Top 10 Predictions about US Nephrologists in 2035. ASN Executive Vice President's Update

Tod IbrahimTod Ibrahim, MLA, is Executive Vice President, American Society of Nephrology, Washington, DC.

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During the past few months, I have participated in several meetings that included in-depth discussions about the future of the health care workforce in the United States. Each time, the discussion started with predictions about shortages of every kind of health professional—from physicians to nurses to physician assistants/associates to other clinicians—and then shifted to concerns about the ability to provide high-quality patient care in the future as a result.

Although this editorial will focus on the future of nephrologists in the United States, I recognize that the situation is dire throughout the world, particularly for nurses. Earlier this year, the International Centre on Nurse Migration—in partnership with CGFNS (Commission on Graduates of Foreign Nursing Schools) International and the International Council of Nurses—estimated “up to 13 million more nurses will be required over the next decade, the equivalent of almost half of the world's current 28 million-strong workforce” of nurses (1, 2). Another recent report predicted that the United States will have “a gap of between 200,000 and 450,000 nurses available for direct patient care” by 2025 (3).

The reasons for the global shortage of nurses and the shortage of other health professionals, including nephrologists, in the United States are similar. The COVID-19 pandemic has taken a toll on health professionals individually and collectively, exposing broader issues within health care systems. Already low before the pandemic, staffing ratios for health professionals have become worse, causing more overwork, dissatisfaction, hopelessness, and burnout. Nearly one-third of health professionals “surveyed intend to reduce work hours,” and one in five physicians and two in five nurses “intend to leave their practice altogether” during the next year, a recent report noted (4).

According to the Association of American Medical Colleges (AAMC), the United States “could see an estimated shortage of between 37,800 and 124,000 physicians by 2034” (5). More specifically, AAMC projects a “shortage of primary care physicians of between 17,800 and 48,000” and a “shortage across the nonprimary care specialties of between 21,000 and 77,100 physicians,” including nephrologists.

“If underserved populations had health care use patterns like populations with fewer access barriers, demand would rise such that the nation would be short by about 102,400 (13%) to 180,400 (22%) physicians relative to the current supply,” the AAMC report added. AAMC defines underserved as “minority populations, people living in rural communities, and people without medical insurance.” It is important to highlight the fact that the United States must address a shortage of physicians overall as well as a maldistribution of physicians across geography, race and ethnicity, economic status, and specialties.

An estimated 10,370 to 12,939 nephrologists currently practice in the United States (6, 7). From 2008 to 2020, the number of US nephrologists doubled, even though only 52% of tracks offered by nephrology fellowship training programs, accredited by the Accreditation Council for Graduate Medical Education (ACGME), filled all their positions through the National Resident Matching Program (NRMP) Medical Specialties Matching Program in the appointment year 2022 Match (8, 9). (NRMP is rebranding this program in 2022 as the Medicine and Pediatrics Specialties Match, because the matches for adult and pediatric specialties are now on the same timeline.)

Because of this history during the past decade and the projected shortages among other internal medicine specialties, it is highly unlikely that the number of nephrology fellows will increase much in the near future. If anything, the number of nephrology fellows may decrease, given the current mismatch between the number of internal medicine residents who matched into nephrology in December 2020 (345) and the number who started fellowship training in July 2021 (454) (10).

As a new cadre of physicians start their nephrology fellowships this month, it is fair to ask, “What are the top 10 predictions about US nephrologists in 2035?”

  1. Like most countries, the United States will face massive shortages of health professionals. Because undergraduate and graduate medical education takes at least 7 years for primary care physicians, 9 years for adult nephrologists, 10 years for pediatric nephrologists, and longer for several other specialists, this is the time to implement a strategy for addressing these shortages as well as the maldistribution across geography, race and ethnicity, economic status, and specialties.

  2. Other health professionals will have a greater role, responsibility, and authority in much of the United States. At least three forces are blurring the lines among health professionals, including nephrologists: Legislatures in states unable to attract physicians are expanding scope of practice for other health professionals, efforts to contain soaring health care costs are creating incentives to shift responsibilities, and technology is forcing a re-evaluation of how best to deploy the workforce.

  3. The public will rely more on both episodic care and omnichannel health delivery via retailers, such as Amazon, CVS Health, Walgreens, and Walmart. This year, all four of these companies “accelerated their investments in healthcare,” focusing on “new areas from primary care to telehealth” (11). Among the Fortune 500, these companies rank first (Walmart), second (Amazon), fourth (CVS Health), and 18th (Walgreens) (12). In 2018, CVS Health launched CVS Kidney Care “to fundamentally transform the treatment paradigm” for the millions of people with kidney diseases by focusing “on early identification of kidney disease, targeted patient engagement, and ongoing education to help slow disease progression” (13).

  4. Patients will depend even more on information from unregulated social media channels to inform their care. “Increasing numbers of Americans have turned to internet sources for health and medical information in recent years, with approximately three out of four searching for health information online today,” observed the National Academy of Medicine (14). Because few of these channels “differentiate between credible and non-credible sources of information,” the quality, accuracy, and truthfulness vary. This reality forces patients to “make their own judgments about how much trust to place in a source and the quality of the information it shares,” and these decisions are “influenced by their level of health and digital literacy, prior knowledge, personal situations, and personal beliefs.” As the leadership of the American Board of Internal Medicine recently stated, “If enough people like, share, or choose to believe something, others will accept it as true” (15).

  5. Local, state, and federal governments will insert themselves more between physicians and patients. In “Confronting disinformation, polarization, and demagoguery,” I tried to describe this issue in the May 2022 edition of ASN Kidney News (16). Since then, this situation has worsened, resulting in a recent perspective, “Physicians as political pawns—the Texas directive on gender-affirming care and other moves” that prophesied: “These political and legal challenges to the profession will be felt unequally, but the reverberations of politicized mistrust will harm everyone who needs to be able to tell a doctor the truth about themselves, as well as any doctor who needs to hear it” (17).

  6. Nearly all US physicians will be born between 1965 and 2005. This 40-year span includes three generations: Generation X (born between 1965 and 1980), Millennials (1981–1996), and Generation Z (1997–2012). Each of these generations will be progressively more racially and ethnically diverse, socially engaged, and politically active (18).

  7. Facing considerable debt, physicians will also be more likely to retire earlier from medicine than previous generations. The first half of this prediction is based on fact: The average medical student debt is projected to exceed $300,000 by 2024, whereas “Black and African American medical students owe more, on average, than their peers of any race or ethnicity” (19). These projections predate the current reality of rising inflation and higher interest rates, so debt is likely to be even greater. The second half of this prediction is informed speculation: Physicians have embraced the “Great Resignation”; both Generation X and Millennials value work-life balance, freedom, and flexibility; and the specialties that currently have the earliest retirement age (anesthesia, emergency medicine, and interventional radiology) were at the forefront of the influx of private equity and employed physicians, which is currently happening in nephrology (20).

  8. Nearly 100% of US physicians will be employed. The number of physicians employed by hospitals, health systems, or corporate entities has increased from 42% in 2012 to 74% in 2021 (21, 22). Additionally, more than 90% of physicians who accepted new positions last year were “as employees and not as independent practice owners/partners,” up from 60% in 2001 (23). In this year's January issue of ASN Kidney News, Katherine Westin Kwon, MD, FASN, and Eugene Lin, MD, MS, FASN, described how “Start-up companies, larger for-profit healthcare providers, and venture capital firms have formed a marketplace of new products aimed at helping nephrologists improve their management of CKD [chronic kidney disease] at a population level,” which often involves employing nephrologists (24).

  9. Current physician specialties will be more specialized, and current subspecialties will be more sub-subspecialized. On the one hand, greater shortages of health professionals could result in more generalization. For example, each nephrologist will be responsible for more patients (especially in underserved parts of the country), necessitating a broader range of skills, knowledge, and experience. On the other hand, every trend in medicine is toward greater specialization, which is incentivized by the current reimbursement system. Moreover, if the future of health care is employed nephrologists working in large, integrated delivery systems (including retailers), then the ideal role for a nephrologist is treating the most challenging cases across the spectrum of kidney diseases, failure, and transplantation, which likely necessitates some sort of structured subspecialization.

  10. Physician-scientists will be fewer, older, and more endangered than ever. Concerns about the future of physician-scientists started in 1979 and continue today (25). As illustrated in “Physician-scientists in the United States at 2020: Trends and concerns,” the “disincentives to research careers—unstable research funding, financial pressures on medical institutions, and student debt—remain,” whereas the gap between when physician-scientists complete research training and receive their first grants from the National Institutes of Health has widened (26). As is well documented, the future physicians in the United States—people who identify as underrepresented in medicine, including women—are less likely to pursue careers as physician-scientists. The future for physician-scientists in nephrology is worse than in nearly every other discipline: “Underfunding of kidney disease research impedes scientific opportunities and innovation and prevents the collaboration of young investigators with research faculty that can accelerate the exodus of talent within the nephrology research workforce” (27).

Earlier this year, the American Society of Nephrology established the Task Force on the Future of Nephrology. The task force is charged with envisioning how best the specialty can meet the needs of people with kidney diseases. By focusing on what is best for patients, the task force will articulate a strategy for accomplishing Robert Frost's wise advice in “A Servant to Servants”: “…the best way out is always through” (28). Nephrology is well-positioned to be a stronger specialty in 2035 than it is today if we are purposeful during the next 13 years and beyond.

Acknowledgment:

Mr. Ibrahim thanks ASN Data Science Officer Kurtis Pivert for his help with this editorial.

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