Nephrology: We Define Our Future

Amy WilliamsAmy Williams, MD, is affiliated with the Mayo Clinic in Rochester, MN, and is a member of the KN Editorial Advisory Board.

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Over the past 10 years, much has changed in the specialty of nephrology and for nephrologists in all career tracks and professional settings. We have a deeper understanding of underlying mechanisms of disease and how to target therapy. Kidney Week 2017 was full of excitement and examples of discovery and translation to improve clinical care.

New care models have grown and matured, and there has been continued exploration of how to manage those with chronic kidney disease (CKD) and to identify those at risk for kidney disease earlier in their disease trajectory. Plus, there certainly is a market for our skills and knowledge with no shortage of individuals who need our expertise and care. To those thrilled with and fascinated by the complexity and power of the kidney, passionate about improving the outcomes of patients at risk for or with kidney disease—or dedicated to tapping into every resource to improve outcomes and decrease the burden of kidney disease through innovation—it is hard to understand why individuals don’t choose nephrology as a career.

How then do we define our specialty’s future? It can get a bit unnerving following the health care delivery and research funding conversations in Washington and watching the movement in the advanced CKD/dialysis industry. Yet we must participate and be active in the conversations, particularly around policy, for example, keeping an eye on any legislative proposals that could limit patient choice, make it more difficult for patients to access care, create silos of care, influence physicians’ decision-making, and decrease patient-centered approaches to care, or overburden providers and patients with administrative tasks. Participating in the ASN Public Policy and Advocacy Community site is an easy way to gain understanding of new threats or of bills worth supporting, with a next step to raise the support of local legislators.

We must also find opportunities to elevate the importance of our contributions as nephrologists. As physicians, we have been trained to manage patients with complex chronic disease and have the most experience working in teams and in bundled and value-based payment models. As CMS and other insurers/payers build care bundles, and as alternative payment models become better defined, we can prove our value as partners by being involved early on in managing and educating about the risks of CKD and acute kidney injury (AKI) and subsequent disease progression, thereby improving outcomes—both medical and financial. Working across specialties and care sites to share knowledge and smooth transitions of care is a step we must take.

Through new collaborative partnerships, we can reach more patients and positively impact outcomes for the populations at risk for or with kidney disease. As always, self-reflection and occasional realignment are key to success. Our patients often have a disease trajectory that is not linear, but with many transitions (CKD–AKI–dialysis–transplant–dialysis, etc.). As we become more and more subspecialized, we must avoid creating silos within our specialty that decrease the overall advancement of care for patients throughout their lifetime.

Last, nephrology workforce concerns continue to loom, but most recent data point to possible stabilization or, thinking positively, maybe a sign that the worst is over. Reasons suggested for the decline in interest for nephrology are many: financial, how renal physiology is taught, lack of exposure to a breadth of renal diseases and patients, lack of enthusiastic mentors, and nephrologists’ satisfaction in their careers. For each resident or learner the influencers may be different, but much of this we can change. We have an opportunity to take advantage of the uncertainty and chaos in health care delivery and funding for research and education by going to our strengths—the ability to manage the riskiest, most complex patients, lead effective teams, innovate and advance the science. Our specialty is essential in the new paradigms in medicine, population health, and health care delivery. It is our responsibility to make our contributions to medicine and the most vulnerable populations more visible.