Transplant Nephrology Accredited by ACGME: A Solution to the Shortage?

In the United States, transplant nephrology training is a 1-year clinical fellowship after general nephrology training. Over the past 10 years, the number of nephrology and transplant positions filled in the country has declined (1). This decline is concerning given the foreseen increase in the transplant workforce in the United States because the Advancing American Kidney Health Initiative aims to double the number of kidney transplants by 2030 (2). Given the concerns, a group of leaders in the kidney transplant field in the United States recently wrote a thought- and debate-provoking article in CJASN asking, “Should Transplant Nephrology Pursue Recognition from the Accreditation Council for Graduate Medical Education (ACGME)?” (3).

There are a few potential benefits in recognizing transplant nephrology by ACGME. Once transplant nephrology is ACGME-accredited, followed by American Medical Association recognition, we can possibly expect recognition from the Centers for Medicare & Medicaid Services (CMS). CMS recognition might add more value to a transplant nephrology practice and better reimbursement. In the educational setting, among other areas highlighted in the Table, we can expect salary support for program directors during nonclinical times. Probably the most crucial benefit of being recognized is the one related to visas; as of July 1, 2023, ACGME-accredited institutions that want to host J-1 trainees in nonstandard training programs are required to obtain ACGME nonstandard training programs’ recognition; otherwise, the programs cannot hire transplant fellows on J-1 visas (4).

Table

Positives and negatives of ACGME recognition by area

View Table

Although ACGME recognition could increase applicants, protect educational time, and boost reimbursement, it also has potential downsides, such as administrative costs associated with the ACGME certification and maintenance process, costs associated with American Board of Internal Medicine (ABIM) exams, and additional examinations for certification. Therefore, the solution to the present and future shortage may not solely lie in ACGME recognition.

Approximately one-third of US nephrology fellows surveyed reported experiencing burnout and depressive symptoms (5). We as a field should consider expanding the transplant nephrology training options for fellows in general nephrology so that those who choose to can finish their fellowship with enhanced transplant nephrology skills. This could be the proverbial stone that kills two birds: 1) diversify general nephrology training, making it more appealing through increased exposure to organ replacement through transplant and home dialysis; 2) generate a cadre of nephrologists who can take care of transplant recipients, extending the actual scope of practice away from in-center dialysis, which will likely decline due to the novel therapeutic advances such as sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and mineralocorticoid receptor antagonists.

In the CJASN article (3), the authors discuss the successes of hepatology and gastroenterology and advanced heart failure with transplant cardiology (AHFTC) fellowships. Even though AHFTC is an ACGME-recognized specialty, the field is struggling with recruitment; approximately 43% of the AHFTC positions went unfilled in 2023. A recent survey exploring factors that influence a cardiology subspecialty choice found that AHFTC trainees were less incentivized by certain career characteristics related to work-life balance. Compared with respondents with other career interests, trainees with AHFTC interests were less strongly motivated by work schedules, geographic flexibility, and financial compensation (6). Perhaps, as a field, we need to understand that ACGME recognition will not solve our shortage, and we are training a unique group of people driven by the desire to take care of patients with complex medical issues.

We need more comprehensive data to better understand why nephrology trainees are not showing interest in kidney transplantation training. Are they prioritizing immediate employment to manage debts or to support their families? If so, transplant programs in the United States should consider the Organ Procurement & Transplantation Network/United Network for Organ Sharing clinical experience pathway. We also need data on kidney transplant programs. Are they not filling up because they cannot enroll trainees on a J-1 visa, or is it due to a lack of applicants? If visas are the main issue, then ACGME recognition could be a potential solution.

We must include other transplant practitioners in this discussion on shortage; nurse practitioners (NPs) can successfully care for patients with complex diseases, such as kidney diseases. A recent study in Canada found that care provided independently by NPs was associated with greater guideline-concordant care than with primary care alone or with care by nephrologists, with clinical outcomes that were similar to those achieved with care by nephrologists (7). Can NPs care for patients in the kidney transplant setting? Yes; we can work along with NPs and accept a more supervisory role as a way to solve the issue. Another potential solution to the shortage is to empower general nephrologists to take care of postkidney transplant patients through robust educational resources.

Most recently, the field of transplantation has experienced significant advances, such as expanding the donor pool by implementing the hepatitis C program, developing new diagnostic tests based on cell-free DNA, and most recently, in xenotransplantation (8–10). These advances underscore the need for a set of specific and unique skills to move the field forward. It is our specialized knowledge and expertise that will drive the interest in the field of transplant nephrology, coupled with innovation and an increase in reimbursement.