work, a society work, a civilization work,” and he could have added  “a PD program work.”

Measuring a Successful PD Program
In sports, a successful team is one that dominates the game. What is a successful PD program? Is it measured by numbers – more patients, better reimbursements, higher Kt/Vs? Yes, in part, this defines success. “Every good tree bears good fruit.” A program dedicated to patient care will naturally produce “good fruits” from its labor. The nurse who meticulously reviews and acts upon an anemia profile will assure that the patient achieves desired hemoglobin levels. The discerning CKD educator will spot the ideal and often the non-ideal, but teachable, PD candidate, which will result in more patients. Numbers do matter, but numbers are not enough.
Ultimately, success is measured by the patients’ well-being. Some patients on PD have no other dialysis options. However, a majority of patients on PD chose PD. Why? For numerous reasons: independence, control, flexibility, travel, less dietary restrictions, and overall, better compatibility with their lifestyle. A successful PD program will enable patients to maintain a  “quasi-desired” standard of living without compromising health care. This requires a balance between objective (adequate urea clearance and ultrafiltration, anemia management, etc.) and subjective factors (“feeling healthy,” “having energy”). For instance, a patient who has a sub-K/DOQI recommended kt/v (say, 1.8) feels “good,” and volume is not an issue. One more exchange is needed to achieve that “magical” number, but it will interfere with his lifestyle. What then? Do you insist he do the exchange, or leave him alone with close monitoring? The patient, not the numbers, should be the focus of care.

Ensure Success by Working Together!

To ensure success, all members of a team must work together. This is true for the world of sports and also a PD program. For instance, a football organization is comprised of several members including the coach, players, and manager. Individually, each possesses unique talents that, when pooled together, result in team success. Similarly, a PD program is comprised of the HTU staff, the patients, and the physician. Each has a unique role that is necessary for the program to succeed.

To be an effective player, a physician must not only be knowledgeable about PD, but must also have a passion for it. The physician must believe in PD and must embrace it. As a natural consequence, the physician will exude an enthusiasm for PD that will be infectious and motivational for both the HTU staff and the patients.

The physician’s basic role is to ensure the well-being of the patients. This is done by reviewing adequacy and monthly laboratory data, developing short-term care plans, and providing management protocols. The physician will intimately work with the nursing staff in developing PD regimens that are conducive to the patients’ well-being and lifestyle. The staff are not only the “heart and soul” of a PD program, but they are also the “eyes and ears” for the physician. Their observations will enable the physician to make more insightful decisions regarding patient care. It is to the physician’s advantage to listen to the staff.

More than anything, a physician needs to be available and attentive to the needs of the team. The physician will be an educator, providing the necessary in-services for his HTU staff;  the cheerleader and team mascot, providing encouragement and support for other team members; and the director, enabling patients to do PD as long as possible, but recognizing when HD may be more beneficial. 

There is no play-by-play manual for success. Each PD program is unique mainly because each member is unique. However, a universal tenet for success exists. Henry Ford said it best, “Coming together is a beginning. Keeping together is progress. Working together is success.”