Show Me the Money: 2024 Nephrology Fellow Survey and Trends in Starting Salary

Incoming workforce

The 2024 survey was distributed in May 2024 to 962 current adult, pediatric, and adult-pediatric fellows in Accreditation Council for Graduate Medical Education (ACGME)-accredited US nephrology training programs. The response rate was 46% (n = 447), which was on par with previous years. Respondent demographics were generally consistent with those reported by ACGME with a few minor exceptions: over-representation of adult US medical graduates (USMGs [43% versus 37%]), adult White fellows (34% versus 26%), and pediatric White fellows (55% versus 47%) and under-representation of adult international medical graduates (IMGs [57% versus 63%]) and pediatric Asian fellows (18% versus 28%) (2). Fifty-seven percent of adult respondents were US citizens, and 24% were J-1 visa holders. Notably, these demographics—including trends in over- and under-responses—have been relatively static for several years.

Base salaries

How might salaries have been impacted by the economic milieu? In 2021, the annual median reported base salary for new fellowship graduates was $200,000. One year later, it was $219,500, before rising to $231,000 in 2023 and to $240,000 in 2024—a 20% rise over 3 years. For comparison, base salaries only rose from $162,500 to $190,000 over the preceding 5 years (17% rise).

What contributed to the rise in base salary from 2021 to 2024? The most obvious explanation is inflation. The United States experienced one of its highest annual inflation rates in history between 2021 and 2022, at 7%. (Higher rates were only seen during World War II and the post-Vietnam/oil crisis economy of the late 1970s [3].) But it seems that salaries rose more than the inflation rate (Figure). Closer observation shows that the primary drivers of the rise in median base salary were IMG salaries. Between 2021 and 2022, IMG base salaries increased 13.9% (compared with only a 0.3% rise among USMGs). The inflation rates were 7.0% and 6.5% in 2021 and 2022, respectively. USMGs experienced a 12.2% base salary increase in 2022 (likely, in part, a response to the previous year's inflation), and IMGs still had a 4.3% increase in 2022.

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Percent change in base starting nephrology salaries and annual US inflation, 2021–2024

Citation: Kidney News 17, 1; 10.62716/kn.000362024

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Why was there such a dramatic increase in the salary of IMGs relative to USMGs? Perhaps this is because IMGs may be more likely to accept employment in underserved (typically, rural) areas, where salaries are higher due to a low supply and a high demand for nephrologists. Approximately 25% of IMGs are J-1 visa holders, which means that to continue to practice in the United States without first returning to their home country, they must complete a waiver in a state-designated underserved area. Pandemic-induced workforce shortages may have further exacerbated the already-existing shortages in these areas, leading to increases in salaries. Also, loss of revenue by health systems during the early stages of the pandemic may have caused budgetary restrictions in more populous areas (where USMGs might be more likely to seek employment). Median base salaries were comparable between private practices (n = 67 respondents, 50% of responses) and academic practices (n = 42 respondents, 32% of responses). However, employees of nonacademic health systems reported substantially higher base salaries (and bonus/incentive pay) than private or academic practices, although there were fewer graduates who took such positions (n = 19 respondents, 14% of responses). Of note, base starting salaries do not reflect the differences in long-term earning potential between private practice and academic positions because it can take several years to become vested as a partner in a private practice and share in the full range of revenue income.

Important factors

Despite rising consumer prices, a competitive housing market, higher interest rates, and significant educational debt (disproportionately burdening USMGs, who have a median $250,000 in educational debt), new nephrology graduates valued lifestyle factors over financial compensation when searching for employment. However, compared with previous fellow surveys, compensation broke into the top five job-related attributes (ranked 5 out of 20) that are “extremely important” to new graduates. It only made the top five by a margin, but this could still potentially be a side-effect of the economy.

Future directions

In 2024, the ASN Data Subcommittee piloted a dedicated transplant nephrology fellow survey with nine current transplant fellows participating. Results from the survey can be found in the 2024 ASN Nephrology Fellow Survey Report (1). This research instrument will continue to expand to ensure that all facets of the incoming nephrology workforce are accounted for.