Resizing Nephrology Training Programs

• Fellowship
• Education
• nephrology
• Education, Medical, Graduate
• Fellowships and Scholarships

A once-attractive medical specialty faces challenges due to an oversupply of practitioners, particularly around large hospitals and in metropolitan areas. The geographic distribution of employment opportunities compels many graduates to practice either outside their specialty or in a manner that results in poor job satisfaction and lower incomes (1). As prospective applicants become aware of these negative economic and professional trends, a marked decline in National Residency Matching Program (NRMP) matching trainees ensues (2). Seeing no decrease in clinical workload, program directors look outside the match and overseas to fill positions. Sound familiar? This was the state of affairs for anesthesiology in the early 1990s. This is hard to believe: Anesthesiology has been one of the most popular medical specialties in the United States over the last 15 years, and in the 2016 NRMP, it had 1.6 applicants per post-graduate year (PGY)-1 position and 3.2 applicants per PGY-2 position. How did they turn it around, and what can we nephrologists learn from their experience?

In retrospect, anesthesiology learned the lessons of supply and demand. Between 1992 and 1999, the number of anesthesiology slots was reduced by 39%, resulting in a decade-long substantial decrease in the number of United States–trained anesthesiologists (3). This decrease in physician supply paid off handsomely as demand for individual physician services increased along with salaries and job satisfaction. Since 2000, there has been consistent growth in the number of matched training positions in the NRMP. Furthermore, during the transition period that decreased physician supply, the increase in demand for services was not absorbed exclusively by physicians—quality of care for patients undergoing anesthesia as well as quality of the work environment for anesthesiologists were buttressed and maintained by a concomitant increase in the number of Certified Registered Nurse Anesthetists.

As our community is acutely aware, there is decreasing interest in nephrology. For those of us in the field, the disinterest is hard to comprehend: we are generally satisfied, well compensated, and enjoy nephrology’s intellectual rigor. However, current trends indicating that younger physicians are not choosing nephrology belies our satisfaction. For the last several years, there have been 0.6–1.0 applicants per position in the nephrology match in December. And yet, by July of the following year, most programs have been able to fill through the scramble, hiring fellows who may not have completed a United States internal medicine residency. We believe that these trends and hiring practices are not good for nephrology and that radical solutions are needed to reverse the ongoing disinterest in our field. We believe that the best way to save nephrology is to reduce the number of training program slots to <300. For the past 2 years, approximately 280 applicants have matched into nephrology. To ensure that only well qualified applicants are accepted, the number of positions should be fewer than the number of applicants; therefore, around 260 positions may be ideal. Unfortunately, a projection of how many nephrologists will be needed in the United States in the next 10 years is not available but is sorely needed.

The effect of physician compensation on the decision to (not) train in nephrology needs to be considered. A recent survey of baseline salaries among physicians just out of training by the American Association of Medical Colleges casts our field in negative light. New nephrologists have the lowest salaries among internal medicine subspecialists. In contrast, however, the Medscape salary survey of practicing physicians shows that nephrologists with higher salaries than those in other subspecialties, such as endocrinology, infectious disease, and rheumatology (4,5). Therefore, although starting salaries may be lower, there is a higher earning potential in the long run for nephrologists. In light of the high debt load of new physicians, low income–earning potential is a tremendous disincentive for physicians-in-training to enter our field. Lower wages in combination with our reputation for working long hours, the complex nature of our specialty, and the redundancy of our field with other specialties that have higher earning potential, such as critical care, task us with the need to find novel solutions that will increase interest in nephrology as a career choice and ultimately, improve our field.

As a field, we take pride in our status as the smartest physicians in the hospital. Unfortunately, our opinion is that this status is in jeopardy of being lost for at least a generation. We worry that hiring less-qualified trainees to fill slots will steadily erode the quality of nephrologists in the workforce. Our fellows serve as current and future ambassadors for the field and are an essential component in our efforts to inspire and recruit new nephrologists. If we graduate fellows who chose nephrology as a second choice and may not be of equivalent caliber of previous generations, we are damaging our brand by just filling our empty positions.

The experiences of trainees are variable around the country depending on whether they train in a large or small center, an academic or community hospital, or an institution with an onsite transplant program and whether they are able to review kidney biopsy slides with an onsite renal pathologist, perform kidney biopsies, or learn how to place temporary dialysis catheters. Hands-on experience with continuous renal replacement therapies and peritoneal dialysis and opportunities for scholarly activity are equally disparate. It would be helpful for us to reconsider and clarify the detailed training requirements for nephrology fellows. The American Society of Nephrology (ASN) could assist greatly with this task of bringing more consistency to the proficiency of graduates and right sizing the number and characteristics of programs around the country.

Nephrology is in an interesting position, with indicators pointing to increased patient volume, robust clinical trial activities, multiple novel therapeutic drug developments on the horizon, and more diverse clinical practice options. Indeed, the expansion of knowledge and expertise in onconephrology, critical care, interventional, glomerular disease, home dialysis, and transplantation has led to additional training opportunities and further subspecialization by our graduates. Payers may be amenable to increasing reimbursement for these subspecialized services that, when well executed, reduce costs and improve outcomes. Anesthesiology has also had recent success in encouraging subspecialization in their field (cardiac, critical care, pain, etc.). We too could benefit from broadening of our certification options.

There has been a call from the ASN to downsize programs for several years, but this has proven difficult. No agency controls the number of fellowship programs in the country, and a program does not need to close and can open if it passes the American Board of Internal Medicine and the American College of Graduate Medical Education requirements. Programs have to close or decrease the number of trainees on their own. The ASN can help by identifying programs that have not filled through the match; have low board pass rates; and do not have access to peritoneal dialysis, continuous renal replacement therapy, and transplantation on site and then working with Designated Institutional Officials to make programs more competitive or downsize.

Previous efforts to estimate how best to reduce the numbers of positions probably no longer apply, because the number of positions filled has decreased dramatically since that time (369 in 2013 to 284 in 2017) (6). Thus, we encourage all programs to start conversations about physician assistants and nurse practitioners to take over some roles previously carried out by fellows. Our programs have hired physician assistants and nurse practitioners to help care for patients with kidney disease. Our hospitals, like most, are only getting busier. Our divisions have hired physician assistants and nurse practitioners to lighten the burden of our fellows without adding to the workload of our faculty members. Under faculty supervision, our physician assistants and nurse practitioners place dialysis orders, insert temporary dialysis catheters, evaluate patients with ESRD, and coordinate with interventional radiology the placement of tunneled catheters and other accesses. A recent survey revealed that, of 177 separate inpatient services at hospitals all across the country, only 14.5% employed physician assistants and nurse practitioners (7). Physician assistants and nurse practitioners can be expensive, but because nephrology is an essential hospital service, administrators with appropriate justification are willing to support their hiring. We are also aware of professional conflict between physician assistants, nurse practitioners, and physicians in other fields. Care would need to be taken in ensuring that nephrologists are still ultimately involved and responsible for medical decision making. Creating multidisciplinary care teams including physician specialists, physician assistants, and nurse practitioners has been successful in other chronic disease models (such as congestive heart failure and oncology).

Overnight call is a problem that hospitals will face if they decrease their complement of fellows. There are several possible strategies to deal with overnight call, and these will differ on the basis of the program and volume of calls and emergencies that happen overnight. (1) The faculty members take overnight call with an appropriate increase in salary. (2) Programs that have overnight home call can lower expectations on the fellows for coming to the hospital to evaluate patients. Most private practice physicians will not come in at night to evaluate a patient with ESRD who missed their dialysis earlier in the day and now has a potassium of 7.0. Are we asking our fellows to do too much? (3) For fellowships with a night float system, there may be a daytime rotation that can be covered by a physician extender. (4) Finally, divisions of nephrology need to start experimenting with newer models of coverage, such as night nephrologists or nephrology hospitalists, in high-volume hospitals.

In sum, we urge the nephrology community, division chiefs, Department of Medicine chairpersons, and our fellow training program directors to consider our plea and collaborate on innovative methods that can be implemented to make nephrology greater than ever.

• Copyright © 2017 by the American Society of Nephrology