10 Years of ASN's Annual Nephrology Fellow Survey—Lessons Learned and Questions Unanswered

This year marked the 10th anniversary of ASN's Annual Nephrology Fellow Survey. With a robust response rate of 47% in 2023 (range, 43%–50% on recent iterations), it provides a snapshot of current U.S. nephrology fellows’ trajectories from medical school through fellowship graduation (1).

After 10 years, what have we learned? Nephrology fellows are largely internationally educated, and nearly one-third require work visas (J-1 waiver or H-1B sponsorship). Just under 40% are women, and 10% identify as Black or African American. Approximately 7% of fellows have not completed residency training in the United States and to become board-eligible must either: 1) perform a U.S. residency after fellowship, or 2) be accepted to the American Board of Internal Medicine's Pathway A, an option for exceptional fellows who are hired as U.S. or Canadian faculty members for 3 years (2). Fellows decide to become nephrologists mostly between their second and third year of residency, but nearly one-fifth of international graduates pursue nephrology after practicing internal medicine post-residency.

After graduation, most fellows are private practice-bound and expect to work in both outpatient and inpatient settings. Despite anecdotes about nephro-hospitalists and nephrologist-to-hospitalist conversions, only five respondents were entering hospital medicine in 2023. Approximately 10% of graduates pursue advanced fellowship training, most commonly transplant (44%; n = 18) or critical care (34%; n = 15).

Quality of life is the chief metric by which new graduates evaluate potential job opportunities. Weekend or weeknight call frequency and a desirable location consistently top the list of most-valued job characteristics (outstripping compensation). However, inadequate compensation is the most common reason cited by new graduates for an inability to find a satisfactory position.

So, how do we contextualize these cross-sectional data and use them to promote a sustainable workforce that benefits both nephrologists and patients? This is particularly important in light of the increasing burden of kidney diseases worldwide coupled with the looming retirement of a significant proportion of the physician workforce (3).

The data give us a great snapshot of the new graduate workforce, but they leave us wondering about the fate of future personnel (Figure 1). For example, what is the career trajectory of J-1 visa holders? Do they continue to live and work in the underserved communities where they complete their waivers? Or do they return to more densely populated metropolitan areas or pursue advanced fellowship training in subspecialties such as transplant, which their original visa requirements may have precluded?

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ASN Annual Nephrology Fellow Survey pipeline: Who is in it, and what happens when they exit?

Citation: Kidney News 15, 12

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What about the hospitalist movement that has likely diverted talent from the nephrology training entry pipeline? Does it continue to siphon off talent in the years beyond training with the allure of higher salaries and more predictable work hours? The median base salary reported for all of the 2023 nephrology graduates (including academic, private practice, and hospital employers) was $231,000. For comparison, the Association of American Medical Colleges reported that the median assistant professor-level salary for academic hospitalists in 2021–2022 was $250,049 versus $221,264 for nephrologists at the same rank (4). Although the income disparity favoring hospitalists persists at the associate level (median $2,017 more than associate professor nephrologists), at the professor level, median nephrology salaries overtook hospitalists ($314,406 versus $303,703), arguing that academic nephrology's earning potential over the long run was higher than in hospital medicine. But to brand-new internal medicine (IM) residency graduates, who are often saddled with significant educational debt (U.S. nephrology fellows reported a median $236,000 of debt in 2023 [1]), pursuing the short-term gain of immediate higher salaries is more attractive than considering the long-term potential of a nephrology career. The question remains whether future or early-career nephrologists are aware of their own long-term earning potential (including revenue from opportunities like joint ventures) and if this is actualized over time.

There are still more questions. What happens to fellows who pursue nephrology fellowship before IM residency training? Do they reenter nephrology after being away from the practice for 3 years, or do they practice general IM? What are the challenges to reentry? What about training kidney transplant specialists so that the United States can realize the bold goals set by the Advancing American Kidney Health Executive Order (5)? There are 62 accredited transplant fellowships in the United States, yet only 18 fellow graduates reported pursuing transplant fellowship in 2023. Will we have enough transplant specialists to care for our patients, and, if not, how can we change this?

To begin to answer these questions, the kidney community will need to both design and participate in longitudinal studies. These studies will need to use creative methods to sample representative cross-sections of kidney health professionals, including J-1 visa holders, nephrology subspecialists, underrepresented minorities, women, and those who completed residency after fellowship. In addition to longitudinal surveys, focus groups and semi-structured interviews are needed to explore the depth of these questions. We need to leverage existing partnerships, like ASN's collaboration with Phairify, to obtain accurate statistics about the current nephrology practice and forge other connections with professional organizations and government entities that will help us quantify the demand for nephrology care. Together, we must take collective responsibility for answering these questions to sustain a healthy and productive workforce.