Selection Committee Member: Yusra Cheema @YusraCheema1
Yusra Cheema is an Assistant Professor of Medicine in the Division of Nephrology and Hypertension at Northwestern University. Her interests lie in medical education and she currently serves as the Nephrology Fellowship Program Director, M1 Renal Module Leader, and Phase 1 Curriculum Co-Director.
Writer: Bethany Roehm @bethany_roehm
Bethany Roehm is currently a fellow at Tufts Medical Center in Boston, MA. She was previously an AJKD Editorial Intern from 2019-2020. She also does clinical research involving patients with advanced heart failure with a current focus on kidney function in patients with left ventricular assist device.
Competitors for the Workforce Region
The recruitment and maintenance of a robust and diverse pipeline of kidney specialists is critical to the evolution of nephrology. The last decade has seen a decline in interest in individuals pursuing subspecialty training in nephrology. The reasons for this decline are multifold and have been debated, discussed, and deliberated. Purported reasons include a lack of mentors, challenging subject matter, lack of procedures, perceived lack of innovation in the field, diminished compensation, and challenging work-life balance, among others. The nephrology community has started to tackle these challenges head-on and is trying to continue to address them. Nephrology educational initiatives are being deployed throughout the spectrum of training from medical school students to seasoned attendings (grass roots, institutional, and society-sponsored). Alongside these educational efforts, nephrology societies, industry, and governments are investing in innovative research, therapeutics, and devices (eg KidneyX, pharmaceutical investment, the NIH Kidney Precision Medicine Project). Recent randomized clinical trials showing the efficacy of sodium glucose co-transporter-2 (SGLT2) inhibitors in patients with non-diabetic and diabetic kidney disease have been a shining example of innovation in nephrology therapeutics. Similar advances have been seen in the treatment of lupus nephritis and other glomerular disorders. While the most recent recruitment season saw a slight increase in applicants (see below), more work is needed to continue to stimulate interest in nephrology.
In addition to increasing applicant numbers and interest, there is an urgent need to increase diversity within the nephrology workforce. In 2015, only 6% and 5% of medical school graduates identified their race as African American/Black or Latinx, respectively, and in 2019, only 7% and 10% of US nephrology fellows self-identified as African American/Black and Latinx. In the general US population (2019 data), 13.4% identify as African American and 18.5% as Latinx. In contrast, 30% of prevalent patients with kidney failure identify as African American or Black, and 18% Latinx. The burden of chronic kidney disease disproportionately affects Black patients, and racial and social inequities significantly impact kidney care. Moreover, there is also a need to increase gender diversity in nephrology.
An ongoing debate with respect to recruitment is where we should spend our time and effort. Should we devote resources to trying to attract trainees during medical school or should we focus our attention towards somewhat-differentiated internal medicine residents? Both, right? NephMadness is all about competition, so this year’s Executive Committee thought it was time to take a deep dive deep into both arenas and examine the data, assess the status quo, and explore the future. Our first matchup pits medical student interest against internal medicine resident interest in nephrology. Who will advance?
The second match up in this year’s Workforce Region should come as no surprise. Though trainees may be unaware of the myriad opportunities that exist in both academic and private practice nephrology, deliberation as to which to pursue may start even before fellowship training begins. The spotlight is now on Academia and Private Practice. Will they show off their best moves, and demonstrate the breadth and depth of both of these areas of nephrology? Let the games begin!
Medical Student Interest vs Resident Interest
Medical Student Interest
“Doctor” in Latin literally translates into “teacher.” Medical school classrooms might be the first place to spark that interest in the kidney. Sure, they already have USMLE Step 1, clerkships, and the Match process looming over them, but if we want to nurture the next generation of nephrologists, is this where we should be putting our efforts?
Medical school provides one of the first opportunities for a trainee to develop a passion for nephrology. Exposure to a variety of experiences including mentors, patient care experiences, peer-to-peer interest, advocacy opportunities, and subject interest can whet the early trainee’s appetite. So when and how do trainees choose a specialty or subspecialty? A survey of internal medicine residents aimed at understanding factors associated with selection of infectious disease subspeciality training indicated that 65% of graduating residents developed their ultimate career choice prior to starting residency. Survey data from nephrology fellows, however, revealed that 68% indicated that they made their decision to pursue nephrology during residency. Does this mean that the nephrology medical student experience is suboptimal? The data here are conflicting; a survey looking at medical student attitudes towards kidney physiology and nephrology identified a substantial portion (89%) of respondents who demonstrated an initial interest in pursuing nephrology (by answering statements positive towards nephrology). In contrast to this, a survey of 10 internal medicine residents reported a lack of medical school exposure as an important reason why they did not choose nephrology.
How can the nephrology community spark and cultivate a potential initial interest during medical school into something long-lasting? Let’s break down each of the issues listed above and expand on them.
Medical Student Exposure to Nephrology
Anecdotally, kidney physiology and pathophysiology courses taught in the pre-clinical years of medical school are often what initially draws people to nephrology. While some may find kidney physiology fascinating, others may find it daunting to learn. Innovations in kidney physiology education seek to teach fundamental nephrology concepts while making it more approachable, digestible, and even fun. For example, the embedding of flipped classrooms into medical school curricula allows for the learning of fundamental concepts outside of the classroom while clinical correlations can be emphasized during active group work (team-based or problem-based learning). Digital chalk-talk videos have been shown to improve knowledge attainment and satisfaction when used as a method to deliver kidney physiology content during medical school. Moreover, the use of case simulation presents another innovative option. Since 2015, several winners of the American Society of Nephrology (ASN) Innovations in Kidney Education contest have sought to improve nephrology education in medical school. Ongoing innovations in pre-clinical education can help demystify kidney pathophysiology and have the potential to grow an early nephrology interest in trainees.
Perhaps the most important factor in cultivating an interest in nephrology is mentorship; it has been identified as a factor in all career choices both within and outside of medicine. Having a trustworthy and effective mentor can simplify seemingly complex subject material and provide real clinical exposure, making nephrology less intimidating. In fact, two common reasons cited for choosing not to go into nephrology include lack of mentorship and the need for better pedagogy. Fellows and attendings have an opportunity to share their stories and passions with medical students interested in nephrology. Mentor-mentee relationships allows the early learner to see what opportunities are available within nephrology and explore what their future professional identity might look like. To supplement nephrology clinical experiences, including internal medicine clerkships and electives, nephrology mentors can create opportunities for trainees to observe diverse arenas of clinical practice including traditional inpatient exposures, transplant clinics, home dialysis clinics, outpatient dialysis, onconephrology, interventional nephrology, palliative care, and glomerular disease clinics.
Mentorship & Networking Opportunities
Over the last several years, several programs have been developed to enhance medical student interest in nephrology and demonstrate the diversity within the field. One of the most notable is the ASN Kidney STARS program which provides travel support to medical students, residents, PhD students, and post-doctorates to attend ASN Kidney Week. Kidney STARS attendees are divided into groups led by a nephrology attending and fellow that participate in activities together throughout the conference. The Kidney STARS program includes trainee-specific sessions that allow like-minded students from around the world to learn about nephrology and to network.
Another ASN initiative is the Kidney Tutored Research and Education for Kidney Scholars (TREKS) program which includes two different opportunities, one at the Mount Desert Island Biological Observatory in Bar Harbor, ME, and the other at the University of Chicago. The Maine course is laboratory-based and focuses on the origins of kidney physiology and also gives students the opportunity to explore the New England coast. The Chicago course is more didactic and teaches students about not only kidney physiology, but also nephrology procedures and healthcare disparities.
ASN has also created opportunities to mentor by establishing the ASN Mentor Match and providing free materials on mentorship. Social media has emerged as a powerful tool to not only expose trainees to innovative free open access medical education (FOAMed) nephrology projects, but also to engage with diverse nephrologists from all over the globe. NephSIM Nephrons is a free, virtual, year-long educational and mentoring program launched in January 2021. This program pairs 15 groups of 8 medical students and residents with 3 faculty mentors to build both peer-to-peer as well and nephrology mentorship. Monthly virtual sessions teach nephrology topics and share with trainees examples of diverse career paths through interaction with nephrologists and career panels.
At the institutional level, initiatives can similarly be designed to promote mentorship between nephrology faculty and students, and should strive to recruit from a diverse population. Medical student interest groups can provide additional opportunities for nephrology faculty to engage with trainees and hold events like career panels. At the national level, we must continue to innovate and create new programs to engage these early learners.
Medical students have been recognized for their efforts as advocates. Nephrology offers many opportunities for early trainees to delve into and be champions of social justice. It was medical students who led many of the efforts around the United States to critically review race and glomerular filtration estimation equations and contributed to the removal of the “race coefficient” from the equation at several US institutions. These efforts have likely impacted the formation of a joint National Kidney Foundation (NKF)/ASN Task Force on “Reassessing the Inclusion of Race and Diagnosing Kidney Diseases.” Other areas of advocacy include the recent passage of immunosuppressive drug coverage by the US Congress for patients with kidney transplants, dialysis coverage for undocumented immigrants, discussion and addressing of race and social inequities in kidney care, and increasing research funding in kidney-related research. These examples can be highlighted for students with a known passion for advocacy to demonstrate the opportunities that exist in nephrology.
Should we be scouting these young prospects so early or do they need more time before they’re ready to contribute on the court? Up next, we turn our attention to internal medicine residents!
Residency is hard, there’s no other way to say it. A steep learning curve, 80 hour work weeks, job hunting… But if you want tons of supervised clinical exposure, this is the only place to do it. How can we get residents hooked onto nephrology during this crucial time in their lives?
While it is important to generate an interest in nephrology right from the beginning, it is likely that medical students’ initial interest in nephrology may wax and wane as they are enticed by other specialties. However, survey data of nephrology fellows does indicate that a majority of trainees choose nephrology during residency. So, the formative residency years are a critical time period on which to focus our attention.
Trainees who enter residency with a love for nephrology may naturally change course during residency as their clinical experiences expand. In general, residents are likely to develop their perceptions of subspecialties based on their experiences. In nephrology, these experiences may involve some of the sickest and most complex patients. Those who have committed to nephrology likely know about the diversity of the field and opportunities for career paths; can we show this to all residents?
Residency Nephrology Education
Residents who only have the opportunity to rotate through the inpatient consult service may not see the full gamut of nephrology care provided by a nephrologist. Caring for complex inpatients in the hospital setting may be associated with moral distress for residents, fellows, and attendings alike. Frequent exposure to these types of encounters may dissuade a resident from going into nephrology.
Can residents learn about the diversity within nephrology that lies outside the realm of their inpatient services? Electives provide an opportunity for residents to delve deeper into a subspecialty. Within nephrology, elective opportunities might include rotating through not only inpatient general nephrology services, but also outpatient clinics, home dialysis, glomerular disease, kidney transplant, onconephrology, and/or interventional nephrology. An interactive ambulatory nephrology curriculum for internal medicine residents substantially improved resident familiarity with clinical nephrology practice. Nephrology fellowship programs that host residents can offer a variety of elective opportunities to allow residents to tailor the elective to their preference.
Educational programs during residency have historically relied on large group lectures either at noon conferences or academic half days. Other methods of educational content delivery are patient encounters, bedside teaching rounds, morning reports, and grand rounds. Much attention has been focused on educational reform of medical school curricula. However, education during residency has continued to rely on traditional learning models. There is room for innovation in education for residents and this has been accelerated as a result of the shift to online learning in the COVID-19 pandemic era. The explosion of FOAMed nephrology tools has the potential to improve quality and engagement during nephrology teaching on rounds or through lectures. An example is the creation of an online nephrology immersion classroom that gives residents access to a library of mobile-friendly nephrology-themed digital blackboard videos that are highly rated. This initiative has resulted in improved rotation-specific clinical skills.
Urine microscopy is a skill often acquired during nephrology fellowship, though it may be of interest to earlier trainees. A survey of internal medicine residents found that almost 75% did not feel comfortable performing or interpreting urine microscopy but the majority were interested in learning. In response to these results, virtual urine microscopy sessions that delivered short didactic lectures with live demonstration of urine microscopy led by fellows and attending nephrologists were developed for residents.
Mentorship & Networking Opportunities
The majority of the programs described above for medical students both welcome and encourage participation from residents. Enrollment in these programs can further enhance residency clinical experiences and allow trainees to meet diverse nephrologists. National organizations like ASN, NKF, and the American Society of Transplantation (AST) provide free or discounted membership for trainees and provide access to educational materials.
KIDNEYcon is a conference that highlights clinical sessions as well as interactive, educational workshops on a variety of topics for both all participants, including residents and medical students. Past KIDNEYcon meetings have included hands-on sessions on ultrasound, kidney biopsy, and interventional nephrology that may be more pertinent for residents than students.
Student Loan Debt & Funding Opportunities
Another commonly cited reason that trainees may choose a field other than nephrology is concern over perceived inadequate financial compensation. In 2018, the average instructor starting salary for an academic nephrologist was $168,000-$180,000/year, compared to >$200,000 for hospitalists. Of note, salary in academia increases as one is promoted to Assistant, Associate, and Full Professor. Nephrologists often garner higher salaries in private practice(an additional $20,000-$100,000 or more, depending on the source). These numbers, however, fail to account for the substantial increase in pay that joining the partnership of a private practice brings. For instance, many private groups (See Team Private Practice below) have diverse revenue streams that consist not only of patient care but also include real estate holdings, research studies, medical directorships, and dialysis and access centers. The added salary contribution of these activities may not be reported in publications like Medscape which generates compensation reports by specialty.
While there is no panacea for increasing nephrologists’ salaries, there are options for student loan relief. Though some trainees are hedging their bets on Public Service Loan Forgiveness, this government program has been fraught with chaos and many applicants have failed to achieve loan forgiveness despite making the required 120 qualifying monthly payments over 10 years. An exciting opportunity to help with student loan debt was announced at this year’s ASN conference, The ASN Loan Mitigation Pilot Program. In its first year, the ASN will plan to focus on minoritized groups underrepresented in medicine, and will award $50,000 over 3 years to its recipients. For those pursuing careers as physician-scientists, the National Institutes of Health (NIH) has created loan forgiveness programs. Recipients of these awards who commit to at least 20 hours of research per week receive funds towards loan repayment for a 2-year period. Recipients can apply for a renewal after the initial 2-year period.
Various loan repayment programs offered in the United States:
|Public Service Loan Forgiveness||Forgives the remaining balance on Direct Loans after making 120 qualifying monthly payments (over 10 years) under a qualifying repayment plan while working full-time for a qualifying employer|
|NIH Loan Repayment Programs (LRPs)||Repays up to $100,000 over two years of a researcher’s qualified educational debt in return for a commitment to engage in NIH mission-relevant research|
|ASN Loan Mitigation Pilot Program||Each applicant will receive $50,000 over three years (6 applicants to be funded)|
The nephrology community is listening to concerns of residents and working to address them. Finding a resident interested in nephrology has been like unearthing a blue-chip prospect. If these efforts are successful, we may find ourselves drawing from a deeper talent pool than we’ve seen in years!
Academia vs Private Practice
Physician scientist, medical educator, expert clinician. “Triple threat” academic physicians are nearly unheard of these days, but academic nephrology is certainly a goal for many of our graduating fellows. What is it about the ivory tower of academia that holds such allure, and what are the important things to know before stepping in?
Before we get into specifics of academic medicine and nephrology, let’s start with some definitions. Merriam-Webster defines academia as, “the life, community, or world of teachers, schools, and education.” Similarly, academic medicine has been described as, “the branch of medicine pursued by doctors who engage in scholarly activities.” The concept of “scholarly activity” has been extensively studied and described. Educational leader Ernest Boyer’s work describes scholarship as having 4 branches: discovery, integration, application, and teaching. Academic medicine was founded in hospitals and universities affiliated with medical schools and facilitates the interplay between clinical care and academic scholarship. Below, we describe academic nephrology career paths that showcase the heterogeneity of scholarship in medicine.
A career as a physician-scientist, during which the majority of time is dedicated to scientific research, is a significant part of many academic nephrology divisions. The Association of American Medical Colleges (AAMC) defines a physician-scientist as, “any physician who devotes regular components of their professional effort seeking new knowledge about health, disease, or delivery of patient care thought research.” For the physician-scientist, academia is often the only option for protected time for research, sustained mentorship, and funding opportunities. The path to becoming a physician-scientist typically begins during fellowship training, or even before. Institutions with NIH T32 training awards (now termed U2C/TL1) allow for protected time for trainees and junior faculty to begin their research careers. Oftentimes, the attainment of another advanced degree, such as a doctorate or Masters degree, is considered.
Different types of research pathways exist, including biomedical research in a laboratory setting, clinical and translational research, epidemiology, clinical informatics, and drug discovery. The nephrology physician-scientist funding and workforce landscape was recently reviewed. The number of individuals pursuing a career as a physician-scientist has been stable over the last decade, as exemplified by the stable number of early career applications submitted to the National Institute of Diabetes, Digestive and Kidney (NIDDK) Diseases and its Division of Kidney, Urology and Hematology (KUH) (see Figure below). In addition, many opportunities are emerging to grow and strengthen this pathway, such as increased NIDDK funding (there was a 4% increase in fiscal year 2020) and investment by societies and governments (eg KidneyX, the Kidney Precision Medicine Project). The key to sustaining a career as a physician-scientist is attainment of grants which fund research programs and allow the researcher to focus their time on research activities.
The Clinician Educator
One of the draws for many in academic medicine is the opportunity to teach and, in parallel, systematically study teaching and learning processes. Like physician-scientist tracks, many academic settings provide a clinician educator track for faculty with targeted interests in medical education. In addition to clinical work, time may be spent teaching medical students, residents, or fellows (using traditional didactics through the affiliated medical school/residency program or hands-on bedside teaching), pursuing medical education projects and research, or leading a training program. Some schools offer special training and even degrees for clinician educators. Clinician educators are in prime position to serve as mentors, whose importance is highlighted in our two teams above.
Academia also provides an opportunity for further specialization in areas such as transplant nephrology, home dialysis, palliative care, onconephrology, glomerular diseases, interventional nephrology, or critical care nephrology. Although many of these clinical skills can be applied in the private practice setting, tertiary care centers can provide the tools necessary to establish the multidisciplinary teams often required for the delivery of care. Academic institutions are more likely to have specialized clinics such as those focused on glomerular disease, home dialysis, onconephrology, or cardio-nephrology (which focuses on advanced care [eg left ventricular assist devices, heart transplant, etc] for patients with heart failure). Pursuing a subspecialty path can allow the clinician to focus on their area of interest, and presents an opportunity to become an expert in the field. This clinical expertise can be used to write manuscripts, engage in collaborative research projects, and speak locally, nationally, and internationally on the topic.
A career in academic medicine offers diverse career opportunities that are rewarding, though it is not as lucrative as joining a private practice. While more time is spent in academia focusing on activities that may not translate to financial gain, those building a career in academic medicine are likely to find these pursuits rewarding and impactful. Regardless of the career choice, one should ensure that their passion aligns with the chosen path.
Hey, maybe you don’t want to do research—you just want to see patients. That’s OK too. If you DO want to teach, there are private practices that incorporate this into their model. In fact, you can build your practice model to have whatever mix you want. This team is for the trainees that feel like they just didn’t learn enough of the “business” stuff in fellowship.
While nephrology fellows are primarily trained in the academic setting, the majority ultimately choose to go into private practice. In a 2018 ASN survey of nephrology fellows, 55% indicated their first job would be in private practice. Despite this, many fellows have little exposure to private practice during their training. Private practice nephrology is a diverse career path with many different opportunities to pursue.
Disclaimer: The primary writer of this region is a fellow at an academic institution, so to learn more about the current state of private practice in nephrology she spoke with several nephrologists who enjoy careers in private practice.
Why choose private practice?
There were many recurring themes that emerged regarding why each person chose private practice, with the biggest being a primary focus on direct patient care. In academic medicine, nephrologists rarely can choose to be solely clinical. They often divide their time between clinical work, research, and education. Time spent performing direct patient care may only encompass 20-50% of their time. While this may be desirable for the academic clinician, the private practice clinicians I spoke to loved being face-to-face with patients as much as they could.
The second theme that emerged was flexibility. Depending on the private practice model (see Table below), private practice can allow for more flexibility in how you choose to run your practice and day-to-day schedule. There are many different combinations and formats in a modern private practice group. Thus, nephrology graduates these days can choose from a cornucopia of options for the type of practice that best fits their needs. One can even build their own independent practice, and two of the nephrologists I spoke with did just that. While this requires some business acumen, the individuals I spoke with enjoyed the freedoms allowed by owning their own practice. Everyone I spoke with does a mix of CKD clinic, inpatient consults, and outpatient dialysis, but those who own their own practices have crafted this mix in a way that has felt manageable and desirable to them. If they identify something they think would strengthen the practice, it can be implemented without having to wade through a lot of red tape. Others may choose to join a larger group of established nephrologists, which affords the convenience of less administrative overhead and less call. It also allows for the creation of speciality niches, as discussed in Team Academia. Many private practice groups have access centers, giving the opportunity to practice interventional nephrology. Other opportunities include practicing transplant nephrology or even partnering with specialists in other areas or larger hospital systems.
|Type of Practice||Benefits||Negatives|
|Solo (or small) Practice||Flexibility and autonomy||Call schedule and administrative burden|
|Large Group (independent)||Less call, less administrative burden, Niche speciality (Interventional, transplant, etc)||Less autonomy|
|Large Group (attached to multidisciplinary practice or hospital system)||Even less administrative burden (billing, bylaws, staffing)||Even less autonomy|
Teaching and Mentoring Opportunities
Trainees may think that by going into private practice they are forgoing the opportunity to teach, but this is not necessarily the case. Many private practice clinicians mentor and teach medical students, residents, and fellows. Tying into our earlier matchup, this is vital for recruiting future nephrology trainees. Rotating with a private practice group can allow for a trainee to experience the full range of nephrology experiences rather than just the inpatient setting. One private practitioner I spoke with mentors about 6 residents per year. Of those 6, 1-2 (15-30%) will typically apply to nephrology fellowship. This success may be attributed to her incredible teaching and mentorship, but she also makes sure residents are exposed to home hemodialysis and teaches them how to run a clinic. This type of approach dispels some of the fears of work-life balance and exposes trainees to the practical aspects of nephrology.
Challenges in Private Practice
Private practice is not without its own challenges; it is busy and fast-paced. Depending on the model, this could leave clinicians at increased risk for burnout. Theoretically, it may seem more difficult to stay up-to-date on the most current therapies and evidence-based medicine, but this does not have to be the case. Some private practices regularly hold journal clubs. Social media and discussion platforms such as Twitter and ASN Communities allow physicians in private practice to engage with other nephrologists and fellows. Another challenge includes navigating the new reimbursement models on one’s own. Those at academic institutions typically have billing departments dedicated to weeding through the red tape that a solo practitioner does not have access to.
Trainees may wonder if the benefits of private practice outweigh the challenges. How will they know this if they never have any exposure to private practice? One such solution would be for program directors to partner with private practice groups in their area to increase exposure to private practice during fellowship. They should also be incorporating aspects of private practice into their teaching curricula and establishing mentor relationships. If logistics allow, an effective approach may be to create elective rotations with private practice groups for trainees who express an interest. The Renal Physician Association (RPA) (free for fellows) can also be a great resource for fellows considering private practice. The RPA offers tools for fellows and early career clinicians to learn about billing/coding and have several podcasts focusing on topics such as implementing new national policy into practice, or working with dialysis organizations. Finally, fellows can learn more about private practice by attending the Nephrology Business Leadership University (NBLUniv). This is a 5-day course that teaches about different types of practice, billing/coding, how to start a practice, interviewing skills, and leadership, to name a few topics.
Private practice nephrology offers the ability to care for patients in multiple settings, while also allowing each practitioner to tailor the business model to suit their individual needs. Training programs should incorporate private practice specific training for their fellows to prepare them to see all the paths forward!
Maintaining the pipeline of future nephrologists will continue to be a challenge for this generation of nephrologists. Currently, there are many higher level issues for which there are no quick fixes. Solving the compensation gap, navigating higher level policy change, and increasing recruitment will take time and energy. We must collaborate and work creatively to resolve these issues. Whether in academia or private practice, we need uniform support to help each other navigate policy changes from the Centers for Medicare & Medicaid Services. At the end of the day we should be striving to recruit both at the medical student and resident level, and different mentors may be better suited for one or the other. Since the learners are at different levels of training, our recruitment strategies should reflect this. Lastly, we must continue to improve diversity within the nephrology workforce to better mirror our diverse patient population.
– Executive Team Members for this region: Tim Yau @Maximal_Change, AJKD Social Media Editor, Samira Farouk @ssfarouk, AJKD Editorial Board Member, and Matthew Sparks @Nephro_Sparks, AJKD Social Media Advisory Board member.
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