Is Dialysis Nephrology's Original Sin?

Abstract

The introduction of hemodialysis in the 1960s, and the subsequent enactment of Medicare coverage in 1972, came to shape the evolution of nephrology as a specialty. The subsequent focus on dialysis care as a principal form of reimbursement led to a host of benefits and challenges for nephrologists. While the specialty initially enjoyed great popularity and exponential growth, a widening schism between researchers and clinicians developed. This limited the growth of robust clinical research in nephrology, while dialysis care encumbered clinicians with exhausting travel, routinized rounding schedules, and burdensome navigation of electronic medical record systems. Poor morale and burnout among practitioners, coupled with the ethical issues associated with corporatized medicine have resulted in severe challenges for the specialty including difficulties with recruitment. The history of nephrology elucidates the convergence of medical science, public policy and corporatization, while providing a lens on the wider issues of contemporary American health care. Ongoing efforts to refocus nephrology on preventive care in chronic kidney disease, new diagnostic and treatment modalities, and shifting of dialysis care to non-physician providers should be accelerated.