Fellowship Recruitment and the Future of the Nephrology Workforce

The past several years have seen a decline in the number of applicants for nephrology fellowship positions with about half of all programs having unfilled slots. It is anticipated that a further decline will be found for the current recruiting season. The recent US Nephrology Workforce 2015: Developments and Trends (1) from George Washington University (ASN Nephrology Workforce report) highlights many of the key issues that are likely to affect the future of the nephrology workforce, issues that are intrinsically linked to interest in nephrology and fellowship recruitment.

It is somewhat ironic that decreasing interest in nephrology careers is taking place at a time when great progress is being made in the care of patients with renal disease. For example, end stage renal disease (ESRD) incidence rates have been falling for the past several years, undoubtedly reflecting the efforts of nephrologists to use angiotensin- converting enzyme inhibitors, angiotensin receptor blockers, and other interventions to slow progression of chronic kidney disease (CKD).

Mortality rates for CKD have been falling and are declining at a rate faster than the non-CKD population. ESRD mortality rates are declining as well. There are new therapeutic regimens and remarkable pathophysiological and genetic insights in glomerular disease, transplantation, hypertension, electrolyte metabolism, and many other areas. Ongoing laboratory and clinical investigations continue to yield valuable results that are having a positive impact and continue to add to the excitement of being a nephrologist.

There are, however, a number of factors that are contributing to declining interest. There is a perceived lack of job opportunities and concern that this will be a continued problem. There is also a perception that the quality of life and compensation of the nephrologist is less compared to those in other specialties. Alternative careers have become more appealing, especially hospitalist medicine, regarded by many as being better compensated and having a better quality of life. The ASN Nephrology Workforce report indicated that about a third of nephrology fellows would not recommend nephrology to others. If practicing nephrologists are negative about their chosen specialty this can understandably be devastating for students and residents who are considering careers in the field.

The composition of the nephrology applicant pool will continue to have important implications for the future workforce as well. Applications from US medical graduates (USMGs) are decreasing. In the past, this has been counterbalanced by nephrology having a substantial pool of international medical graduates (IMGs), but as outlined in the ASN Nephrology Workforce report, IMGs face particular challenges in pursuing nephrology careers. While IMGs have less educational debt to manage compared to their USMG peers, they report having a harder time finding jobs, with 72.5% reporting having a difficult time finding a job with which they were satisfied in 2015. Only 62.7% of IMG fellows said they would recommend nephrology as a career. The percentage for USMGs recommending nephrology was somewhat higher at 74.4%.

While interest in nephrology has been declining in recent years, over the past 15 years there has been a large increase in the number of fellowship slots, with an almost 50% increase since 2000. The impetus for this increase has been based on past predictions of eventual shortages of practicing nephrologists. Projections of large increases in the numbers of ESRD patients have helped provide support for increasing fellowship slots. However, the demand for nephrologists has been complicated by a number of factors. First, while there continues to be an increase in the number of patients with ESRD, incidence rates for ESRD have decreased as noted above. Second, the models of care for patients with ESRD are in transition with nurse practitioners (NPs) and physician assistants (PAs) playing increasing roles. Third, as for ESRD, CKD care can involve not only NPs and PAs but internists as well, further affecting the demand for nephrologists. Finally, there is a maldistribution of the ratio of nephrologists to patients throughout the country, a problem without a simple solution as choice of where to practice is influenced by additional factors aside from patient location.

Fortunately, ASN is making great efforts together with the nephrology community to promote interest and provide a robust nephrology workforce for years to come, with many promising interventions being implemented and published. The variables discussed here and detailed in the ASN Nephrology Workforce report merit close observation.



Salsberg E, et al. The US Nephrology Workforce 2015: Developments and Trends.