Fewer medical graduates are applying for nephrology fellowship training, and I see this as a workforce crisis. Today, of more than 400 fellowship positions across the nation, some 40% remain unfilled when match results are announced in December of each year. More than half of training programs have had at least one unfilled position. Although my nephrology program at the University of California Irvine has never had unfilled matches, this does not make me feel relieved about the challenge of attracting new doctors into nephrology. The workforce crisis in nephrology could have a domino effect on many aspects of patient care.
The United States has some 8000 adult and 500 pediatric nephrologists who are engaged in patient care or related positions. Each year, some 300 to 400 young physicians complete nephrology training and enter the market and a similar number of senior nephrologists retire. The annual median nephrologist income ranges from $180,000 to $240,000, which is not very different from average internist income in this country but, believe it or not, it is 50% to 100% lower than the median income of a nephrologist in Canada, although it is higher than Germany, United Kingdom, and Japan.
The rise of the hospitalist field and its relatively luxurious income and work hours has affected subspecialty training in internal medicine. It is heartbreaking that many internal medicine residency graduates tend to conveniently embark on a hospitalist position without any interest in a subspecialty. In nephrology, revenues appear to have declined by 5%–10% or more over the years. Many nephrology groups tend to hire nurse practitioners (NPs) and physician assistants (PAs) for such responsibilities as weekly dialysis clinic rounds. This has likely resulted in diminished demand for nephrologists. Recently I was surprised to learn that the private practice group I used to work with has downsized from 20 to 22 nephrologists down to 15 nephrologists and hired more NPs and PAs.
With regard to a shortage of new doctors entering nephrology, I believe we have reached the nadir. In coming years, we should see increasing interest in nephrology. Ongoing growth in the dialysis population from better patient survival will improve nephrology job security and many hospitalists return to subspecialty practice—including nephrology—after a few years of training gap.
Efforts should be directed at making nephrology more appealing. This can be done by strengthening sub-fellowships in kidney transplantation, glomerulonephritis, interventional nephrology, and even certification in dialysis therapy and techniques (as in Japan). Adding combined fellowships in critical care, rheumatology, and endocrinology can result in more triple board-certified nephrologists. Combined medicine/pediatric residency graduates should be encouraged to consider dual fellowships in nephrology for children and adults to expand the pool of quadruple board-certified nephrologists. Together, we can make nephrology even more popular than before.
Kam Kalantar-Zadeh, MD, MPH, PhD Chief, Division of Nephrology & Hypertension, Professor of Medicine, Pediatrics and Public Health, University of California Irvine School of Medicine.