The results of the 2024 Pediatric Nephrology Fellowship Match have once again highlighted an ongoing concern in the field. This year, 45 fellowship programs offered a total of 73 positions, yet only 39 of these positions were filled across 20 programs (1). This continues the current trend in pediatric nephrology seen over recent years (1):
2023: 42 programs, 67 spots offered, 36 filled in 17 programs
2022: 43 programs, 60 spots offered, 33 filled in 18 programs
2021: 44 programs, 69 spots offered, 51 filled in 28 programs (outlier year)
2020: 41 programs, 64 spots offered, 38 filled in 19 programs
Decreasing workforce amid rising demand
This steady decline in fellowship match numbers comes at a time when the demand for pediatric nephrologists continues to increase. A 2018 analysis of referral patterns demonstrated a significant rise in consultations for conditions such as acute kidney injury, hypertension, chronic kidney disease, and kidney failure, among others (2).
Despite this, a workforce survey conducted in 2013 highlighted that one-third of pediatric nephrologists who responded planned to reduce their clinical practice, and nearly half intended to partially or fully retire in the coming years (3). As of June 2023, there were only an estimated 709 board-certified pediatric nephrologists under the age of 70 years in the United States. On average, this equates to just 13.3 pediatric nephrologists per state, although this number highly varies, with a range of 0 to 73 per state (4). This shortage is reflective in findings of increased faculty and trainee burnout rates associated with significantly lower quality of life, higher perceived stress, and lower satisfaction with career choice and work–life balance (5).
The question that remains is simple: Can the current trends keep up with the rising demand for pediatric nephrologists? A microsimulation model conducted by the American Board of Pediatrics in partnership with the Carolina Health Workforce Research Center estimated that in 2020, there were only 0.5 pediatric nephrologists per 100,000 children in the United States. Even if the current match rate persists, the model predicts only a 26% increase by 2040, reaching 0.63 pediatric nephrologists per 100,000 children, which only equates to an average rise of one physician per state (4).
Potential solutions: How can we reverse the trend?
Increasing interest in pediatric nephrology
Pediatric nephrology has consistently been one of the least competitive pediatric subspecialties. To address this, we must continue to explore ways to engage trainees early. By identifying programs that successfully generate pediatric nephrology applicants, other programs may be able to replicate their strategies in increasing interest among residents to the field. Other strategies can include expanding elective rotations and research opportunities in nephrology to spark interest among residents.
Shortening the training pathway
The current length of the 3-year pediatric nephrology fellowship has been a highly debated topic in the field of pediatric nephrology over the past several years. A 2016 American Academy of Pediatrics survey of pediatric nephrologists found that 49% supported reducing fellowship to 2 years, whereas 34% opposed, and 17% were undecided. The primary concern about shortening training lies in research, with opponents arguing that research is essential for academic centers and fearing that loss of research would lead to a decrease in pediatric research findings (6).
However, workforce data from 2018 to 2022 found that only 15% of pediatric nephrologists spent more than 25% of their work time on research, whereas 75% focused primarily on clinical care. Offering a 2-year clinical track alongside a 3-year research track could attract more applicants while maintaining research opportunities for those interested. This in turn could open the opportunity for pediatric nephrology to expand from being primarily affiliated with academic programs to small, private practices, which could allow for easier access to pediatric nephrology physicians, particularly in regions currently without physicians.
Pediatric nephrology could consider restructuring its training pathway to resemble pediatric neurology, in which trainees complete 2 years of general pediatrics followed by 3 years of subspecialty training, streamlining the process while maintaining clinical and research competency.
Advocating for higher compensation
Financial concerns remain a major barrier. Pediatric nephrology is one of the lower-paid pediatric subspecialties, and, on average, pediatric nephrologists earn significantly less than adult nephrologists. Given the current economic climate, requiring trainees to undergo 6 years of training with minimal compensation—only to enter a field with relatively lower pay—is increasingly unsustainable. Addressing salary disparities and advocating for increased compensation could help attract more trainees.
The ongoing challenges in the pediatric nephrology match highlight the need for thoughtful solutions to strengthen the workforce. Encouraging interest in the field, exploring flexible training pathways, and addressing compensation concerns could help attract more trainees. A collaborative effort will be essential in ensuring that children with kidney diseases continue to receive the specialized care they need.
Footnotes
References
- 1.↑
National Resident Matching Program (The Match). Results and data: Specialties matching service 2024 appointment year. February 13, 2024. https://www.nrmp.org/match-data/2024/02/results-and-data-specialties-matching-service-2024-appointment-year/
- 2.↑
Hanevold C, et al. Changing outpatient referral patterns in a small pediatric nephrology practice. BMC Pediatr 2018; 18:195. doi: 10.1186/s12887-018-1164-1
- 3.↑
Primack WA, et al. The US pediatric nephrology workforce: A report commissioned by the American Academy of Pediatrics. Am J Kidney Dis 2015; 66:33–39. doi: 10.1053/j.ajkd.2015.03.022
- 4.↑
Weidemann DK, et al. Child health needs and the pediatric nephrology subspecialty workforce: 2020-2040. Pediatrics 2024; 153(Suppl 2):e2023063678P. doi: 10.1542/peds.2023-063678P
- 5.↑
Halbach SM, et al. Burnout in pediatric nephrology fellows and faculty: Lessons from the Sustainable Pediatric Nephrology Workforce Project (SUPERPOWER). Front Pediatr 2022; 10:849370. doi: 10.3389/fped.2022.849370
- 6.↑
Primack WA, et al. Pediatric nephrology training worldwide 2016: Quantum educatus? Kidney Int Rep 2016; 1:144–147. doi: 10.1016/j.ekir.2016.07.002
