A Different Type of Practice. Workforce Trends and Mentorship Opportunities Highlighted at Kidney Week

There continues to be a limited supply of nephrologists available to manage an increasing number of patients with kidney diseases in the United States, Eleanor Lederer, MD, FASN, said during Kidney Week 2023. As care is being delivered more in a team-based fashion, and technology options are increasing, nephrologists will need to keep pivoting toward a different type of practice.

During a session on the nephrology workforce for the 21st century, Lederer, the John S. Fordtran, M.D., Professor in Calcium Research at The University of Texas Southwestern Medical Center's Charles and Jane Pak Center for Mineral Metabolism and Clinical Research in Dallas, explained that there are currently an estimated 11,000 nephrologists in the United States, but approximately 37 million individuals with chronic kidney disease (CKD) and 800,000 with end stage disease.

A 2016 report from ASN and The George Washington University estimated that the number of nephrologists would increase from 8533 in 2016 to 17,256 by 2030 (1), said Lederer, a past president of ASN and assistant chief of medical services for research and co-director of the Network of Dedicated Enrollment Sites (NODES) program at the U.S. Department of Veterans Affairs North Texas Health Sciences Center. While the workforce has increased, it is not quite keeping up with projections, she said. This has occurred in the face of a declining number of applicants to the field.

The year 2023 saw an encouraging increase to 458 nephrology match applicants, but for the appointment year 2024, the number declined to 379, Lederer noted. However, the overall percentage of fellows going into nephrology has remained relatively stable since 1991, at approximately 7% to 8%, she continued (2). According to Lederer, several trends will challenge the nephrology workforce going forward:

• Democratization of health care delivery. As much as health care is being consolidated into larger health systems, patients tend to identify with these systems more than individual practitioners. There also has been much more emphasis on a team approach to care. “It has really switched around the relationship between the patient and the physician,” Lederer said. “The physician is certainly no longer at the top of the pyramid.” Instead of the doctor giving instructions to the patient or other caregivers, multiple practitioners are interacting with the patient, who is no longer in a subservient position. Additionally, there has been a steady increase in the number of physicians employed by an entity and a progressive decrease in the number of independent practitioners.

• Shift to task-oriented focus. Health care is seeing both an increase in the division of responsibilities among health care practitioners as well as an accumulation of ancillary requirements, Lederer said. Physicians were once considered to be diagnosticians and knowledge and treatment experts. Today, they are also expected to know about documentation, data entry, coding, insurance, and value-based medicine. “It doesn't take a genius to see that once all these other responsibilities are added to every time I see a patient…it's going to be a distraction from my primary focus, which may be helping this person cope with their CKD,” she said. “There's a marked decrease in thinking time.” Work is trending toward decision making based on immediate data, without necessarily taking the time to conduct full medical histories, she said.

• Sub-sub-subspecialization. Niche practices have been developing requiring advanced skills, such as onconephrology, Lederer said, which raises the question of who is going to care for “garden-variety” CKD.

• Patient autonomy in health care decisions. Multiple sources of health care information—from the internet to direct-to-consumer advertising to virtual medical care—also have disrupted the traditional physician-patient relationship and have given greater power to patients to weigh in on treatment decisions, demand for therapies, and referral patterns. Patients will continue to assume more responsibility for their care as time goes forward, Lederer predicted.

• Artificial intelligence (AI) and other technological advances. “I think we all realize that we’re living with AI right now,” Lederer said. Big health systems are using AI to assess practice patterns, outcomes, costs, and patient satisfaction, she continued. But it also can be used to improve health care delivery and transitions of care. Potential applications could help with accumulation of data, identification of patterns within each patient, classifications of diseases, and differential diagnoses. Generative applications could be “an amazing timesaver,” allowing for creation of notes and letters and chatbots for patient interactions, she said. However, she cautioned, “physicians need to understand the limitations of this resource.”

Going forward, Lederer said she expects that nephrologists will be team members with advanced practice providers (APPs) and others, developers of diagnostic and therapeutic algorithms, secondary resources and diagnosticians for “outliers,” and overseers of population health trends. “We actually may not need as many nephrologists as we think we do,” she said. Yet, there will be a need for APPs, support personnel, and computer scientists and information technology specialists.