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Daniel Edmonston, MD
Despite initiatives to improve access and delivery of preventive care, much of medicine is still reactionary. We wait behind brick-and-mortar walls for our patients to come to us with a list of problems in hand.
The field of nephrology is not immune to this limitation. Arguably, we are among the most susceptible. Like the “silent killer” hypertension, most patients with chronic kidney disease (CKD) are asymptomatic until the disease approaches advanced, often irreversible, levels. This lack of symptoms leads to patient under-recognition of even advanced CKD.
Compounding this problem, provider recognition of CKD may also be lacking
Procedures have played an integral part throughout the practice of nephrology. However, it is time to evaluate this tradition. Competency in our “core” procedures (e.g., kidney biopsies and non-tunneled hemodialysis catheter placement) is required by the Accreditation Council for Graduate Medical Education (ACGME) for graduation from nephrology fellowship, although there is no minimum requirement for the number of procedures to be performed (
Medical students and residents are often intimidated by renal physiology and struggle to understand the many aspects of the kidney’s role in medical disease. If trainees have trouble grasping the complexities of the kidney, it should come as no surprise that our patients feel the same way.
Health literacy, or the ability of an individual to be actively engaged in a dialogue about his health, has been linked to patient outcomes. Adequate health literacy is particularly important in chronic kidney disease (CKD), which often requires patients to navigate a complex health system and make drastic lifestyle changes. Patients may be
Millions of lives have been successfully prolonged through dialysis. However, the world of dialysis has changed since its inception. With time, our patient population has evolved from young and fit to old and sick. Belding Scribner, the father of chronic dialysis in the US, noted the need for a “deselection committee” just five years after the Medicare payment benefit for ESRD was established in response to his perception of the loosening of dialysis criteria (
The US nephrology community has been concerned about lower numbers of trainees in Nephrology in recent years. A trend of fewer applicants to nephrology has been noted since 2011. Between 2013 and 2014, there were a slightly higher number of Nephrology Programs and fellowship positions opening. This led to a higher number of available positions than the number of applicants available to fill those positions in 2014 and 2015. This problem, if it remains unsolved, could translate into a possible future decline of the nephrology workforce and of nephrologists’ ability to meet the needs of patient care in the US.
My grandmother’s struggle with chronic kidney disease (CKD) motivated me to consider, and ultimately choose, medicine as a career. During medical school, I had the opportunity to work with a nephrologist and attend renal clinics with him. I was intrigued by the complexity of patients with kidney disease and felt pulled toward a career in internal medicine and nephrology, which brought me to the University at Buffalo for my internal medicine residency.
My decision to become a nephrologist was reinforced throughout my residency. During my nephrology elective, I liked the fact that it was both challenging and comprehensive. I felt
“Mrs. S, has anyone discussed moving toward comfort measures?”
I can still remember the question leaving my lips, followed by the look of surprise and discomfort on Mrs. S’s face. I was a first-year fellow caring for her husband, Mr. S, a dialysis patient whom I had admitted numerous times that year. This time he had been brought unresponsive into the emergency room, and he had been lying in bed for a week, receiving pressors and ventilator support but with no signs of neurologic recovery. As I sat with Mrs. S I felt helpless. How could I begin to explain
According to 2009 National Resident Matching Program (NRMP) statistics, international medical graduates (IMGs) comprise more than half—52 percent—of the fellowship applicants matching in nephrology. Here I describe my personal experiences as an IMG on an H1-B visa applying for a nephrology fellowship. I have also applied for fellowships through the couples match program as my wife is pursuing fellowship training in infectious diseases. Although I present my own personal experiences throughout the match process, it is important to keep in mind that these experiences are not in any way unique. Most of my colleagues have encountered many of the same
The nephrology subspecialty, both at the fellow and practitioner level, has a greater percentage of international medical graduates (IMGs) than any other internal medicine subspecialty with the exception of geriatrics. As such, the contributions of IMGs to our field are tremendously important and we must work to continue to make nephrology an attractive career choice for them.
There are a number of challenges relating specifically to potential IMG fellows. Since J-1 and H1-B visa holders are not eligible for funding through the NIH, their options are substantially limited if they are interested in research training. Owing to limitations imposed by
The outlook for securing a job after nephrology training has become increasingly more difficult. A glance at the
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