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“My first patient at WVU had driven here from Elkins to see a nephrologist,” recalls Rebecca Schmidt, D.O. “Little did I know how telling this experience was and how deeply ‘rural nephrology’ would impact my life.”
In 1993, when Dr. Schmidt saw her first patient at WVU, she was fresh from Henry Ford Hospital in Detroit, Michigan, and had no experience with patients who had to drive for hours to see a specialist.
“I thought ‘It would be nice if we could go to them,” she said. And go to them she has. She’s now the leader of West Virginia University’s Rural Nephrology Initiative, which brings chronic kidney disease clinics to the patients.
When she became the chief of the Nephrology section in 2001, Schmidt was finally able to move forward with her goal. “We started a chronic kidney disease clinic in Elkins in the back of another doctor’s office. We had no nurses, no copy machine, and no money. We used a cell phone to communicate.”
Schmidt reports that the nephrology section had more than 750 new patients from July 1, 2004 to June 30, 2005, with approximately 350 at the Physician Office Center (POC) in Morgantown, and the remainder at the outreach clinics. Clinics are located in Elkins, Fairmont, Buckhannon, and Moorefield, a Veterans Affairs clinic in Clarksburg, and in Cumberland and Oakland, Maryland. Another will open soon in Bruceton Mills. More than 4000 return patients were seen, with more than 1500 visiting the rural clinics.
“Each clinic site is different. There is no cookie-cutter approach to starting these clinics," she said. "The approach we take when opening a clinic is based on the resources that are available at each particular site.” At the POC and the Elkins and Fairmont clinics, a nurse practitioner sees some patients regularly, while either Schmidt or Bethany Pellegrino, M.D., oversees the care and sees the patient less frequently. Nurse practitioners are being incorporated at the other clinics.
Dr. Pellegrino, a West Virginia native who completed her undergraduate degree, medical school and fellowship at WVU, says one of the challenges of opening a new clinic is getting the word out to patients and doctors. "Alerting the local physicians to the new clinic, letting patients know that they can stay in their own area for treatment, allows us to help as many people as possible."
Schmidt says another challenge is being fiscally responsible with the new clinics. "We have to operate efficiently enough to not lose money, but we have to provide vital care to patients, and we like to do it in a family-like atmosphere."
Nearly 19 million Americans have some degree of kidney disease, Schmidt said, and many don’t know it. “The biggest problem with kidney disease is that it often has no symptoms. There are some warning signs, but many people don’t have any physical symptoms until the kidney damage is already done.
“In West Virginia, there are more than 50,000 cases of moderate to severe loss of kidney function,” she added. “Another 400,000 people suffer from mild loss of function. And many of these people don’t even know their kidneys aren’t working correctly.”
Schmidt is a graduate of the University of Osteopathic Medicine & Health Sciences in Des Moines, Iowa. She completed her residency in Internal Medicine, as well as fellowships in nephrology and clinical research at Henry Ford Hospital in Detroit, Mich. She is a member of the American College of Physicians, the American Society of Nephrology and the Renal Physicians Association.
According to Schmidt, the majority of her rural patients would like to avoid a regular drive to Morgantown. “I have patients that come to the Elkins clinic once a month for lab work. It’s a two-hour drive from Elkins to Morgantown. Many of my patients don’t have a car that they trust to make that trip, or a car at all. Some can’t afford the gasoline to make the trip. In some cases, their family doctor treats them, and in others they just forego treatment altogether. By bringing the clinics to them, we can help them maintain some kidney function, and possibly head off dialysis.”
“Primary care physicians have so much to worry about,” Pellegrino said. “They care for patients with diabetes, heart problems, and every other health problem. Chronic kidney disease has its own set of problems – anemia management, electrolyte problems – that can be overwhelming for a primary care doctor. By identifying and treating patients early, we can do what is necessary to protect kidneys and prevent the disease from progressing.”
"What impresses me about this program is how grateful the patients are that we are bringing this clinic to them," Pellegrino said. "About half of our patients at the clinics are new diagnoses, while the other half used to come to Morgantown for treatment."
Yvonne Farnsworth had a kidney transplant in May 2000. She had polycystic kidneys, and was on dialysis for 13 months prior to the transplant. Before the Elkins clinic opened, she went to Morgantown for follow-up laboratory work once a month. "That was an hour and a half drive," she said. Now she makes the 30 minute drive from Buckhannon once a month to see a nurse practitioner, and sees Schmidt every two to three months.
In addition to teaching patients the best way to care for their disease and working to prevent further loss of kidney function, anemia management is an important facet of the chronic kidney disease clinics. “As the kidneys decline in function,” Schmidt said, “their ability to produce the hormone erythropoietin declines, and the bone marrow is thus not signaled to make the red blood cells that carry hemoglobin. It is a challenge to maintain the hemoglobin within the target range, and requires serial blood tests, including iron testing and constant monitoring of the EPO dose.”
Roy Haddix of Buckhannon is one of the lucky patients, says Barbara Weaner, nurse practitioner at the clinic. "He has been in renal recovery since 2002, which is very rare," she said. He visits the Elkins clinic once a month for follow-up tests.
"These people here are a godsend," Haddix said. "I couldn't have been treated better."
“My dream, my goal, my charge is to decentralize the care of kidney disease,” says Schmidt, “heighten public awareness of kidney disease as an escalating health problem and place West Virginia in the lead of the quest to improve outcomes for these patients.”