Why Are International Medical Graduates Not Choosing Nephrology?

Recently, a substantial decline in interest in the field of nephrology has occurred, not only among medical graduates in the US (USMGs) but also among international medical graduates (IMGs) (1). Factors such as lifestyle, income potential, job opportunities, and others have been discussed (2), but little is known about the declining interest of IMGs. This article is a personal narrative of the first author on why he chose nephrology as a career. The article will also communicate the gist of our conversations and email communications with our IMG colleagues about these questions:

  • Why did they not choose nephrology?
  • Why have they not chosen nephrology as their subspecialty?
  • Why are they not practicing nephrology despite having completed formal fellowship training?
  • Why would they not advise other people to choose this field?

I am an IMG currently working as a faculty member in the department of nephrology and hypertension at the Cleveland Clinic. During my years of training and appointment as a faculty member, I have been a mentor to many talented IMGs, both formally and informally. I did not develop my interest in nephrology during my medical school training but found it to be quite interesting during my residency.

One of the main reasons I became interested in nephrology was that I had the good fortune to work with a great role model and mentor who was also a nephrologist at my residency training institute, a community-based hospital with an academic affiliation. She led case conferences, and presented the subject matter in a very interesting way. The complexities of renal physiology, the delicacies of acid-base and electrolyte disorders, and the challenges of glomerulonephritis management, when presented in a logical and understandable way, eventually led to my decision to choose nephrology as a career. My residency program also offered me the opportunity of a formal mentee–mentor relationship that not only helped me in developing a research project during my residency but also inculcated a lifelong habit of intellectual curiosity. In my case, one single mentored research project led to several other research projects and a persisting interest in clinical research even after I had matched with a nephrology training program.

My personal story highlights the important fact that even in a semiacademic institution, role modeling and research opportunities can inspire residents to choose a particular field and even pursue an academic career in that field.

In our observation, declining interest in nephrology is not restricted to the US but affects other countries as well. This is documented by the recent match results for nephrology fellowship positions (3).

Nephrology concepts at times can be hard to understand and, if not taught in an approachable and interesting way, can lead to disinterest in this fascinating specialty. Recent efforts by the American Society of Nephrology through the renal educators’ listserv, sessions on nephrology education at the annual meeting, and travel grants and learning sessions for medical students and residents at Kidney Week attest to the realization that teaching clinical nephrology is important to our specialty. Additional research examining the trends of formal medical school teaching in nephrology may be helpful. More collaborative efforts between nephrology societies across the globe to formulate a standard nephrology curriculum and medical student teaching strategies may also be useful. A nephrology lecture series by renowned educators across the world could be organized and may attract more talented medical students to nephrology.

Many IMGs have the privilege of serving and training in internal medicine programs in community-based teaching hospitals, where they may or may not be exposed to well-rounded faculty members who can serve as role models and attract them to the field of nephrology. Many of the attendees in such programs are in private or group nephrology practices and are not necessarily committed to teaching. Perhaps formal teaching workshops for such community physicians who also hold teaching appointments at community hospitals could be arranged. Nephrology societies could organize such programs along the lines of regional nephrology reviews and provide continuing medical education credits. Exceptional nephrology teachers could be recruited as faculty for these programs and could share their tips for making clinical nephrology attractive to residents as a career choice.

Visa issues, future job prospects, and nephrology

Visa issues and future job prospects were not the primary focus of the first author in selecting a subspecialty for additional training. But not everyone makes decisions based solely on passion and interest in a field. For some IMGs, visa issues can make or break the deal in choosing a career (2).

Two types of visas are available for those wishing to do residency and fellowship training in the United States: the H1-B visa and the J-1 visa. Ordinarily, an H1-B visa can be extended for a total of 6 years. An H1-B visa holder can spare the sixth year to file for a green card, which is usually employer-based, and the IMG physician is still able to work under that visa. A total visa duration of 6 years makes it challenging for some IMGs to pursue additional training years in research, although it is theoretically possible if an employer sponsors a green card application during the IMG’s second or third year of fellowship. However, academic institutions typically do not hire a faculty member 1 or 2 years in advance. This situation may result in fewer candidates choosing research careers, despite the desire of many talented IMG physicians in training. It is also important to note that H1-B visa sponsorship legally requires programs to pay for the sponsorship fee, an unattractive option for some programs.

A J-1 visa held by an IMG candidate can be extended for a total of 7 years. However, this visa option is tied to a requirement that the IMG practice for 3 years in an underserved area or return to his or her home country for 2 years to change immigration status and then be eligible for long-term residency in the United States. This whole process can take several years, depending on the country of origin. From the research training standpoint, if a J-1 visa holder does an extra research training year, the chances of pursuing a research academic career are small because the waiver requirement of 3 years of practice in an underserved area of the United States or 2 years in the home country would still need to be completed. If only a clinical fellowship is completed, finding a decent job in an underserved area at times may be difficult. There is some concern that a future employer may take advantage of the nephrologist with a J-1 visa because of the legal requirement of practicing in an underserved area and relatively fewer decent job opportunities (2). Training programs have no financial obligation to pay for visa fees for J-1 visa holders.

Hospitalist medicine and nephrology

The declining interest in nephrology perhaps parallels the rise in hospitalist medicine. Hospital medicine offers several potential advantages to IMGs, such as more geographic options, a better job market, and relaxed timelines for filing green card applications. The more favorable work schedules of hospitalist jobs are equally attractive to both USMGs and IMGs. The prospects of income in this field may be similar or slightly better, or they may be worse.

Some IMGs who train in nephrology choose a hospitalist job because of better opportunities in terms of geographic location and income. Typically, hospitalist employers may sponsor a green card ahead of time for a more qualified physician who has received advanced training in a subspecialty field and has taken care of patients with very complicated conditions. Many IMGs have heard the statement from recruiters that “nephrologists make excellent hospitalists.” Our IMG colleagues who have chosen to become hospitalists invariably base this decision on lifestyle, geographic preference, and easy-to-find green card jobs in a better location and—more importantly—in a timely fashion. Frequently, they aspire to return to nephrology, either full time or part time. Their hope is to make connections with local nephrology groups that will help them find a job and resolve immigration issues. However, depending on the time required for processing a green card, the available job opportunities in their preferred area, and the duration of a partnership track, IMGs may return to nephrology after several years or, in some cases, choose to continue a career in hospital medicine.

Although there are no easy solutions to these issues, a change in legislation regarding visa options to prevent a workforce crisis in nephrology may be of value. Changes to visa requirements may also attract more IMGs to fellowship training in nephrology. Collaboration by the international nephrology societies may be of value in preventing the global future workforce shortage we face. And attracting IMGs to nephrology may best begin in their medical schools and extend to residency training programs in community hospitals here in the United States, where enthusiastic, committed nephrologists can be seen as excellent teachers and role models.

References

1. 

ASN NRMP SMS Nephrology Match for Appointment Year2015. https://www.asn-online.org/education/training/workforce/ASN_NRMP_SMS_2015_Analysis.pdf.

2. 

Salsberg E, Masselink L, Wu X. Findings from The 2014 Survey of Nephrology Fellows. Washington, DC: American Society of Nephrology; 2015.

3. 

Field M. Addressing the global shortage of nephrologists. Nat Clin Pract Nephrol 2008; 4:583.