Tufts-New England Medical Center concentrates on providing a kinder, gentler form of dialysis.
Dr. Klemens Meyer was seated in his Boston office recently, talking with a reporter about the challenge of providing dialysis humanely under the economic pressures of contemporary medicine, when a message came over the pager he held in his hand. "Oh, I see the morning mail has arrived," he said, brightening. "I had better get over to the unit and see if it contains any checks we should deposit."
Things are tough all over, but you can’t sniff around dialysis for long without bumping into economics. That’s because dialysis—the whole intricate business of hooking patients with end-stage renal disease up to a machine that will do the blood-filtering work of their failed kidneys and help prolong their lives for months and years—can easily lose money for non-profit inner-city operations like those at Tufts-New England Medical Center, which for the past 15 years has been run by Meyer, associate professor of medicine within the Division of Nephrology.
Medicare and Medicaid pay for most of the care in the Tufts dialysis operation and others like it. Back in the early 1970s, the U.S. government set up a Medicare payment plan to cover the costs of dialysis. Unfortunately, its fee schedule has remained essentially unchanged, with hardly any adjustments for inflation, since then.
"Most dialysis units in the United States are run by for-profit companies and make a gazillion dollars," says nephrologist Dr. John T. Harrington, dean emeritus of the medical school, who opened the first such unit at T-NEMC some 35 years ago. "We don’t—we’re the good guys." The T-NEMC outpatient dialysis unit is run by Dialysis Clinic, Inc. (DCI), the nation’s biggest non-profit provider of dialysis services.
Meyer and his nurses are swimming against the tide, and shining. Despite the handicaps of an inconvenient location, an aging physical plant and stringent budgeting, they have managed to provide exemplary levels of care to patients who are, in most cases, nearing the end of their lives. (The average life expectancy of a patient beginning dialysis is five or six years.) "We are not pretty—we could use a new floor—but I think we do a great job," says Connie Bruno, R.N., assistant manager of the unit.
An industrial process
Meyer describes dialysis, which first became available to desperate renal patients in the mid-1960s, as an "industrial" process whereby people are hooked up to machines in a public space as though they were on an assembly line. He’s right about that. The dialysis unit at T-NEMC has 24 dialyzing stations aligned in rows, the DCI facility in Concord (though newer and cushier) has 16 stations, and both places are nearly identical in the way they look and feel. The sound track at either site consists of a faint shhh-thwock as the machines do their rhythmic work, moving like clocks or pistons.
In dialysis, people are connected to machines for exorbitant amounts of time. A typical dialysis patient is obliged to spend three to four hours a day on the machine, three times a week, indefinitely. Because of the highly technical and prolonged nature of the patients’ treatment, any human kindness shown those patients matters all the more.
Dr. Meyer comforts a patient.
"We try to foster a treatment environment in which people feel taken care of," says Meyer, a slender man with pale blue eyes and wisps of gray hair at his temples, standing with his arms folded. "We want to have an ethos among our staff where they feel their role is more than just hooking up the patient and switching on the machine, because our underlying belief is that patients benefit from having people get to know them over the years they’re in our care."
Continuity of staffing means everything. Owing to the emotional toll built into the job, the tendency among dialysis workers is to get a taste and then move on. In contrast, Meyer proudly notes that Jean McCorry, R.N., staff nurse at the T-NEMC unit, has been there for 31 years; Bruno has 25 years to her credit—and their dedication is not atypical. Even technicians in the unit boast a median tenure of nine years.
"We have people who are dedicating their whole lives to this work," says Meyer, who was named "Outstanding Physician in Nephrology" early this year by the New England branch of the National Kidney Foundation.
On the unit
For a visitor, the dialysis unit at T-NEMC is worn and comfortable feeling, like a pair of old shoes. It’s not, as you might expect, a scary place to be. Lined up in their widely spaced giant chairs, the patients getting treatment resemble nothing so much as passengers on the deck of an ocean liner. The atmosphere is calm, punctuated by the soothing, barely audible rhythm of the blocky, whirring machines.
Because of the mortality that shadows patients, Bruno and McCorry have witnessed the demise of many old friends. Life spans of individual patients may be unpredictable—"We’ve had some people come in at age 75 and go 10 years," says Bruno—but the actuarial tables generally rule. According to McCorry, one of the sober underlying missions of her job is to help patients die with dignity. "We try to do well with that," she says. (continued)
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