CHOOSING NEPHROLOGY: The View From Fellows

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As the new academic year begins, nephrology fellows beginning their adult nephrology training can look back at the application process with a unique perspective compared with previous years’ fellows. They are the first class to enter the fellowship through the National Resident Match Program. The match has been considered a success in the fellowship community (Kohan and Rosenberg, 2009).

As one applicant cycle has closed, however, fellowship directors begin thinking about the recruitment process for future years. Given the projected shortage of nephrologists (Rosenberg, 2007), fellowship directors wonder if the pool of high-quality applicants will continue to grow. Pediatric nephrology fellowship directors face the same concern about the number of high-quality applicants.

Resident physicians are influenced by many factors as they consider whether to enter nephrology: developing a good understanding of the kidney’s complexities, being exposed to the field early in their educational training, and addressing the personal challenges of balancing family versus fellowship.

Why nephrology?

If you are reading this article, you will most likely agree that nephrology is the best organ system to study. What is the thought process that leads to this conclusion? Simple: “The kidney is the smartest organ in the body,” says Abha Harish, MD, a first-year nephrology fellow at the University of Alabama, summarizing the general consensus among recent graduates of internal medicine and/or pediatric residency.

This love for the intricacies of the kidney is what inspires many to study nephrology. For these individuals, the cerebral side of nephrology—the complexities of acid/base disorders, electrolyte abnormalities, and the clinical problem-solving— needed in the profession is a larger draw to the field than procedures.

When do residents decide?

Thinking about recruiting a resident into applying for nephrology? Start early! Most physicians interviewed for this article made their decision to enter fellowship early in medical school. All decided by the time their intern year was ending. Perhaps this early decision-making is due to the time constraints of the application process. Residents wishing to enter fellowship immediately upon graduating from residency must start applying by the first half of their second year of residency.

More often, however, a nephrology faculty member gave a medical school lecture, sparking interest in an aspiring internist or pediatrician. Melanie Lind-Ayres, who is starting her pediatric nephrology fellowship at the University of Minnesota, said the renal pathophysiology lectures at her medical school captured her interest.

Don’t give up on trying to recruit a resident if they are considering another field. Durgalakshmi Duraikannan, MD, a fourth-year internal medicine-pediatric resident at Creighton University/University of Nebraska, was set on endocrinology until she began a nephrology elective at the start of her second year of residency. Seeing the management of electrolyte disorders handled so well is what swayed Duraikannan to study nephrons as a career.

If the curriculum at a residency program is not designed to offer a nephrology elective during an intern year, don’t fret. Even other rotations can convert interns into seeking nephrology. Kevin Heath, MD, a first-year nephrology fellow at Stanford University, was considering cardiology, but switched his career preference to nephrology during his intern night float month. He felt the repetitive–routine chest pain–rule out myocardial infarction―admitting diagnoses were not providing the intellectual stimulation he was seeking in a career. “I enjoyed the mystery of trying to figure out the cause of someone’s abnormal lab values,” Heath said.

Challenges of entering fellowship

Even if nephrology is a resident physician’s top choice for a subspecialty, there is one more challenge that must be worked through before he or she decides to enter a nephrology fellowship—balancing family and fellowship.

Rugmini Warrier, MD, and Anna Lavedan, MD, are two recent graduates from Creighton University’s internal medicine and med-peds residency program, respectively. Both enjoy nephrology immensely. They differ in their approach to balancing family and fellowship, and the two approaches are used by many women physicians today. Lavedan, who is also married to a physician, decided to put a fellowship quest on hold so she could spend more time with her husband and three children. She satisfies her love for nephrology by trying to thoroughly work up some of the acute renal failure patients or electrolyte abnormality patients before referring them to a consultant.

Like Lavedan, Warrier also entered primary care upon completion of residency. She knew having children during fellowship would be challenging. Now that her twins are toddlers, she is entering the applicant pool for the entering nephrology class of 2010. Being a wife and mother is one reason Duraikannan, a med-peds resident, chose adult nephrology over pediatric nephrology. “It’s one less year,” she said. “With a family, I want to be done sooner.”

The decision to choose nephrology as a fellowship is complex. Inspiring students early on is one of the best ways to ensure a future generation of top kidney specialists. Students and residents need to be exposed to the wonderful world of nephrons early in their medical education through mentors or lecturers. Lavedan summarized her general passion for nephrology: “It [the kidney] makes sense!”

Sharing this love for nephrology, I invite you to recruit the next generation of nephrologists by helping medical students and residents feel that the kidney “makes sense.”

Notes

[1] Stephen Darrow, MD, is a graduate of Loyola University Chicago medical school and Creighton University/University of Nebraska’s internal medicine-pediatric residency. He is beginning a four-year combined medicine-pediatric joint nephrology fellowship at the University of Minnesota.