What Do Fellows Want? What Does Nephrology Need?

After several years of declining interest, the future of nephrology as a career choice continues to be uncertain. Preliminary results from the Nephrology Match AY 2017 revealed a continuing trend toward unfilled nephrology tracks, with almost no change from AY 2016 (95 vs. 93 filled tracks). Programs may face the difficult choice of trying to recruit post-match or perhaps reducing program size and recruiting either more attending nephrologists or physician extenders including physician assistants or nurse practitioners.

Last year’s match rate for nephrology was the lowest for all medicine fellowships. A particularly noteworthy trend has been the progressive decline in the number of international medical graduates (IMGs) matching in nephrology, with only 100 for the current academic year, down from 192 as recently as 2011.

As has been well described elsewhere, careers in nephrology have been viewed less favorably in recent years for a variety of reasons, including perceived lower compensation compared to many other fields along with a workload and quality of life felt to be inferior compared to other specialties. There is also concern regarding the ability to find nephrology jobs, with a large proportion of fellows describing difficulty finding positions in nephrology after graduation, as described in the 2015 Survey of Nephrology Fellows.

Need for innovations

Other factors may be playing a role as well. Dialysis and transplantation represent extraordinary therapeutic milestones that transformed end stage renal disease care, and these modalities have continued to improve. However, many fellows and trainees who are considering careers in nephrology are looking for new therapies comparable to what they see taking place in other fields. Trainees describe seeing many recent advances in cardiology, rheumatology, hematology/oncology, and endocrinology with new therapies regularly introduced. In contrast, for a number of renal conditions such as diabetic nephropathy, many note that there have been no major new therapies introduced in the past several decades with a string of disappointing clinical trials.

There are potent competing forces as well. Careers in hospital medicine appear to be a frequent alternative chosen by trainees considering nephrology careers. Better compensation, controlled schedules, and perceived better quality of life draw a number of residents away from nephrology. Whether such choices typically lead to long-term career satisfaction remains to be determined.

There have been some favorable trends whose impact will require observation over the next year. While the high percentage of fellows reporting difficulty in finding a satisfactory job as noted above is of great concern, this percentage has recently fallen, mostly for US medical graduates, but to some extent for IMGs as well. If this trend continues, we might see a positive impact on the perception of nephrology by residents considering it as a career and hopefully greater career choice satisfaction for nephrology fellows.

Nephrologists’ role in emerging health care

At the same time that changes in the nephrology workforce and in what fellows want are taking place, several variables are affecting the emerging needs of nephrology. There has been a decline in the incidence of ESRD, likely in part due to more aggressive treatment to slow progression of CKD. Nephrologists will need to continue to be a part of this effort if this trend is to continue. Despite a decrease in incidence, the prevalence of ESRD has increased, due to factors such as the growth of the population, with a large percentage having diabetes mellitus and hypertension, and improved dialysis care leading to a reduction in mortality. Nephrologists will obviously be essential to their care, even as the role of physician assistants and nurse practitioners continues to evolve.

Kidney transplantation has seen the introduction of new agents such as belatacept that require additional expertise on the part of nephrologists. Hence a larger number of nephrologists who are highly competent and comfortable in the use of such therapies may be needed. The nephrology workforce, as for many other physician specialties, tends to be unevenly distributed across the country, with some areas having high concentrations of nephrologists and others with a severe shortage and large obstacles to recruitment. Challenges with recruitment to certain areas could potentially be addressed through telemedicine, for example in areas with large distances between dialysis units.

A further area of uncertainty that will affect the needs of nephrology will be the impact of emerging models of health care including the roles of physician extenders. For example, as described in the US Adult Nephrology Workforce 2016 Report, the ESRD Seamless Care Organization (ESCO) will be one such model whose potential impact cannot be determined at this time in terms of the job market for nephrologists. Whether through an ESCO or other model, increased use of physician assistants and nurse practitioners is a phenomenon whose impact on future career opportunities for nephrologists merits close watching.

Nephrology has made enormous advances but is in need of much more progress to ensure the ability to draw fellows who will pursue careers in clinical practice as well as those with potential for careers as nephrology researchers and educators. The excitement and vast potential of nephrology research, the deep personal rewards that come from caring for patients with renal disease, and the satisfaction derived from mastery of the subject matter of nephrology while maintaining a strong command of general internal medicine all need to be communicated to students and residents. Novel elective models and other interventions to expose students and residents to a broader spectrum of nephrology have been proposed and are being utilized at various institutions, with impacts that deserve further study. It is hoped that over the coming year we will start to see some reversal in the recent trend away from pursuing careers in nephrology and gain further insights in how to facilitate this.