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