As mounting evidence makes the waning interest in nephrology obvious to all of us, we must ask, “Why have we been asleep behind the wheel?” The accompanying articles in this special issue of ASN Kidney News detail many of the problems that have finally gotten our attention.
For instance, why were our colleagues in Australia the first to raise similar concerns about the nephrology workforce (1)? Why did the nephrology leaders in the United States not notice that the majority of medical students in this country do not take electives in nephrology? This decision means that their exposure to clinical nephrology is limited to first- and second-year courses, which are primarily taught by basic scientists. Although they are superb educators, these faculty lack the experience in, and passion for, clinical nephrology that is needed to convey the relevance and excitement so many of us feel.
Why are internal medicine residents in the United States not required to complete a rotation in nephrology, especially if they intend to become hospitalists or intensivists? When did fluid and electrolytes, acid base, hypertension, and all forms of kidney disease cease to be recognized as an integral component of an internal medicine resident’s knowledge?
Finally, I find it somewhat ironic that participants in the Kidney Research National Dialogue—sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to identify the most critically important questions or research objectives in nephrology—identified the nephrology workforce of the future as a top concern.
To gain a better understanding of where we presently are and what is being done to help move nephrology forward, please read the excellent articles in this special issue of ASN Kidney News. These articles outline the problem, explain how this crisis may affect our ability to provide care to patients, and begin to provide some potential solutions for the future.
Using data from the Accreditation Council for Graduate Medical Education and surveys designed by the ASN Nephrology Training Program Directors (TPDs), ASN Policy Associate Rachel Shaffer provides evidence of a lack of interest in nephrology among graduates of medical schools in the United States. She also delineates the primary reasons for this apathy. Together with the marked reductions in J-1 visas issued—limiting talented international medical graduates from filling positions to help meet the increasing clinical needs—and the lack of gender and racial diversity, the problem is real and growing.
In another article, Ms. Shaffer and TPD Executive Committee member Mark G. Parker, MD, describe how the already rising population of patients who are best cared for by nephrologists will receive a rapid influx of additional patients as we enter a new era for health insurance coverage and accountability, as well as a change in the way we deliver care and are reimbursed for it. Attention is also given to the need for expanding other essential members of the nephrology health care team.
Always a contrarian, ASN Executive Director Tod Ibrahim contributes a controversial view of the workforce needs in nephrology. Reductions in reimbursement (especially the internal medicine component of dialysis patient care), bundled payments for care of patients with ESRD, and movement toward a more standardized approach to patient care may mandate the increased use of other providers, such as nurses and physician assistants, especially in dialysis units and accountable care organizations.
Another article, by ASN Policy Associate Daniel Kochis, predicts the results for nephrology of the 2011 Medical Specialties Matching Program. Although the fellowship match will not take place until this June, Mr. Kochis forecast this year’s results using data from the Electronic Residency Application Service. Unfortunately, the near future is worse than the recent past when it comes to interest in nephrology careers.
What is the ASN doing about this deteriorating situation? I am pleased to assure you that the ASN has made this issue a top priority for the next few years. An ASN Task Force on Increasing Interest in Nephrology Careers has already completed its mission of identifying the problems and making suggestions regarding potential solutions. One suggestion, the formation of an ASN Workforce Committee to devise and implement a plan, is proceeding. ASN Grants and Development Associate Evelyn Shapiro discusses the goals and approaches of the committee in this special issue. These recommendations cover a wide range of target audiences and implementation strategies, from first-year medical students through faculty and from education reform to research stimulation.
In summary, nephrology faces a critical problem with declining interest and expanding demands. This crisis seems paradoxical because 95 percent of nephrology fellows are happy with their career choice (Figure 1.1) (2). Therefore, we must work together to find a way of designing, developing, improving, and marketing what we know to be a rewarding, stimulating, and fulfilling career.
American Society of Nephrology Training Program Directors Executive Committee. 2010 ASN Survey of Nephrology Fellows, June 2010.