Moving Forward: Innovation in Science and Continuing to Foster Interest in Nephrology

The year 2023 continued to be optimistic for nephrology. We witnessed exciting advances in our field: Treatment options for immunoglobulin A (IgA) nephropathy are increasing, with the US Food and Drug Administration (FDA) granting accelerated pathway approval of endothelin antagonists and budesonide (1). In 2024, we may see inhibitors of complement (2) and anti-APRIL (a proliferation-inducing ligand) inhibitors emerging (3) for the treatment of IgA nephropathy. We are starting to see the four pillars of care for patients with diabetes and chronic kidney disease (CKD) treatment come to fruition, and we may finally see a major decline in the incidence of kidney failure (4). In the field of hypertension, aldosterone synthase inhibitors are emerging as potential therapeutic options (5), along with FDA approval of renal denervation (6). Lupus nephritis treatments are on the rise, and we may see more to come in 2024 as obinutuzumab may make a big splash (7). Finally, kidney xenotransplantation continues to take steps forward (8). This year will be remembered for nephrology.

In November 2023, Match Day for nephrology fellowships arrived, and the trend of unfilled positions in the United States persisted (9). However, although the number of applicants is down compared with the last few years, the trend has continued to rise over the past 10 years (Figure 1). Recruitment to a field is a long game, and we will see ebbs and flows from year to year. It is important that we keep pushing to innovate and improve advances in kidney care and how we deliver this care. As devoted nephrologists who are passionate about our field, how can we continue to push the envelope?

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Trend in nephrology fellowships based on matched applicants

Citation: Kidney News 16, 1

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The field of nephrology continues to be filled with excitement. CKD care is seeing novel treatments, and glomerular disease randomized clinical trials are rising. The Kidney Health Initiative has led to a new, accelerated drug-approval pathway by the FDA. It has already resulted in novel drugs in the hands of prescribers. Which aspects of nephrology should we continue advocating for?

Approximately a decade ago, we completed a survey of 714 fellows across all disciplines of internal medicine, except nephrology, about why they did not choose nephrology. This survey revealed some eye-opening findings (10). Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% considered nephrology a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field generated higher incomes or if the subject was taught more thoroughly during medical school and residency. The top reasons for not choosing nephrology were the belief that patients with end stage kidney disease were too complicated, the lack of a mentor, and insufficient procedures in nephrology. Have those factors changed now with the current applicant pool? There is a perception that demand for non-procedural fields like endocrinology and rheumatology is greater than nephrology.

In 2023, the matching process for medical specialties saw different levels of applicant success: Endocrinology accepted 350 fellows; infectious disease, 303; and rheumatology, 273, whereas nephrology filled 321 positions. Endocrinology and rheumatology have lower total spots than nephrology. Although not all nephrology fellowship spots are filled during the match, most are filled post-match. This situation may be undesirable for both the program and the candidates.

Are patients with kidney diseases too complex? A study from Canada confirmed our assumption (11). This study was a population-based retrospective cohort study of 2,597,127 residents of the Canadian province of Alberta, aged 18 years or older, with at least one physician visit in 2014 through 2015. Data were analyzed in September 2018. When types of physicians were ranked according to patient complexity across all nine markers, the order from most to least complex was nephrologist, infectious disease, neurologist, pulmonologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician. Regarding the mean number of comorbid conditions that a specialist treats, nephrologists were the highest followed by infectious diseases physicians. More often, nephrologists (followed by infectious disease physicians and neurologists) supported patients with chronic conditions, often involving emotional concerns—not a surprise to most of us. Nephrologists also treated patients who were prescribed the most medications (not just by nephrologists but by all of their treating physicians). As a result, medication discrepancies are not uncommon in patients with kidney diseases. Most patients who were referred to renal specialists were also more often treated by other physicians, a close second to those treated by infectious diseases specialists. Strikingly, nephrology also included patients with the highest mortality (significantly higher than in other fields). What is more important is not where nephrologists stand in the ranking but that there is such a wide variation in the degree of complexity of patients with kidney diseases compared with those in other specialties. As the authors suggest, this impacts educational and health policy.

Complexity and curiosity drove us to nephrology, but for some physicians exploring the field, it might push them away. In addition, physician or facility reimbursement in the United States does not reflect the complexity of the patient. There is no question that patient complexity requires time (including the time required to communicate with multiple other physicians), expertise, and resources to optimize management. However, reimbursement of physicians and facilities in the United States is most commonly based on fee-for-service compensation. The complexity of medical decision-making is addressed by assessing the number of diagnoses and management options considered, the medical risks, and the amount of data to be reviewed. Adjusting payments to encourage physicians to spend more time and resources caring for patients at the highest risk of complications makes sense from a health care payer's perspective. However, how do nephrologists do this and discourage those who may take advantage of the system by overbilling? This reimbursement dilemma is crucial in nephrology, given the declining interest in this field. Changes in reimbursement could potentially reverse this trend.

Nephrologists are at the center of a complex field of medicine, with high regard from many medical disciplines, and should take pride in this. As a result, improvements in negotiations with policymakers who decide dollar amounts for work relative value units (wRVUs) should be initiated. According to a recent study, compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation (12). It is actually the factors outside of the wRVU system, such as payer mix and work hours, that can be targeted if narrowing the difference in compensation across specialties is desired. The commonly used benchmarking surveys do not capture the essence of the work done by a nephrologist and join the call for national nephrology societies to lead efforts to clarify the scope of the problem and identify the non-patient encounter activities for which value has yet to be recognized. We need to educate the payers that complexity takes time, and treating patients with complex conditions is equally as hard as undertaking an interventional procedure. As mentioned in a 2021 Kidney News issue (13), a survey of patient care activities occurring outside of patient encounters would be of tremendous benefit to the nephrology community and provide a more realistic basis for applying wRVU targets. This would provide both academic and private nephrology practices with benchmarks and points of comparison through which value for currently uncompensated work could be determined. Meanwhile, we may consider other ideas to overhaul and adapt the field of nephrology to the new generation of learners and physicians. We need to identify what the true problem is. Repeating the original survey of non-nephrology fellows (10) after 10 years may help identify current obstacles before we consider drastic changes.

What can we do in 2024 to improve nephrology? Table 1 discusses some potential ideas, and we welcome other potential ways to improve and move nephrology forward. Let's start a dialogue to change nephrology for the better and improve our patients’ and practitioners’ lives.

Table 1

Potential ideas to change the way we view nephrology

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