• Figure 1

    The decline of IMGs in nephrology parallels the rise in unfilled fellowship positions

  • Figure 2

    Percentage of IMG fellow respondents entering without US IM residency

Fellowship First, Residency Next: The Untold Story of Exceptionally Qualified Candidates in Nephrology

Sujith Kumar Palleti Sujith Kumar Palleti, MD, is a nephrology fellow with Loyola University Medical Center, Maywood, IL.

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The decline in interest in nephrology fellowships is well documented (1). However, what is more striking is the decline in interest in nephrology among international medical graduates (IMGs) (2, 3). In the United States, IMGs are defined as graduates from a medical school located outside of the United States and Canada. In 2019, 65% of US nephrology fellows were IMGs, a high number compared with other specialties, such as cardiology (37%), hematology oncology (35%), and gastroenterology (31%) (4). Although the number of IMGs who pursue nephrology fellowship is high, the absolute number of IMGs in nephrology fellowships has substantially declined by almost 50% from 2009 to 2019 at the same time as fellowship positions became unfilled in nephrology (Figure 1, see jump page).

Figure 1
Figure 1

The decline of IMGs in nephrology parallels the rise in unfilled fellowship positions

Citation: Kidney News 15, 2

Common reasons for the declining interest include the challenging patient population (6), perceived difficulty of the subject, declining competitive compensation rate, and lack of work-life balance (7). However, the recent decline in nephrology interest among IMGs, who may share some of the same reasons as US graduates, needs to be further studied.

It is now obvious in the nephrology community that foreign-trained physicians, who are joining as exceptionally qualified candidates, as defined by the Accreditation Council for Graduate Medical Education (ACGME), after completing their home-country residency and credential verification, are a growing group and form an incredible pool to support our nephrology community (8). Thus, obtaining exact data on the numbers and outcomes of IMG physicians who helped to fill nephrology fellowship positions that would otherwise go unoccupied is an unmet need. According to the annual ASN Nephrology Fellow Survey data from 2019 to 2022, the percentage of IMGs who entered fellowship training without prior US internal medical training has increased from 1.5% to 7% (Figure 2). However, the survey respondents only included a fraction of the total nephrology fellows in training (~20%).

Figure 2
Figure 2

Percentage of IMG fellow respondents entering without US IM residency

Citation: Kidney News 15, 2

Who is an exceptionally qualified candidate?

As defined by the ACGME (10), an exceptionally qualified applicant is someone who has 1) completed a non-ACGME-accredited residency program in the core specialty and 2) demonstrated clinical excellence, in comparison with peers, throughout their training. Additional evidence of exceptional qualifications, which are required, may include one of the following: 1) participation in additional clinical or research training in the specialty or subspecialty; 2) demonstration of scholarship in the specialty; 3) demonstration of leadership abilities during or after training; or 4) completion of an ACGME-International (ACGME-I)-accredited residency program. ACGME-I accreditation demonstrates that graduate medical educational programs outside of the United States meet established requirements for institutional, foundational, and advanced specialty education (11).

What happens to these exceptionally qualified physicians?

Fellowship training is usually the last phase of training for most physicians, and they start practicing right away. But for many of these exceptional pathway candidates, it is only the beginning of the hard and long road ahead. They cannot become eligible to sit for the American Board of Internal Medicine (ABIM) Nephrology subspecialty examination after completion of fellowship, according to ABIM guidelines, which require first passing the Internal Medicine ABIM examination. Eligibility to sit for the Internal Medicine ABIM examination requires completion of an internal medicine residency in the United States or Canada accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada, or the Collège des médecins du Québec. Additionally, the candidates are unable to obtain a permanent license in 26 out of the 50 states in the United States, according to the data compiled by the Federation of State Medical Boards (12). These 26 states require completion of 3 years of training. (Some states require this to be in an ACGME-accredited training program.) Thus, most candidates need to undergo an additional 3 years of US residency in internal medicine after a fellowship to fulfill various requirements to practice in the United States.

A hypothetical case of an IMG

Dr. X is an IMG who completed medical school in Country XYZ and studied hard to join an internal medicine residency in Country XYZ. However, she always dreamed of working in the United States as a physician and thus completed all the required United States Medical Licensing Examination program exams to apply for an ACGME-accredited nephrology fellowship in the United States as an exceptionally qualified IMG. She came to the United States with hopes of getting an unrestricted license after 2 years of nephrology training and working as a nephrologist in the United States, as the demand for physicians is huge and felt everywhere. As she navigated her fellowship training as a busy nephrology fellow, she realized that her options were far more difficult and uncertain than she had anticipated.

Many states do not allow her to obtain a permanent or unrestricted license because as mentioned above, they require 3 years of training in 26 of the 50 states (some requiring ACGME accreditation for all 3 years) or completion of a US internal medicine residency. Unfortunately, nephrology fellowships are accredited by the ACGME for 2 years, not 3 years; thus, she will not meet this requirement. She was also told by many that the ideal situation is to re-do internal medicine residency in the United States, but obtaining residency has gotten tougher year by year for IMGs.

Although doing a fellowship in the United States is one of the most challenging phases of a physician's career, having limited options and the potential of having to leave the United States permanently can take their toll on anyone. Under current circumstances, fellowship training in the United States without Nephrology ABIM certification does not carry much value, which means a waste of time and effort. The situation is not ideal for the health care community either, as there is a growing need for physicians, which makes it a lose–lose situation.

Difficulties in obtaining a job for exceptional pathway candidates

Limited J-1 waiver positions are available. The specialty of Nephrology has always relied on IMGs in fellowship training and beyond. Many of these IMG fellows train on the J-1 exchange physician visa sponsored by the Education Commission for Foreign Medical Graduates (ECFMG). Any J-1 exchange physician sponsored by the ECFMG is subject to a 2-year home-country physical presence requirement (13) before applying for jobs in the United States. To waive this requirement, the physician needs to work in underserved areas for 3 years. Although many doctors are willing to work in those areas, the waiver slots are limited to 30 per state under the Conrad 30 Waiver Program (14), which can be extremely competitive. Historically, when waiver slots become available in September or October, many states get filled immediately (15). For example, in Texas, the waiver program opens and closes on the same day on September 1st every year, as all of the slots are filled within a few minutes of opening (16). States such as Illinois, New York, Florida, and California receive a higher number of applications than the available waiver slots, and slots are exhausted in the first few weeks (17, 18).

A permanent license to practice is limited. The inability to obtain permanent or unrestricted licensure in many states is a huge drawback because of the state licensure requirements in 26 states, previously discussed. Of the remaining 24 states, although getting a waiver spot is a difficult task in many of them, as mentioned above, other states have very few programs that can offer faculty positions for nephrology-trained fellows. There is an inability to join private solo or group practices due to the difficulty in obtaining hospital privileges or an inability to become a dialysis director without ABIM Nephrology certification.

Fewer opportunities are available for faculty positions at teaching institutions because they require the approval of the credentialing committee to accept a physician without board eligibility, as well as for the reasons stated above.

Recommendations to help this vulnerable group of physicians

  • Request that state licensing boards give special consideration to provide permanent or unrestricted licensure following fellowship training for these exceptional pathway candidates.

  • Collaborate with hospital credentialing committees to hire these physicians, especially during times of shortage.

  • Apply measures to allow more programs to sponsor H-1B visas (allowing US employers to temporarily employ foreign workers in specialty occupations) for internal medicine residents and fellows instead of J-1 visas to eliminate the need for a J-1 waiver.

  • Present better data as to how many trainees in nephrology have entered the exceptional pathway (a de novo US nephrology fellowship without US internal medicine residency training), and clarify what their outcomes are.

  • Allow these exceptional pathway fellows who complete an ACGME-accredited nephrology fellowship to become ABIM Nephrology eligible immediately after completion of the fellowship and not wait until 3 years in a teaching hospital under Special Consideration Pathway A of ABIM (19).

The results of the fellowship match show that nephrology needs talented doctors who are genuinely interested in working in the field. The nephrology community needs to provide a secure pathway to allow for future practice after fellowship for exceptionally qualified physicians because they are filling those voids to some extent. This may potentially shift the game for the future nephrology workforce as well as the US health care system by encouraging more physicians with foreign training to pursue this pathway in the future.


I wish to gratefully acknowledge the contributions of Matthew A. Sparks, MD, in the development of this article.

A version of this article originally appeared on the Renal Fellow Network blog (2).