Well-Being in Nephrology Education

Ursula C. Brewster Ursula C. Brewster, MD, is a professor of medicine and program director of the Nephrology Fellowship Program at the Yale School of Medicine, New Haven, CT.

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There is a growing movement, particularly in the United States, focusing on enhancing wellness initiatives for trainees at various levels across all specialties. Notable adjustments include reduced call hours, more weekends off, and dedicated study leave. Although these changes have received praise, there is some concern among educators regarding potential unintended consequences, such as less effective training and lack of preparedness for an attending position after graduation. To gain insights into the impact of these initiatives on trainees’ well-being and education, Kidney News Editorial Fellows asked both a current fellow and a program director to provide their opinions on the matter.

The Kidney News editors want 300 to 500 words on well-being in nephrology education—not an easy task for a program director. I believe that program directors profoundly believe in maintaining a sense of well-being for our patients, our fellows, and our communities. That is, after all, why we are physicians. But the practicalities of our jobs, the needs of our patients, and the regulatory and financial pressures can make things murky.

Clinical nephrology, physiology, and research techniques are expanding at a breakneck pace, as are the Accreditation Council for Graduate Medical Education requirements for teaching important topics like population health, data science, team-based health, and quality/safety. As educators, we promise our applicants, the American Board of Internal Medicine, our patients, and society-at-large that we will have fellows ready to practice nephrology independently and safely within 2 years. There is simply more to do in the same amount of time, and we all feel the pressure of that great responsibility. Program directors should support the well-being of our fellows, and given the diversity of career trajectories possible, we need to listen carefully to what an individual fellow thinks that they need to be prepared to embark on that career journey. But at a systems level, a focus on fellow well-being is sometimes paired with a perceived lesser emphasis on attending well-being and can result in tension in the training environment, which should never be the case.

This is where our current systems of payment, reimbursement, and education let us down. Fellows need reasonable work hours, time for self-care, and supportive environments for learning, as do practicing nephrologists, our nurses, and social workers. Although the Accreditation Council for Graduate Medical Education can leverage change through accreditation requirements focusing on trainee wellness, the Centers for Medicare & Medicaid Services and private payers focus on cost abatement and reductions in reimbursement, making it challenging for fellows to find balance when they graduate. To head home in the evening, coach our children, and get some sleep at night, practicing physicians know that we must learn the medicine cold, so we do not spend hours second-guessing all of our decisions. However, we also need to learn to efficiently manage a long list of patients on a clinic day when we were on call the night before. As program directors and faculty, we feel a great responsibility to get our fellows ready for the very real reality of practicing medicine in 2024, in order to ensure lifelong wellness.

A fellow's job is to understand the enormous privilege and responsibility that lies ahead of them, and they need to do all that they can to be ready for it. And as program directors and attendings, our job is to provide them with a supportive learning environment and guidance to help them grow and stretch, often beyond what they have done before. As physicians, we hold a covenant with the community of patients who we are here to serve—to protect their health and well-being. Ours is a profession, a calling, and so much more than “a job.” This profession brings wonderful opportunities our way, provides us with financial and social stability, and fills our worlds with a sense of wonder at what is possible, day in and day out. And although challenging, it is our profession that is often the very thing that restores us when least expected. Wellness is, after all, what we are about as doctors.


The author reports no conflicts of interest.