#NephMadness 2021: Commentary on the Workforce Region

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Stephen Sozio headshotStephen Sozio @stephensozio

Stephen Sozio is an Associate Professor of Medicine and Epidemiology at Johns Hopkins. He has served on ASN’s Workforce and Training Committees for six years, and currently co-leads ASN’s Students and Residents (STARS) Program and Annual Fellows’ Survey. His work shapes how training programs understand and build the nephrology workforce. 

Competitors for the Workforce Region

Medical Student Interest vs Resident Interest

Academia vs Private Practice

Workforce Commentary

Copyright: Yevhen Tarnavskyi / Shutterstock

From the time of Homer Smith, nephrologists and kidney physiologists have been considered some of the best teachers, most astute clinicians, and crucial individuals to understand and explain complex physiology. Who else would examine urine at 2 AM to determine a diagnosis? Who else can be at the forefront of life-changing decisions such as when (and whether) to initiate dialysis? Who else can collaborate with nearly all other medical specialties in research and clinical care?

Perhaps this is asking too much of our field and its practitioners. A landmark paper from 2011, The Future Nephrology Workforce: Will There Be One?, saw a workforce and recruitment problem developing and described measures the American Society of Nephrology (ASN) and the kidney community could do to increase interest in the field. A 2013 paper by Jhaveri and colleagues, Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows, found that internal medicine residents choosing a field other than nephrology felt the complexity of kidney disease, lack of mentors, and insufficient procedures were key reasons they avoided nephrology. Kidney researchers, educators, and clinicians have worked to overcome these barriers and provide personal connections for students and residents alike.

Despite this concerted attention to nephrology interest, recruitment to the field of nephrology saw declines over the past ten years. The AY 2016 nephrology match appears the low point, with only 59% of fellowship positions filled and 41% of programs’ tracks filled. Just think about that. How can over half of programs go unfilled and we still have a specialty? With fewer residents entering nephrology fellowship, how can we recruit the best and brightest to pursue important clinical, research, and health policy topics? If we have less trainees entering the field, who is ultimately going to be our workforce, caring for patients with kidney disease?

NephMadness 2021 tackles these important topics. Where should our workforce efforts focus? Should we consider the upstream pipeline of recruiting new fellows (medical student vs. resident interest) or consider the downstream aspects of practitioners in kidney disease (academia vs. private practice)?

This brings us to our bracket challenge. The first pairing in this workforce category looks at medical student vs. resident interest. My colleagues are all pushing for medical student interest, but resident interest wins out.

Blasphemy! NephMadness got it wrong!

Nephrology interest is like kindling. One can have that spark in medical school, but there are so many paths along the way that lead to a fire developing in “something-else-other-than-nephrology”. Whether primary care, hospitalist medicine, or another cerebral sub-specialty, our internal medicine residents have looked elsewhere. And if the Jhaveri study and those conducted since are any indication, perception issues during residency are the biggest barrier we face to recruitment.

The second pairing in this category looks at academia vs. private practice. Again counter to conventional wisdom, private practice wins out. With the complexity of nephrology noted by internal medicine residents (and graduates), there is a need for nephrologists to be key parts of care. The top practice setting after fellowship for 2019 fellowship graduates was primarily clinical nephrology in a non-academic hospital (i.e. private practice). Yes, academia is the site of mentorship, recruitment, and research; however, the life of our workforce is the practitioner.

And in the final pairing, resident interest wins out. Our workforce is ultimately dependent on those entering it, and we have not yet had stable gains in recruitment.  The good news is that this tide of low-interest may finally be turning, with the AY 2021 match showing a 25% increase in nephrology fellowship applicants, its highest total since AY 2015, leading to the most filled fellowship positions in seven years. In the 2020 ASN Annual Nephrology Fellows’ Survey (focused this year on the response to COVID-19), 87% of nephrology fellows nationally would recommend the field of nephrology, the highest percentage we have seen since asking that question.

We have seen gains in recruitment to nephrology fellowship, but we must stay vigilant in these efforts. Only with a healthy pipeline will our workforce and our patients benefit from the advances we are seeing in kidney health. I hope that resident interest goes far in this year’s NephMadness!

– Guest Post written by Stephen Sozio @stephensozio

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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