Nephrology Workforce Crisis: Don’t Forget International Medical Graduates (IMG)
The declining interest in our specialty among young physicians in the United States is a major concern for the nephrology community. Reasons for this lack of interest include nephrology being perceived as difficult, arduous, and un-inspiring with poor career prospects and reimbursement potential. All this is occurring in the context of an anticipated increased need for nephrologists, based on current ESRD incidence rates.
While the decline among US medical graduates (USMGs) has been evident for several years, the recent match reveals another concerning trend. Applications from International Medical Graduates (IMGs) have plummeted, with dire consequences. Over 32% of fellowship positions failed to match, and 68 out of 134 programs (50.7%) did not get filled. This has worsened from 9.3% and 24 of 142 programs (16.9%) in the 2012 match, respectively.
Nephrology has recently relied on IMGs to fill fellowship positions due to the ongoing lack of interested USMGs. Despite this, it may be argued that these crucial IMG have not been prioritized. Certainly, individual institutions have appreciated the contributions they make, but the wider medical community likely does not appreciate the significant barriers to practice for IMGs, which have become more draconian in recent times. These include punitive visa requirements, particularly with the ubiquitous J-1 visa. At any time, there are 170,000 individuals on J1 training visas in the US, of which physicians make up a tiny minority. However, it is only physicians who must abide by the “home rule” requirement that mandates the doctor leave the US for a 2 year period after training. The only way around this is by getting a “J1 waiver” post in an underserved area. These posts are rare, and mostly primary-care based. This is a huge impediment for our IMGs to practice nephrology. It gets worse for senior trainees who have completed overseas training. IMGs who have not completed residency in the US cannot sit for the Internal Medicine boards, and therefore specialty board exams. This may be despite having board certification in Europe or elsewhere, and possessing highly regarded (at least outside of the US) qualifications such as membership of a Royal College of Physicians. With a highly restrictive visa process and inability to get board certified in the US, senior trainees from overseas, in effect, cannot practice nephrology in the US.
Maybe research is an option? After all, we struggle to find enough interested USMGs to perform high-quality research. Unfortunately, this is another avenue fraught with obstacles for IMGs. Only US citizens and permanent residents are eligible for most NIH grants, leaving the IMG in a position to either secure their own funding or give up on a research career in the US. Of course there are other sources of funding, such as the ASN and NKF, but overall the opportunities for IMGs are severely restricted. As an IMG who was in this position, I always struggled to understand the logic in this.
Career prospects for IMGs have become increasingly bleak, and this recent collapse in their interest in US nephrology fellowships does not surprise me. We need to embrace these enthusiastic physicians as well as figuring out why USMGs are not choosing our specialty. These two tasks are not mutually exclusive.
Dr. Paul Phelan
AJKD Blog Contributor
Very well written.
There is decline in the interest for Nephrology.
Lack of work force is a huge concern for future.
Everything you say is correct, except that the incidence rates of treated ESRD are declining not rising- this needs to be taken into account in “manpower” needed projections- also the rising trend for home dialysis treatment selection needs to be taken into account.
Richard J. Glassock, MD
Thank you Dr Glassock, you are correct.
Dr Verma< I appreciate the comment.
Dr Desai, you're absolutely right. The choice between J1/H1-B should not be what drives a physician to choose a specialty. Many institutions will only accept candidate on the draconian J1.
Great article by a knowledgeable writer. Thanks Paul for your consistently insightful comments.
One idea is to have the federal government declare the field of nephrology as unable to attract US citizens. This would begin the process of allowing programs to offer (more easily) H1B positions to interested IMGs. One big hesitation for IMGs in choosing nephrology is that many have worked very hard to acquire H1B status and really struggle to downgrade to a J1 visa. When push comes to shove, many IMGs will take the opportunity to become a US citizen over following their professional passion to become a nephrologist.
Tejas Desai, MD
Assistant Professor of Medicine
Director, Nephrology Fellowship Program
Division of Nephrology & Hypertension
East Carolina University
Greenville, NC
Founder and Editor-in-Chief
Nephrology On-Demand
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Very Interesting Article, I work in UK and the situation is relatively similar, nephrology is becoming less attractive, very hard work to be skilful nephrologist and at the end the Job Market is very Tight, many trained Renal physicians ended up doing Acute or General medicine.
I think we should rely on physician assistants or nurse practitioners to help with service and don’t lure more trainees (Home grown or international graduates) and they ultimately end up in very congested market.
While the statement regarding less “incident” ESRD may well be correct, the bulk of renal care is largely focused on an ongoing pool of longer surviving ESRD patients who have a number of complex medical issues that need to be taken care of. I am not sure how a physician assistant or a nurse practitioner can help in this situation given that most of their clinical approach is very protocolized and so of limited use. The same holds true about the suggestion of excessive manpower even if home dialysis becomes available. I am myself an IMG and have felt it very palpably in the interview process that even in states and areas where a sponsorship of J1 or H1 B visas are possible employers would not want to do so largely due to their unwillingness to do the extra paperwork/extra money that they would have to spend to get IMGs in. I believe that the importance /contributions of IMGs to the nephrology community is appreciated much less than what it needs to under the current circumstances and has made the nephrology market more congested than what it can be if one were to reason through pure economics….
With myself being an IMG, been here for 20 years, I have seen dramatic decline in renal field. I remember nephrology as a competitive fellowship program. Working in a teaching hospital, we used to have 3-4 residents applying for nephrology every year. Now there is not a single resident interested in this field. In addition to visa issues, residents feel there is far less reimbursement (earning potential) for the work load of a nephrologist – caring for ICU, chronic illness including dialysis patients. In my opinion, there is no other specialty that is so regulated by Government Agencies/For profit Corporations and this does not appeal to IMG residents when they are looking for high reimbursement fellowships like GI, Cardiology etc.