2 AM. Pager beeps… Nephrology Consult please.
“My patient has a serum potassium of 6.4 mEq/L. Can you please assist with his management?”
“What is he admitted for? Is he hemodynamically stable? Does he have EKG changes? What is his kidney function?”
“Cellulitis of the leg. Yes, he is stable. No EKG changes. Kidney function is normal.”
“Can you please send a STAT plasma/whole blood potassium level and page me back with the results?”
3 AM. Pager beeps.
“His whole blood potassium level is 4.9 mEq/L. Thanks for your help. I’m sorry for the trouble.”
Isn’t that a moment of déjà vu for most of us practicing nephrology?
A nephrology fellow on call invariably gets numerous pages after-hours, unless it is a Super-Bowl night, which miraculously brings pathophysiology to a standstill. These pages can regard anything from a new consult to a “just-wanted-to-let-you-know” dialysis-related issue. And should you have a patient with a critically low sodium level or soaring potassium level, sleep would only be an illusion for that night.
It has been contemplated that the high volume of after-hour pages could be one of the potential contributors to the busy work schedule of nephrologists, which in turn leads to considerable frustration with their career choice. Also notable is the progressive decline in the number of applicants to nephrology over the past decade. Sandal and colleagues analyzed the nature of after-hour pages received by nephrology fellows at the University of Rochester, as a part of a quality improvement study. They found that only 24.5% of the 615 after-hour pages were for new consults, the rest regarding consults previously seen (25.5%) or patients undergoing dialysis, including dialysis access issues (38.9%). Approximately 27% of the pages resulted in no further action. Reflecting upon these observations, Sandal and group speculated whether improved communication with the respective primary teams and/or dialysis nurses as well as modification of dialysis order sets would result in fewer after-hour pages.
The study by Sandal et al provides a guiding light for future educational research. It would be interesting to analyze the burden of after-hour pages across other non-procedural specialties in which fellows take home-call (endocrinology, infectious disease). Furthermore, comparisons with fellows in non-academic or community settings would also be interesting.
However, the impact of after-hour pages on the future nephrology workforce must be considered within the bigger picture. In other words, fellowship training is only a fraction of one’s career, and call is yet a smaller fraction. The major factors reported to contribute to discontent with nephrology as a career are limited financial potential in proportion to the long work hours (8.1% decline in income according to Medscape Nephrologist Compensation Report 2014 – the highest decline across all specialties) and poor job opportunities, which essentially come into play after one’s training is over.
The complex nature of our specialty makes untimely emergencies and pages inevitable. However, for those of us who truly enjoy the intellectual stimulation and the challenges involved in caring for patients with complex kidney disorders, this may represent only a minor concern compared to the challenges that follow fellowship. What may help the most is a multifaceted approach, aiming at creating more job opportunities for graduating fellows, lowering the patient-nephrologist ratio and/or improving nephrologists’ compensation in order to improve the overall quality of life after nephrology fellowship. Undoubtedly, changes in this direction require actions at multiple organizational and government levels. Could such interventions eventually result in enhanced interest in nephrology as a career? Only time will tell.
Ritu Soni, MD
Clinical Instructor of Medicine, University of Pittsburgh Medical Center