Mind the Gap: Augmenting Kidney Care Services as Older Nephrologists Look to Retire

Preparing nephrology fellows for current workflows and incorporating advanced practice providers (APPs) and international medical school graduates into nephrology practices are ways to augment nephrology services to meet patient needs during a challenging time, a panel of experts said during Kidney Week 2021. This could also help bridge the current time period where some older nephrologists are looking to retire, and there is a shortage of newer trainees in the field, they said.

“The goal of nephrology training is to ensure fellows are well equipped to take on the care of a diverse patient population, while adapting to the ever-changing medical, societal, business, and regulatory changes,” said Matthew A. Sparks, MD, FASN, associate professor and director of the nephrology fellowship program at Duke University School of Medicine in Durham, NC, during the session, “Developing a Workforce So That We Can Retire One Day.”

Trainees need a solid foundation in patient care, Sparks said, but their experiences should be interwoven with educational opportunities to ensure they are not only able to diagnose but are also able to treat patients using the best evidence-based approach. Professional growth and development are also important, and all activities should occur in a supportive and positive environment. Flexibility should be given so fellows can switch tracks if they choose or if their life occurrences change, he noted.

On the patient-care side, inpatient services continue to get busier, and nephrologists’ roles are expanding throughout the healthcare system, but work-life balance should be a priority for trainees and attendings, Sparks said. Additionally, there is continued subspecialization in the field and a need to ensure scholarly activity and research. Furthermore, trainers need to teach business and regulatory issues that are becoming more complex.

Going forward, Sparks said, the Advancing American Kidney Health initiative, launched in 2019 during the administration of former President Trump, is changing the landscape of care such that nephrology training will need to include a foundation of peritoneal and home dialysis, kidney transplantation, and outpatient nephrology (both prevention and patient education).

To achieve this, several skills will be needed, Sparks said. Fellows will need to be able to handle a large volume of patients and be efficient. Ethical dilemmas and issues will arise and should be embedded into training programs. Nephrologists also need to learn to lead multidisciplinary teams and to have work-life balance to achieve a sustainable workforce.

With medical information being rapidly disseminated, it is important to teach fellows lifelong learning skills, said Sparks. They need to understand how to clinically reason, critically appraise literature, prepare for and pass board exams, and learn communication skills. Free open access medical education (FOAMed) is transforming how education and learning are happening, he said, with increased interest in podcasts, simulators, conferences, virtual fellowship programs, and more. Continued training must also address topics in the business of nephrology, such as billing and coding, and value-based care and payment models.

Sparks offered the following advice for training program leaders:

• Listen to your trainees—that is how you know what their needs are.

• Provide opportunities for growth, and invest in them.

• Be proactive in building mentorship and sponsorship teams.

• Push trainees to develop new skills.

• Anticipate future obstacles and help traverse them.

Incorporating APPs also can help expand a nephrology practice's reach, said Leah Smith, MS, APRN, CNN-NP, FNP, NP, director of APPs at Metrolina Nephrology Associates in Charlotte, NC. With the number of kidney patients continuing to rise in the chronic kidney disease (CKD) and end stage kidney disease (ESKD) populations, APPs “can be a great solution to help get you to the point of being able to successfully retire from your practices,” Smith said.

APPs can provide general patient care as well as lead CKD clinics, manage hypertension clinics or edema or fluid overload issues, support hemodialysis clinics, run education programs for patients, and see new or follow-up hospital patients, among other tasks. “The possibilities are endless,” Smith said.

If you choose to go this route, she said, first, make sure you have the budget to hire. Also determine what the roles of APPs will be, and where you will use them, such as in outpatient dialysis, acute care settings, home care, etc. If you need board approval to go this route, prepare to make your case. It helps to have a physician champion who understands the roles of APPs and can state the benefits of adding them, she said.

Setting up an onboarding process for new APPs is key for the best integration of these healthcare extenders and for longevity in the practice, Smith said. Nephrology is not taught specifically in schools for nurse practitioners or physician assistants, she said, so your practice will need to offer some hands-on education and training. Choose how much time you will spend on classroom time, or give them materials or resources to study at home versus clinical observations or rotations, she noted. Then have them spend time with the physicians or other APPs you identify as trainers. Make sure some time is spent observing their performance to check their skills and ensure they understand your protocols. Work them up slowly, from one patient or a few patients to a full workload. Teach them how to use your electronic health records.

Also, have new APPs meet with Human Resources to set up benefits and tax forms. Introduce them to your staff and collaborative partners. If you have credentialing team members, have them work with the new APPs to get them credentialed. Assess the competency of APPs periodically, and offer opportunities for continuing education through support for meeting attendance.

Adopting APPs can often add revenue but can also bring additional quality or help practices meet certain measures such as dialysis history and physicals, she said.

Another way to extend a practice's breadth is through hiring and supporting international medical graduates (IMGs), said Samira Farouk, MD, MSCR, FASN, an assistant professor of medicine and medical education and associate director of the Nephrology Fellowship Program at the Icahn School of Medicine at Mount Sinai in New York, NY.

Nearly 250,000 physicians in the United States workforce—almost 25% of all US physicians—are IMGs, Farouk said, citing 2018 statistics from the American Immigration Council (1). Percentages are higher in nephrology, as 50% of practicing nephrologists (2) and 65% of nephrology residents and fellows (3) were IMGs in 2019, according to the American Association of Medical Colleges.

The two main pathways for clinical training for IMGs in this country are through the J-1 and H-1B visas, Farouk said. To stay on after training to practice, one option is the Conrad 30 waiver program, which allows J-1 foreign medical graduates to apply to waive the requirement to return to their home country for 2 years. However, the program is administered by the states and will approve applications for a maximum of 30 physicians per year. Other avenues include the Appalachian Regional Commission, which can provide waivers for individuals living in the Appalachian area, and the Delta Regional Authority, which can provide waivers for those living in Delta communities. The Department of Veterans Affairs also can sponsor individuals and provide waivers, although there are fewer spots. An alternative for individuals focused on research and clinical care is the US Department of Health and Human Services Exchange Visitor Program, which accepts waiver applications for those doing research in a high-priority area of interest.

Leaders of academic programs or practices interested in pursuing these pathways for trainees should start their discussions by late spring to early summer, Farouk advised, or even as early as the prior September, to allow time for waiver applications to process. The caveat is that practices or institutions must be in areas with an underserved population or in an area with a physician shortage.

“Preparation and timing [are] key,” she said. “Individuals really have to be careful and work with their program leadership to meet these deadlines so that they do not miss them.” It is also important to have a backup plan in case the waiver is not approved, or there is a challenge with the application. Legal help is often required.

“We as a community really have to advocate for this group of individuals,” Farouk said. “They are incredibly important to our workforce, not only as a whole but particularly within nephrology.”