Perspective on Nephrology Fellowship in the United States

• United States
• Fellowships and Scholarships
• nephrology
• Internship and Residency

Interest in nephrology as a career choice has been steadily waning among internal medicine residents in the United States. The recurrent message many of us hear is that our specialty is facing a challenge to its very existence (1). Declining interest is reflected by a decrease in the number of applications to open fellowship positions. These new trends have taken the nephrology community by surprise and generated frustration among academic medical centers as well as private nephrology practices. The charm of nephrology has long included the appeal of understanding kidney physiology and the visually appealing pathology of glomerular disease. The fascination for these two key aspects of nephrology has created a unique blend of art and science in a medical subspecialty that allows us to provide care to those afflicted with kidney disease, which is often a devastating condition. Unfortunately, the practice of nephrology has stalled in a numbers game of how many patients can be seen to maximize revenue. This practice has resulted in a reputation for nephrology of working long hours for lower earnings. This is a reality of our current health care delivery system that we have to accept in an environment of decrease in reimbursement. However, interest in other medical subspecialties has remained high despite similar challenges with reimbursement. These issues are highlighted by two perspectives articles in this issue of the Clinical Journal of the American Society of Nephrology (CJASN) that discuss trends, challenges, and solutions to the adult nephrology fellowship program in the United States.

The first perspective article by Braden and Ross (2) reviews the evolution of the Match for Nephrology since it was implemented in 2009 and provides a comprehensive description of the All-In Policy for the Nephrology Match approved unanimously by the Council of the American Society of Nephrology (ASN) in 2015. This ASN policy ensures that all candidates have fair and equal access to training programs and examine the full spectrum of training opportunities before making a final decision. This article also describes how the ratio of nephrology applicants per position offered in the Match has had a dramatic decline from 1.55 in 2009 to 0.6 in 2016, which was unchanged in 2017. This implies that only 41% and 42% on nephrology programs completely filled through the Match in 2016 and 2017, respectively. To those looking for good news, here it is: the 2017 number represents an end to the steady decline in the fill rate that occurred since 2009, when 95% of the 367 nephrology slots in the Match were filled. However, the 2017 numbers have to be placed into context, because many of the unfilled positions are filled during the post-Match period. The article concludes that additional efforts are needed to increase the number of applicants choosing nephrology as a career.

Where do we go from here? The second perspective article by Melamed et al. (3) makes a brilliant parallel of the current state of nephrology to the state of affairs for anesthesiology in the early 1990s. This perspective article offers solutions like downsizing fellowship spots and hiring physician extenders to help out with daily clinical duties. The challenges of this approach might be that researchers and clinical educators will be asked to do more clinical time, which will result in less innovation, research, and time with nephrology trainees.

CJASN hopes that these considerations provide some guidance to our field to best tackle the challenges faced by our specialty in attracting talented individuals.

• Copyright © 2017 by the American Society of Nephrology