A New Nephrologic Syndrome: Acute Fellowship Insufficiency
Invited commentary by Dr. Warren Kupin
The fallout from the nephrology fellowship match this year and its short and long-term consequences are becoming painfully clear to program directors as well as those of us in clinical practice. Fewer than 50% of programs filled their open positions, and some large academic programs did not match even a single fellow for next year. The declining interest in nephrology is pervasive among both U.S. graduates and International Medical School Graduate applicants. We are at a crossroads regarding the future viability of our specialty. It is worrisome that with fewer available nephrologists, more and more nephrology care will be simply absorbed by internal medicine. Other than occasional renal consultations and running a dialysis unit, the nephrologist may cease to be a recognized clinical specialist.
Nephrology has been losing ground steadily over the past 5 years. Recognizing this issue and addressing the multiple contributors that have brought us to this juncture is the responsibility not only for our national organizations, the ASN and NKF, but more importantly those of us in clinical practice, especially at academic centers.
Initial interest by students or residents in a nephrology career occurs through their interactions with the medical school nephrology faculty. Students and residents are not only positively influenced by the passion and expertise of their faculty, but also negatively influenced by the direct and indirect messages we send them regarding our professional satisfaction and career fulfillment.
There is a quote that states “we have met the enemy and he is us”. How can we expect others to go into nephrology when we ourselves are woefully dissatisfied with our careers. Recent surveys show nephrologists near the bottom of all medical subspecialties in career satisfaction (also see Medscape survey). No doubt this is a result of the fact that nephrologists are at the highest tier for weekly work hours, but are experiencing the steepest drop in salary and reimbursement of any medical subspecialty.
The issue of income and compensation for the hours of effort cannot be solved at the level of the community nephrologist, but must be addressed by our representatives at the national level. Over the past years, we have failed to distinguish ourselves in regard to the complexity and detail of our management of CKD from general primary care physicians. Our office visits are held to the same coding levels as a general medicine visit. Reimbursement for office visits for the management of CKD stage 4 or glomerulonephritis do not reflect the comprehensive and time consuming nature of what we offer to the care of the patient. Coupled with the diminishing payments for ESRD, it is no surprise that nephrologists are pessimistic about the future of our profession.
I have no doubt that we as nephrologists routinely offer students and residents the academic motivation to join us, but the economic constraints and high work loads are major obstacles that represent formidable barriers. These appear to dissuade most of the trainees, and the match results speak for itself.
The fall in fellowship applicants needs to be stopped immediately or we will find the workload even more unacceptable as we fail to fill positions being opened by retiring physicians and the increasing need of an expanding CKD population. We cannot change the reimbursement issues overnight—but I think that we would all feel more optimistic if the national leadership level focused on this goal.
A recent published ASN response to the fellowship match detailed the need to improve the educational and academic experiences of trainees to convince them of how exciting a career in nephrology can be. I think this is already established, and not the reason for our failure to attract applicants for the past 5 years. Nephrologists need to be recognized for the cognitive skills they bring to the table in the management of kidney disease that cannot be duplicated by primary care physicians. The ASN and NKF should be at the forefront by lobbying for our unique contributions to be recognized by government and third party payers.
There is no one easy answer and multiple issues to address in order to reverse the falling interest in nephrology. This year’s match results should be the final incentive for us to make a concerted effort to address the future of nephrology. Everyone’s opinion matters and this is the opportunity for us to pool ideas and ultimately solve this problem.
Warren L. Kupin, MD
University of Miami Miller School of Medicine
I think, what increases a value of a medical specialty is the extent of invasive intervention that can be made by the specialist oneself.
Patient’s coherence is also deeply related to this fact as far as I can see.
My suggestion is to train and certify nephrologists so they can perform and report urinary ultrasonography, palce tunneled catheters, perform renal biopsy, place nephrostomy catheter, create arterivenous fistula, perform angiography, place renal artery and fistula stents.
Some of my collegues do not like to do these, and prefer only to expel their considerations and just give medicines. But, i think and deeply hope that a nephrologist should be able to give the most comprehensive care to patients on his/her own, and i would very much like to go through this. I would like to invite you to think about what gastroenterologists can do on their own today in this manner.
Sisli Hamidiye Etfal Educational and Research Hospital
Unless you’re planning on dealing with all the surgical complications and bad outcomes related to rampant unnecessary renal artery stent placements, don’t do it. We’re still coming out of a bad place with this drive-by intervention by the cardiologists over the last decade; data shows it hurts more than helps.
Vascular Surgery Fellow
As Executive Director of the International Society of Nephrology, I believe our Society could help attracting young Fellows to nephrology, by organizing a short-term experience within our humanitarian programs in an emerging country. This will give them a feeling that they CAN impact patients (particularly young ones) in a very meaningful way, and potentially convince them that nephrology is not just caring for the elderly and the never-to-be-healthy again.
What nephrology needs is innovative ideas and going back to science/innovations especially in the fields of dialysis and CRRT where nothing exciting has happened for 20 years. Restructure these fellowships so that fellows will learn management instead of just talking abstract. Let us be honest, the lectures in these conferences practically drive me into a coma, most of the attendees would not make it till noon if Starbucks is not in every corner. I attended a dialysis course in one of these big meetings, thought I will get something out of it, learn something. Instead, all I heard was epidemiology jib-jab, body surface area, outcomes of creams (in the form of survival curves), etc. That was the scintillating moment of the day! I practically walked away from most of the lectures. I still have nightmares about it!
The rest of the sessions will be dedicated to redefining AKI every other year (by adding 0.3 here or there) and speaking about it as a ground breaking science. Then spend the year after publishing AKI papers with this new ground breaking definition.
I couldn’t agree more… It’s been decades since dialysis has been performed in its current form, despite the fact that in 80% of the world countries it is neither accessible nor affordable to the average citizen. It is high time a new dialysis procedure, which is low-tech and cheap, is brought forward and made available on a large scale. The ISN has plans in this regards, stay tuned…
Leon, I agree with you. My keynote lecture at the upcoming Annual Dialysis Conference is “The Decline and Fall of Dialysis Medicine”.
Yesterday talked about this with one of my teachers who have witnessed the evolution of nephrology in the last 50 years, referring to the current situation of nephrology worldwide has everything to do with the fact the industry is who has taken advantage of this branch of medicine, in recent decades the industry monopolies nephrology (known to all) are those who have done business and are gradually have “devoured” this specialty; nephrologists increasingly work for the growing number of kidney patients, but despite having more work is equal or less financial reimbursement, and who always comes to economic profit is the industry because more patients on dialysis will be increased the number of devices to perform this therapy, as already said, perhaps this is one reason why has lost interest in studying nephrology and medical students opt for other specialties. Today in my country is virtually impossible for a nephrologist in the private media will compete for industry, it takes long time to open your dialysis unit, but will immediately open around competition in the industry.
Resident of Nephrology
The situation will get worse unless countries which call themselves advanced in every way realize that IMG from other countries that does not include USA, Canada etc. do possess immense experience and valuable qualifications that given the right opportunity will help fill in that void that USMGS cannot do. It is indeed unfortunate that Canada encourages the HSMWP and then when you do make that transcontinental shift after leaving a flourishing career behind in one’s own home country behind with the hope of succeeding elsewhere, you are grounded since that country will not recognize the previous medical degrees worthy enough to get a medical license and then essentially you are a no-body! So all this talk of getting increasing nephrology workforce is rather all humbug.
As a recent nephrology graduate and having somewhat recent perspective of the ongoing job market, I think there are multiple reasons why it is no more attractive to either US or International Medical Graduates (FYI: this has to do more for community job market situation and not for academic centers):
1. If you want IMGs to pursue for fellowship, you need to keep the downstream open which means more visa job opportunities. If someone looks into the job market, no one wants to even look at your CV if you need a visa. So why will someone opt for fellowship, just for interest and not having to practice in future??
2. Even if someone ends up getting a job, some established nephrologists who are in hiring position are not ready to offer a decent salary for the amount of wRVUs that the budding nephrologists generate (not even close to half).
3. There needs to be a cap on the amount of dialysis patients a nephrologist can have or if not that at least let the new-comer be allocated some dialysis patients; this is the only way the base salary of the nephrologist can increase (there will be many who may not agree but this is a bitter truth, I know this is the money bank for many nephrologists). This is the only way you can make nephrology lucrative.
4. If you think a US graduate with debt in five digit figure to start a job with 150-170K for starting 2-3 years and then can expect variable increase depending on the employer, then we need to do some calculations. Getting 150-170K for 3 years = 450-500K (working 24 days/month in the best case scenario). If the same person does a hospitalist job for the same number of days,he can earn easily 1M dollars sitting at one hospital. The only way for him/her to pick a nephrology job will be if he/she is assured of the partnership/dialysis patients down the line and can make up for the first three years of hardship.
According to me the condition of nephrology these days is like: “Rich are becoming richer and poor are becoming poorer”. I hope if these concerns are surveyed and looked into by the ASN, NKF, academic centers in collaboration with Fresenius/DaVita; we may have more answers. I don’t think the demand for nephrologists is going down and if we redesign/realign/reset the job market; it will bounce back.
is the ABIM certification exam in Nephrology more difficult to pass ?
I just graduated from nephrology fellowship in 2015. I am still looking for a job in nephrology. I think the amount of work, and traveling from hospital to hospital that you are expected to do for the amount of money private groups are offering is just ridiculous. I am truly questioning myself about the choice I have made and if in fact this is the lifestyle I want to have while taking care of my kids and enjoying them….
Nephrologists are unique breed, we surrender our skills meekly to hungry predators from other specialities as intensivists/IR/Hospitalists. Patients have scant respect for those who help them little and kick them around to get help and thats not cool for future fellowship aspirants. Frankly I spend so much time in wards networking to get procedures done on my patients by other specialist which I should have done in first place, it feels lousy, a few decades ago some smart cardiologist tried out PCI and now they do PCI aortic valve replacement/device closures etc and the field continues to attract large prospective aspirant pool and great trials, now imagine if only a smart kick ass nephron did the same for lets say some post-renal AKI then, we would have taken over cystoscopy and nephrostomies/DJ stenting at least. The last Nephro bastion transplant is not anymore on Nephrology plate with surgeons slowly but surely taking it away in US (although for now thankfully not so in Canada) – Like Mother Teresa once said-” helping hands are better than preaching lips”. ASDIN needs to restructure fellowship program and get program more hands on/apprentice based – get the guys to the vascular lab/dialysis/CRRT/biopsy suits … before we close it with an obituary.
I am applying for fellowship this year ,I always liked this speciality since medical school .
But very sad to see how this speciality is underrated .
I want some experienced thoughts and revs about pursuing it as my career .