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