When is the right time to request a Nephrology eConsult?
Ankit Patel, MD, PhD. Nephrology Specialist at AristaMD
The question does come, “Well, when is the right time?”, And I would say that I would ask yourself when you’re considering whether it should be appropriate to have a nephrology referral either through an eConsult or in person. Does the patient have any comorbidities or unusual features that make you concerned that this is something that’s potentially rapidly progressive, certainly that would require an urgent in-person chronic kidney disease? Is there something about the patient where they don’t have diabetes or hypertension and their kidney function is, is kind of stable, but it’s it’s not normal and they have a little bit of proteinuria and you’re unclear, well, what is the cause of the chronic kidney disease? It is helpful to get either an eConsult or in-person consult to think through what are any other diagnostic workups that may be helpful.
Another piece is, well, is there anything with the chronic kidney disease that I’m having difficulty managing? Is the anemia challenging to manage or is their PTH high? Are they having hyperkalemia that I’m having trouble managing? I think hopefully the nephrology consult can be helpful, in terms of ongoing management. And then lastly, if a patient is approaching and progressing, I like to think that at least by CKD stage three B, so if their eeg FFR is between 30 and 45, we start thinking about planning in the setting of, well, are they potentially a transplant candidate? Making sure that we get the patient referred to a transplant center or a kidney transplant evaluation when appropriate. Would they consider dialysis and do they understand what dialysis is? What the different forms of dialysis are and what goes into them? What kind of preparation needs to be done in advance for any of those specific forms? Thinking about hemodialysis and the preparation of having an AV fistula, and evaluated to ensure it’s capable of being utilized. These are all pieces that we think of as considerations of why we may want to include nephrology in our CKD patient management.
Improve Patient Access Management and Support Advanced Practitioners
Patient access management is currently a high priority due to a short supply of providers. Merritt Hawkins reports that the average wait time for a specialist appointment is 26 days. In numerous metro areas and specialties, patient wait times exceed 100 days. With a flood of patients overdue for care, states are turning to nurse practitioners (NPs) and physician assistants (PAs) to improve access to primary care.
What’s Causing the Healthcare Staff Shortages?
According to the U.S. Bureau of Labor Statistics, of the 4.5 million people who quit their jobs in November 2021, 6.4% were healthcare and social assistance workers. That’s one of the highest quit rates in any industry, second only to accommodation and food services. Burnout rates among healthcare workers are also skyrocketing. Major news outlets have reported that many doctors are exiting the field completely.
This exodus comes at a time of high appointment demand, with rebounding patient volumes in hospitals and health systems from people who put off care during the pandemic. As healthcare providers leave the workforce, the ability of APs to provide unrestricted care is expanding to fill the gap.
In 2020, California tackled the primary care provider shortage by passing a law to allow nurse practitioners to practice without physician supervision after meeting certain criteria. The timely passage of this legislation will help address an expected shortage of more than 4,000 primary care physicians in the state and reduce the number of patients waiting for care because of the pandemic.
Advanced practitioners (APs) in 25 states and the District of Columbia care for patients with minimal limitation or supervision by physicians. In these States, NPs and PAs are supervised by a physician for a defined period of time before being able to practice independently. In states that limit the ability of APs to provide care, physician supervision is generally required for the duration of the AP’s career.
Ankit Patel, MD, PhD
Nephrology Specialist at AristaMD
Ankit B. Patel, MD, PhD is a board-certified nephrologist who completed his MD at Weill Cornell Medical College and PhD at Weill Cornell Graduate School of Biomedical Sciences. He completed his internal medicine residency at Brigham and Women’s Hospital in Boston and his Nephrology fellowship at the combined Brigham and Women’s/Massachusetts General Hospital Fellowship. His clinical interests remain broad in adult nephrology and include acid-base and electrolyte disorders.