Dear Authors,

I work with patients with chronic kidney disease as a nephrology nurse care manager. I had a patient who was quickly worsening and whose vascular access—or fistula—had healed for nine weeks and looked developed enough to use for treatment. Because of the patient’s condition, we needed to start hemodialysis treatment ASAP.

The problem was that the surgeon specifically told us to avoid use of the fistula for twelve weeks. That meant we would have to take the (in my view) unnecessarily risky step of placing a temporary catheter in the patient for access. So I went to the surgeon’s office to see if he would take a quick look at the fistula just to weigh in on whether it might be usable.

The surgeon’s response was “Absolutely not. Twelve weeks is my rule; I will not even look at his fistula today. You dialysis people keep ruining my accesses because you stick them too soon. They need a minimum of three months before they can be used.” That ended the conversation and, in my view, put the patient in more pain and risk.

What could I have said or done in response to this first statement (with a doc whom I didn’t know) to shift the focus of the discussion back to the patient’s best interests after being shut down like that?

Signed,
Conversational Failure

P.S.
The patient started dialysis one week later at another center—where the nephrologist and nursing staff felt the fistula appeared sufficiently mature.

Dear Conversational Failure,

I’m glad there are so many like you in our healthcare system. Thank you for seeing yourself as a “patient advocate” and playing the role so soulfully.

Here are a couple of thoughts I hope are useful to you as you try to deliver great care to your patients and as you encounter crucial conversations with doctors about clinical issues.

First, be sure to have the right conversation. The issue you’re describing is much broader than one doctor who has an idiosyncratic way of treating patients. Your problem is that you work in a system that allows for idiosyncratic clinical practices in some cases rather than demanding evidence-based protocols. You should be having conversations with the appropriate clinical leads about the pattern of decision making you see in relationship to fistula readiness. Do your best to point out inconsistencies in practice and to gather data about best practices to try to influence protocols—not just one doctor.

Second, let’s talk about this doctor. You would know better than I that there is much in medicine that is still uncertain and subject to judgment calls. I’m not smart enough about fistula preparation to say whether this is an open or shut issue or not, so let me make a more general point. Your biggest challenge in holding crucial conversations in somewhat ambiguous areas is to ensure that you don’t let your motives move from “patient advocacy” to “being right” or “winning the point.” As you approach this doctor, do so with an open mind—where you’re prepared both to share your data and to learn about issues you might not have considered. If you approach him with a goal of mutual learning, you will not come across as smug (which might be particularly tempting when you know the patient went to another center that agreed with your recommendation). Instead you will come across as curious, interested, and honest.

Third, you can’t have this conversation with him if he doesn’t want you to. You’ll need his permission. Realizing that you should seek his permission to have the conversation will put you in the right frame of mind to make it safe. As you and I both know, the doctor is the final decision-maker in clinical questions. If you respect that fact, and don’t measure his character by whether or not he agrees with you, you’ll come across as far more respectful. As a result, he will feel safer with you. For example, you may create safety by proposing the conversation the following way:

“The other day you and I disagreed over whether a patient’s fistula might be ready for access in less than three months. I’ve thought about that a lot since and wonder if you’d be willing to talk with me at your convenience so I can understand that better. I want to work with you well and I also want to do what’s right for patients. I’ve had some experiences that make me question the three month rule and would benefit from airing those with you as well as having you challenge my thoughts. Would you be willing to spend a few minutes with me on this?”

Finally, before having this conversation, do your homework. Gather evidence whether it confirms or disconfirms your beliefs. As you engage in the conversation, lay out this evidence and allow the conversation to take you to whatever conclusion best serves your patients and his.

Thanks again for your commitment to serve. If my kidneys ever fail I’ll come looking for you!

Joseph