Dr Fuquay. I am so glad that we’re gonna get to sit down together today and really walk through the journey of what it would be like to be a new patient with Dallas nephrology associates, and also what that relationship looks like as you continue the relationship between the DNA care team, as well as the primary care physician. So how can a patient really be prepared for that first visit with a kidney doctor or a nephrologist?
Dr. Fuquay (00:28):
Okay, good question, Bri. Thanks for having me. I would say always writing down questions is a good move for a patient and that’s across the board. A lot of times patients are wondering why they’ve been referred to the kidney doctor and that’s a fair place to start. And so usually the first five or 10 minutes of the appointment, we’re just reviewing lab work and answering the question of how did you come to be here? And one of the challenges in our field is not a lot of symptoms discussion, and a lot of it revolves around lab work. And so we usually start the first few minutes breaking down that lab work and just establishing why they’re here and what kidney disease is.
Yeah. What this means. Here’s what your labs are. Here’s what this actually means. Well, I feel like I should probably have backed up what exactly does a nephrologist? What is a nephrologist?
Dr. Fuquay (01:19):
A nephrologist is a medical specialist, not a surgical doctor. And we manage people with low kidney function, which could be chronic kidney disease, which is a long term problem or acute kidney injury in the hospital. And we also manage patients with difficult blood pressure and electrolytes. But I think today we’re gonna be talking about chronic kidney disease or CKD. And what that means is a long term reduction in the filtration of your blood by your kidneys.
And so knowing that, I mean, what actually happens, we talked about the first visit and how they can prepare right. Like you mentioned, asking questions. I can imagine a lot of that is, I don’t know what I don’t know. So I’m sure they’ve come equipped with Google, Google recommended questions. So what actually is happening, you know, what types of exams and tests have been performed up until that point?
Dr. Fuquay (02:12):
Most commonly a patient comes to us when the PCP sees an elevation in the creatinine. And what I always explained is creatinine isn’t that important in and of itself, but it’s a handy marker for us to see how well the kidneys are filtering the blood. And if that number is elevated, that means that we may have a problem. And and then what I’m seeking to do as a kidney doctor is identify what could be reducing your kidney function and fix everything that’s fixable and manage that reduced kidney function and hopefully stabilize it, keep it from turning into a serious or progressive problem.
And so do you really feel like you have to walk them through, you know, in a step by step manner of here’s what each of these labs, you know, again, this is the first time they’re hearing probably some of these words in terminology,
Dr. Fuquay (03:00):
We walk through logically starting with the serum creatinine. There may be other labs that they come with urinalysisestimation of albumin in the urine or protein in the urine. They may have a kidney sonogram, and even if they don’t have those things, it’s still a good jumping off point. And I’m gonna order those tests to fill in the gaps and paint a picture of what’s going on with their kidney health.
I can imagine from working with a primary care physician, some people have never seen a specialist before. Do they have some of those questions initially? Like what does this mean? I’ve only worked with my general practitioner.
Dr. Fuquay (03:41):
Absolutely. A lot of people are really anxious when they show up in our office. And the first question they say is, does this mean I’m gonna need dialysis? And so a lot of times I take that one head on and the vast majority of the time I can say, no, this is very unlikely to lead to dialysis or transplant, or I think that’s a low risk sort of scenario. And here’s what we need to do to figure out what’s going on. But I like to try to take that head on, because I can see a lot of anxiety in the first five minutes.
Right. And then it ends up clouding the rest of the, the appointment because they’re not sure just where things are gonna end up going. You’re right. I can imagine. Well, and so who else is a part of their care team, you know, as from, with DNA.
Dr. Fuquay (04:25):
So besidesthe nephrologists that they see we have nurses that help the patient and really run our office. We have a nurse navigator who often helps coordinate care and pull together. We have dieticians that we arrange consultation with as needed and, and then there’s other specialists in certain situations, but, but really it kind of, it’s a whole team approach and the nephrologist is, one part of that team,
Absolutely. With the one mission of slowly either, you know, in ensuring that the decline, the progression or decrease the progression
Dr. Fuquay (05:05):
Slow or halt that progression is the goal.
So do you have any other thoughts that you’d like to share if somebody is listening right now and, you know, has just gotten a referral from a primary care physician that what they need to be prepared for, you know, in moving into that journey, working with nephrologists?
Dr. Fuquay (05:23):
I mean the first step is come to the appointment show up, bring a family member when you can, because two heads are better than one. Even when I go to the doctor, sometimes I walk out the door and then I suddenly realize, I don’t remember the conversation or all the details of the conversation I just had. Bring your medicines in the bottle. The actual pills is really important. And I, that seems so simple and kind of too simple, but I think that’s really important.
I would not have thought of that. I don’t think, if I look at myself as a patient, I’ve never had to start asking you about any medication that you’d take. And that’s the point where you’re either trying to scramble and remember it, or you’re trying to open up your notepad.
Dr. Fuquay (06:05):
The plastic bag with the actual pill bottles is the best way to go, because then you’re not calling your family and saying, would you read to me the bottle that’s on my dresser? And you’re also not relying on a med list from another doctor’s appointment from seven months ago. And it’s a safety issue. If we don’t really know what meds you’re on, I’m very nervous about prescribing anything or adjusting anything because I don’t know exactly what I’m doing.
Yeah, absolutely. And so obviously once they’ve come to see you and they’re starting that journey and you’re having this conversation with about their new care plan specific to chronic kidney disease what does the relationship then look like with their primary care physician?
Dr. Fuquay (06:43):
I don’t think it changes that relationship at all. They still are gonna be seeing their PCP regularly and the PCP is still the point person for their health. And I’m not trying to replace that or change that in any way. And I’m really focused on, on anything that touches on their kidney health and their, and their blood pressure in particular other medical problems, including diabetes really remain under the control of the PCP. So I’m not trying to overtake that.
And why do you think that’s important though, to try and not overtake that right. Where you’re, you’re not trying to just say that you only need to listen to me. Why is it important that they continue that?
Dr. Fuquay (07:20):
I’m not a PCP, so I’m not doing everything for that patient. I’m not keeping track of colonoscopies and PSAs and they still need the PCP to do that. Additionally, they have usually years of track record with that PCP and that’s something I don’t have. So I’m not, I don’t take away from that or replace that. And so they want to stay totally up to date with their PCP.
What do you feel like are generally some questions that you’re asking patients in order to get to know them better and build that relationship with them? Because I can imagine a big piece of, you know, some of these early appointments is establishing trust and getting to know them. We’ve talked about in some other episodes and conversations that, you know, not only is every patient different in their care plan, going to be very customized to them, but it’s also the way that they learn and adapt to the new information can be different as well. So what types of questions do you like to ask patients?
Dr. Fuquay (08:21):
I’m really asking about their medical history first and foremost. So trying to get all the risk factors, which starts with diabetes and hypertension, but it may be past medications, past hospitalizations and really get a sense of not only what medical problems started when and how they’ve been treated, but, but how did the patient adapt to all that? And were there times at which things were simply overwhelming or out of control or has this always been a pretty you know, pretty under control process and get a sense of the patient’s health and sort of a trajectory of like, is this person, you know, doing a a good job of dealing with the set of medical problems they have or are things accelerating or snowballing and how’s this patient doing in the long view.
Being able to try and understand where they’re at and meet them where they’re at, because I can imagine if you feel like there is some sort of snowball, or there’s not being things that are not being addressed, that you want to figure out how you can work with them to alter that.
Dr. Fuquay (09:21):
Sometimes I have a meeting or two with a patient and an appointment or two, I should say, and, and I get the sense, this person is really clicking and they understand everything that’s going on. And sometimes I say, wow, let’s back up a little bit. And sometimes we’re talking about medical problems and kidney health and trying to fill in gaps and make sure they really understand what’s going on with their.
Well, and so can the health once diagnosed with chronic kidney disease, can that be improved or, you know, can the progression be slowed?
Dr. Fuquay (09:56):
Yes. So there’s tons of patients we see in the office who have chronic kidney disease that turns out to be non progressive and they have a stable creatinine for years or decades. And really, it turns into a relationship of checking in, reassuring them, educating them about things to look out for. But they do not have progressive CKD. And that’s wonderful.
So if someone does have progressive chronic kidney disease, what’s one of your goals in working with them in their appointments.
Dr. Fuquay (10:27):
Good question. And and so this is, this is the more complicated patient we’re, we’re gonna be having more appointments with them at probably a tighter interval and goal. Number one is medically. I want to figure out what’s the cause for that and fix everything that’s possible to slow down that process. And, and that in it of itself may take multiple encounters. It may take lab work. It may take more imaging in certain cases, it takes a kidney biopsy, but it’s, it’s it’s not a one shot. Yeah. And then, and then for the patients that seem to be on a trajectory towards progression, we’re trying to lay out a game plan and come up with a strategy for success. And it’s not a one shot thing. It’s gonna be a conversation over multiple encounters, multiple appointments. And coming up with a plan that will set them up for success and a year or two years or more years in the future. And that’s, you know, talking about the pros and cons of transplant, dialysis, different forms of dialysis, conservative management in this whole range of ways we take care of kidney patients.
I can imagine when you are having those appointments, do you have someone who’s coming to you and they’re sitting with a binder, like being able to keep all this information sounds tricky.
Dr. Fuquay (11:42):
It is. And some patients bring their own binder. Some patients who are going through CKD education, which I’m super proud of the way our practice has innovated in that area. And they have a binder that’s part of that. Oh, perfect. But, but yeah, whether they have a binder or they don’t have a binder where we’re building a picture and a game plan for how we’re gonna take care of you in the long run.
Yeah. They ultimately, you can have the game plan, but it’s a matter of being able to build on it in each appointment saying, okay, this is where we left off last time. This is where we need to address today. And so if they don’t have progressive CKD and I honestly didn’t realize that there, you know, that there were some of those cases, I’m not sure if, you know, you know, off the top of your head, what’s a percentage of differences between how many do have progressive versus non progressive.
Dr. Fuquay (12:26):
Well, I, I don’t know a number for you. The most patients who have CKD three will never end up on dialysis, but let’s just start right there. Yeah. And dialysis is what scares a lot of people and with good reason. But most patients who start in our office with CKD stage three will never see the inside of a dialysis clinic. And so and so there’s a lot of sort of preventive care and reassurance that takes place with all those patients. Then we do have, you know, a different relationship with the patients who do have progressive CKD and are gonna ultimately need renal replacement therapy, which could be dialysis or transplant. But, I can say that most patients who come to see me for the first time ever are never gonna see the inside of a dialysis clinic.
I ask that because I can imagine there’s absolutely a part of the population that may only see their primary care physician once a year. And that’s for an annual, you know, an annual checkup. And so if all of a sudden they’re being referred to a specialist, you know, how does that relationship change? Do you expect to see them? You know, let’s say they have non progressive CKD, do you still expect to see them once a quarter or that relationship look like?
Dr. Fuquay (13:36):
Well initially I see once quarter like it’s business, but I’m gonna see people frequently, but, but for the non progressive patients, we space out to six months and 12 months. And I try to not over doctor people and if, if they’re doing well and everything’s under control, I’m gonna see them only as much as I need to, honestly keep an eye on things.
Yes, absolutely. Well, and so what are the methods of being able to, to improve their health or to slow that progression? What are some of the different ways that can happen?
Dr. Fuquay (14:10):
Starting with lifestyle, you can never overemphasize lifestyle. So daily exercise, healthy diet overall good, healthy habits is so important within that blood pressure. Okay. And so we spend a ton of time on blood pressure. And one of the things I say quite a lot is let’s, let’s keep it simple blood pressure, blood pressure, blood pressure. Mm. And the first order of business is let’s get that pressure within guidelines and reasonable people can disagree about what are guidelines for different groups of patients. But I want to get all the patients to, to a decent blood pressure that I feel is safe.
I can imagine a big piece of that is then stress. And then it’s like stress related to blood pressure. I can imagine is a big piece of the conversation.
So when should a primary care physician schedule or start working, you know, work to obtain a nephrology consultation for their patient? Sure.
Dr. Fuquay (15:12):
So if somebody has elevated creatinine with an estimated GFR under 60, they should come see us. And if they have an album into creatinine ratio, that’s more than what we call severely increased, or more than 300 milligrams per day on an estimation, they should come see us. And there’s more gray areas I’m mean you can disagree about other patients, but those are things that I can confidently say would be a reason to come see the kidney doctor. But I think that anytime that the primary care doctor is unsure or uncomfortable with state of a patient’s either creatine or blood pressure or analysis, they should come see us.
You know, something, I imagine let’s say chronic kidney disease happens to be in the family, or you’re a patient. And all of a sudden. your friend or family gets diagnosed with CKD. And all of a sudden, you know, they’re saying to their primary care physician, have we ever looked into this? Is this something that I should get checked out as well? And let’s say that that primary care physician decides, you know, no, I haven’t seen any signs of it. Is it something that they’re able to come to you directly, like, say for some reason they have these concerns and they just kind of wanna check the box that it’s not an issue.
Dr. Fuquay (16:24):
So you’re saying, can a patient self refer if they’re concerned? Yeah. They can do that. That, that’s a pretty rare thing. I would say 98% of patients who come to me are referred by the PCP or sometimes by after a hospital study, that’s another scenario. But self-referral does happen. It’s not super common, but yeah. If, if you have, if you have some concern about either lab work or blood pressure, then we would be happy to see.
No, it was more, just a matter of if you’re sitting there with your PCP and having the conversation and there, you know, I think as a, you go in and you’re kind of hoping that your PCP, for example, is doing all the right tests. I’m kind of like, I’m open to the tests. I’m free to do the test, to check it off. That it’s not an issue. You know what I mean? To make sure that we are good. So other than that, you know, I’d love if you have any lasting thoughts about what it is like, you know, either being a new patient or maybe you’ve been working with a nephrologist for, for years, how to continue or maybe improve their relationship with a nephrologist or improve their relationship overall with their healthcare team.
Dr. Fuquay (17:29):
I think communication is so key with all your doctors and in today’s healthcare environment. We don’t have tons of extra time. I, I wish we had all the time in the world, but we don’t. And making those visits high yield by having your questions written down ahead of time and being ready to have that conversation. And again, the little things, it sounds so basic, but pill bottles with you and a family member with you. If you can swing, it is gonna really help.
I’m so glad you mentioned that. I think those are, like you said, they may seem straightforward, but those are really sounds like important pieces of advice that we need to be taking into account. So I’m incredibly grateful for your time. Thank you for spending sparing the, the few moments that I’m sure that you do have with, with us today.
Dr. Fuquay (18:09):
Likewise. Thanks for having me. Appreciate it.