Nephrology Attracting Fewer Doctors

Fellowship positions go unfilled as the US faces expanding population of kidney disease patients.
Fellowship positions go unfilled as the US faces expanding population of kidney disease patients.

Researchers expect the population of patients with kidney disease to swell in coming years as a result of a growing elderly population, increasing diabetes incidence and prevalence, and other factors. The trend has raised concerns about whether the nation will have sufficient nephrologists and other kidney care specialists to keep pace with—and provide quality care to—this expanding population of complex patients. A report titled “US Nephrology Workforce 2015: Developments and Trends,” which was prepared for the American Society of Nephrology (ASN), noted that “changes in the general health care system and delivery of kidney care make it unclear how increases in need will be translated into demand for nephrologists.” If the demand does increase, however, the country may not have enough young doctors entering the subspecialty to meet it.

The number of medical residents filling nephrology fellowship positions has been declining. For example, the proportion of filled nephrology fellowship positions dropped from about 91% in 2012 to 89% in 2013, 76% in 2014, and 68% in 2015, according to the National Resident Matching Program Specialties Matching Service.

Lack of innovation

Reasons for the relative lack of interest in nephrology are varied and speculative. Ruediger W. Lehrich, MD, director of the nephrology fellowship program at Duke University Medical Center in Durham, NC, offered some possible explanations. First, nephrology may not be viewed as an innovative field, at least not like such popular subspecialties as oncology and cardiology. “It might be perceived by applicants that nothing really has happened in nephrology for a long time,” Dr. Lehrich told Renal & Urology News.

Even though dialysis has improved, it is has not change dramatically in decades. Fewer “breathtaking” trials take place in nephrology, and many yield negative results, he said.

Perceived inadequate pay

Another reason for nephrology's relative unpopularity may be the view that nephrology does not measure up to other subspecialties in terms of compensation, said Dr. Lehrich, adding that this is a misperception. “I think nephrologists are very, very handsomely compensated,” he said.

Young physicians may see nephrology as particularly demanding, with obligations to travel to different dialysis units and hospitals to provide care, as well as frequent call duty. “I think it is perceived that the compensation does not match up to the heavy workload and the limitations as it pertains to lifestyle,” he said.

A third factor that may discourage interest in nephrology may be the stringent regulatory burdens imposed on nephrologists by the Centers for Medicare and Medicaid Services (CMS) and the large dialysis providers, Dr. Lehrich said.

Lastly, Dr. Lehrich noted that foreign medical school graduates historically have gravitated toward nephrology, perhaps because they find obtaining a fellowship position in this subspecialty less competitive. The number of these international graduates is shrinking, however, possibly because the number of US medical school graduates is nearly identical to the number of  PGY 1 positions, “meaning there is less room for foreign graduates to train in the US,” Dr. Lehrich said.

Skewed view of nephrology

In response to declining applications to nephrology fellowship programs, the ASN's Workforce Committee began looking at the trend systematically about 5 or 6 years ago, said committee chair Mark G. Parker, MD, nephrology division chief and nephrology fellowship director at Maine Medical Center in Portland and clinical associate professor of medicine at Tufts University School of Medicine in Boston. The committee started out by surveying fellows, residents, and medical students and found that the content of nephrology education and perceptions of the balance between professional obligations and personal life contribute to a negative view of nephrology. Committee members speculated that students and residents were getting a skewed view of a day in the life of a nephrologist, Dr. Parker said. Many institutions were giving students and residents narrow clinical experiences, exposing them mostly to acute care inpatients and dialysis populations, especially subsets of those populations that were most critically ill and frequently using acute care services.

“Students and residents weren't really seeing the full breadth of what we do in nephrology in the outpatient realm, in the transplantation realm, and interventional nephrology realm,” Dr. Parker said.

Another negative view of nephrology that emerged from the surveys was that the subspecialty is not adequately compensated, he said. “The perception is that nephrologists work harder, but for relatively less money,” he said.

Programs to inspire interest

Through the workforce committee, the ASN started programs to inspire students “about the exciting things that there are to do in nephrology,” Dr. Parker said. The major program is Kidney TREKS (Tutored Research and Education for Kidney Scholars), whereby medical students are invited to a scientific retreat at Mount Desert Island in Maine, near Bar Harbor, for about a week. Students take a course at Mount Desert Island Biologic Research Laboratory called “Origins of Renal Physiology.” In addition, the students are matched with a nephrologist mentor at their home institutions who will interact with them over the course of medical school, graduate school, or postdoctoral training.

“That's been so successful in our estimation that the ASN has invested more funding into it and we're now going to have a second site for students to consider as an option at the University of Chicago,” Dr. Parker said.

Another ASN program is Kidney STARS (Students and Residents), which is held in conjunction with Kidney Week. The goal is “to stimulate interest in nephrology careers by targeting medical students, residents, and graduate students with an interest in nephrology but have not yet committed to applying to a fellowship,” according to the society's website.

A third program is Kidney MAPS (Mentor and Assessment Program for Students), aimed at promoting interest in nephrology through student-organized community screening programs.

“We developed all of these programs to try to grab students at the earliest levels, at the earliest stages of their training and nurture their interest in nephrology,” Dr. Parker said.

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