Advancing Nephrology

Asserting the Value of Nephrology to the Health System

More than any other discipline, the nephrology service line is central to all health systems because it provides core medical and surgical services that are necessary for every adult and pediatric medical and surgical specialty. In the critical care setting, nephrology provides clinical support in the medical, cardiac, surgical, neurologic, and trauma intensive care units. Collaborative, collegial, thorough, thoughtful, and up-to-date nephrology support for AKI and congestive heart failure is essential, especially when intermittent dialysis, ultrafiltration, or continuous RRT is needed. Nephrology supports the health system’s growing cancer and trauma programs. Kidney complications of cancer immunotherapies have become increasingly common and have led to the genesis of a new focus within nephrology—onconephrology. Collaborations are necessary for patients with autoimmune kidney diseases and patients at high risk for obstetrical complications. High-risk surgical procedures, whether general, vascular, cancer, cardiac, or orthopedic related, often require nephrology consultation and, in some cases, dialysis for those who deteriorate postoperatively. Nephrologists are the primary care physicians for all patients with kidney failure (patients with kidney transplants and patients on dialysis), and these highly complex patients need inpatient and outpatient services. The value of nephrology services provided is high only if these services rendered are of high quality. Timely, effective, and meaningful consultation; expert advice on fluid electrolyte and acid-base disorders; and expert technical support in RRT are crucial. Sub-subspecialty clinics are being established, such as oncology nephrology, GN, and nephrolithiasis clinics. These clinics will enable critical expertise that will generate a referral base for greater consultative activity. Additional programs, such as transition start units where patients initiate long-term kidney replacement, are gaining interest among health systems (16). Transition start units are specialized dialysis programs that can care for patients with late CKD stage who are unprepared for kidney failure and “crash-land” into dialysis. This specialized unit provides more intense care than regular dialysis units, and early indicators suggest that patients benefit. Nephrologists are now creating new care models of CKD for stages 4 and 5 and kidney failure after the Executive Order on Advancing American Kidney Health (14,17). These new initiatives may offer value, and it will be necessary to develop and track metrics that demonstrate clinical and financial effectiveness.

The Merritt Hawkins report for 2019 is derived from surveys sent to 3000 hospital chief financial officers, resulting in 62 completed surveys from 92 separate hospitals (18). They reported the combined annual net inpatient/outpatient revenue through hospital admissions, procedures performed at the hospital, tests and treatments ordered, prescriptions written, etc., for various specialties and subspecialties. Nephrology was one of the few cognitive subspecialties to rank with the high revenue earners for institutions.

Physician Productivity and Compensation

The data for average salaries for nephrologists are variable, and the average annual nephrology salary is often perceived incorrectly as low. Accurate reporting of salaries is important given the complex, time-sensitive, and exacting nature of the work, even when adjusted for regional variation. According to the Merritt Hawkins 2019 Survey, the average annual salary for a nephrologist is $272,000 and competitive compared with other cognitive specialties (18). Salaries for cognitive specialties were $241,000, $261,000, $301,000, $230,000, and $261,000 for family practice, internal medicine, neurology, pediatrics, and psychiatry, respectively. Other cognitive subspecialties in internal medicine, such as rheumatology, endocrinology, and infectious disease, were not listed but unlikely to exceed the salary of nephrologists. Recent data from Medscape indicated that the average salary for a nephrologist is $305,000, which is much higher than other cognitive specialties (19) (Figure 1). For newly graduating fellows in their first job, a recent survey by ASN Data and Johns Hopkins University indicated that median base salary was $198,000, similar to 2018 data reported by George Washington University–Health Workforce Institute. Salaries were higher for men than women. According to the Merritt Hawkins 2019 Survey, if salaries are on the basis of net revenue generated annually per physician, then the salaries could be considered commensurate with revenue generated; however, this assumes that the data are accurate. For example, it is unclear how the revenue for dialysis facility fees is attributed. For hospital systems that own their own dialysis facility, revenue generation through facility fees will be attributed to the nephrologists—but not for hospital systems using the services of external dialysis organizations. If this is the case, then the salaries on the basis of the revenue generated would appear lower than other subspecialties. A better understanding of “downstream” revenue generation is critical and must be gained given the spectrum of consultative services provided by nephrologists, the number of procedures that nephrologists oversee, and the complexity of revenue generation through dialysis services provided by external dialysis organizations. Thus, the current data suggest that the average nephrology salary is competitive. Detailed data, including the downstream revenue generated for hospital systems attributable to nephrologists, will provide an accurate basis for determining salaries in the future.

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Figure 1.

Average salaries of internal medicine subspecialties and other cognitive specialties. Data depicting the average salaries of medicine subspecialties and other cognitive specialties were redrawn from Medscape Survey (19).

In the meantime, by providing timely and expert consultation, clinical practice should thrive, generating greater clinical revenue that will ultimately result in greater compensation. Salaries of private nephrologists are not substantially different than academics unless they are employed as medical directors by large dialysis organizations. However, significant differences exist in some geographic areas. Adjustments in salaries are necessary in order to recruit nephrologists to less desirable but essential geographic areas for provision of care for patients with kidney disease.

Approximately 80% of the dialysis units in the United States are owned by large dialysis organizations that are responsible for nephrology medical director compensation. Although the cost of kidney care to the health care system is high, the facility fees have become profitable for large dialysis organizations. This limits the revenues available to academic and private practices to raise salaries and make nephrology a financially rewarding specialty. New relationships are necessary (and timely with the development of new Centers for Medicare and Medicaid Services [CMS] kidney care models) for nephrologists and corporate dialysis programs to become true partners for delivery of high-quality, cost-effective care with better distribution of revenue. Furthermore, if we raised academia salaries, that would set a new level for the Association of American Medical Colleges (AAMC) benchmarks, tend to keep graduates in academic programs, and create competitive forces to induce the industry to raise compensation to attract nephrologists.

The majority of academic programs use the regional AAMC tables to set salaries around the median for rank, with some adjustment for time at rank by some programs. Market forces in some regions stimulate upward (and in some regions, downward) pressures. The spectrum of work for different types of nephrologists (e.g., transplant nephrologists, intensivists, interventionalists, hospitalists, full-time dialysis providers, or office-based nephrologists) can vary widely, and market forces influence salaries. Additional data are needed in order to determine compensation for sub-subspecialty nephrologists. Most programs that employ PhD scientists also use AAMC tables. Basic scientists are major contributors to the field of nephrology, and we should determine if their salaries are appropriate.

Relative value units (RVUs) are the dominant form of work productivity indicators used by institutions (20). About two thirds of academic programs use Vizient (formerly University HealthSystem Consortium) wRVU targets for dialysis and E/M services, which are used to determine clinical productivity and, hence, compensation. Depending on the return on wRVUs (payer mix), this may or may not be sufficient to cover the component of salary dependent on cFTE. What is clear is that the wRVU does not completely cover the actual work involved in the delivery of care. There is additional time spent outside the clinic visit (e.g., coordination of care, preauthorizations for medications, laboratory orders and reviews, and use of EMRs) that is not captured by the wRVU (20). There is little transparency in how these data are obtained, with no reporting of whether wRVUs are assisted by the presence of advanced practitioners or obtained independently. There are also several questions regarding the accuracy of the data generated by Vizient. A full analysis is needed to determine benchmarks for productivity in nephrology.

To remain competitive in attracting trainees into nephrology, we need to address physician compensation. Similar to other specialties, addressing appropriate compensation is important, particularly for US medical graduates who have considerable debt. For physician scientists, there is a financial disincentive for graduating fellows to apply for career development awards, such as National Institutes of Health K awards, because the salaries are well below their clinical peers at the instructor or assistant professor level. Moreover, not all programs make up the difference. Promising fellows completing T32 or F32 awards frequently need bridge funding and support before they are successful in getting K or initial R awards. This investment is wasted if they discontinue research efforts or are required to do more clinical work to adjust for the lack of salary.

Financial Support of Faculty’s and Divisions’ Educational Efforts

Nephrology faculty members play a significant role in medical education at academic institutions and have historically been regarded as some of the best educators in medicine. With the change in workflow and clinical demands, educational missions can suffer. To ensure nephrology’s preeminence in health care education, we must (1) provide a road map for continued teaching and educational opportunities using innovative educational methods (21⇓⇓–24), (2) identify funding sources for education, and (3) position ourselves to be leaders in health care education.

Teaching classically involves preclinical and clinical education of medical students. However, many faculty members also find opportunities to teach students in physician assistant, pharmacy, and graduate programs. There are a number of opportunities in inpatient and outpatient clinical settings to teach trainees and introduce them to research methods. Opportunities for resident and fellow teaching by program directors, associate program directors, and key faculty members are typically at the discretion of the division chief and the internal medicine program director (25).

Education is what attracted many nephrologists to academic medicine, and the education mission distinguishes academic from nonacademic nephrologists. Although rewarding, these are time-consuming responsibilities, funding for these efforts is limited and obscure, and protected time is minimal or nonexistent. The literature suggests that academic faculty members’ educational time is undervalued, and although systems have been implemented that more accurately define the educational effort (e.g., educational value units), there has not been widespread adoption of these strategies nationally (26). For nephrology, there is no literature on the utilization of an educational value unit system. Medical student education is often funded, but support for resident and fellow education is often lacking. Although the Accreditation Council for Graduate Medical Education (ACGME) outlines necessary support for residency and fellowship activities, this can be highly variable between institutions (27). Nontraditional funding sources include college- or university-wide teaching academies and philanthropic sources.

To assert the value of nephrology faculty in the educational mission, we must do more than excel as teachers. Nephrology faculty members who are interested in education need to be recognized as experts in educational theory and educational research and, by pursuing additional training via teaching academies or advanced degrees in education, become local leaders in kidney education and the medical school curriculum. Recognition of the educational leadership and commitment by nephrologists could enhance our exposure, generate more excitement for the field, and attract more candidates to nephrology careers.

Faculty Recruitment, Retention, Diversity, and Inclusion

Work-life balance/burnout and fellowship recruitment are important challenges for nephrology faculty today. These are tightly inter-related and overlap with all of the other major discussion topics from this meeting. However, it is important to ensure that faculty recruitment (and our pipeline) and retention should not be clouded by misperceptions. Although nephrology faculty and trainees suffer from burnout, it is not specific to nephrology. In a national survey, burnout is highly prevalent among early career physicians (≤5 years in practice), residents/fellows, and medical students (28). There are a number of factors leading to burnout (29,30) that are common to all physicians and trainees. A major driver, however, is the corporatization of health care delivery with enhanced corporate-style efficiency and electronic medical record systems that contribute to physicians spending additional hours each day to document medical information. Despite the increase in workload that has spilled over into off hours, including weeknights and weekends, physicians remain bound to their commitment to the ethics that brought them into the field of medicine (31). Another major driver of burnout is the use of the wRVUs, which is often used by institutions but inaccurately reflects physician work productivity (20). It is unlikely that the rate of burnout among nephrologists is greater than in other specialties. In fact, the data from a Medscape survey indicate that nephrologists suffer less from burnout than other specialties (32). In 2019, among the 29 specialties surveyed and reported, burnout ranged from 28% to 54%; the percentage of nephrologists who experienced burnout was 32%, ranking second best with regard to burnout. This lower rate of burnout among nephrologists correlates well with other factors surveyed. Nephrologists experience the highest percentage of happy marriages (61%) and are the fifth happiest of all specialties in their personal lives.

For nephrology, work-life balance issues can be exacerbated by fellowship recruitment issues (29,30). Finding ways to attract bright young minds to our field will require careful thought and creative solutions.

Our current workforce challenges may offer an unexpected opportunity to enhance diversity in a field where the patient population tends to be heavily weighted to minority groups. Beyond racial and ethnic diversity, innovative approaches to work-life balance and compensation may attract a broader range of new nephrologists. We need to make nephrology topics more accessible and understandable by exploring different pedagogical approaches in both formal course settings and informal seminars (21⇓⇓–24). These innovations could reach a wider audience and attract a more diverse future faculty with distinctive strengths. Advancements in building new practice models, embracing technology, and modernizing our educational efforts would benefit from investment in current faculty who could drive these efforts. This leads to the related discussion of compensation for educational efforts. One specialty, hospital medicine, has achieved some of our goals by providing higher salaries and more favorable work hours, which support recruitment.

There are still gaps in our knowledge that prevent us from painting a complete picture in our effort to expand our workforce pipeline. We need to positively exploit the ways in which nephrology is unique from other subspecialties and use these differences to increase recruitment, retention, diversity, and inclusion. The number of women in nephrology has increased; however, like other areas of academic medicine, there are still gender gaps in leadership. ASN serves as a role model in addressing diversity, inclusion, and equity within its leadership and committees. There are still significant gaps in attracting under-represented minorities to our field, and whether the reasons are the same as in majority groups or are unique remains unclear. The Network of Minority Health Research Investigators supported by the National Institutes of Diabetes and Digestive and Kidney Diseases establishes a network of mentor-mentee relationships among minority junior investigators. Diversity in trainees ensures a vibrant research environment. A formal assessment of our subspecialty’s level of inclusion and engagement of diverse populations may help (33,34). Specific strategies as outlined here may help diversify our field (35).

Ensuring that Fellowship Programs Prepare Trainees to Provide High-Value Nephrology Care and Enhance Attraction of Trainees to Nephrology

Longitudinal data consistently demonstrate marked discrepancies between a large number of fellowship training positions and a reduced number of applicants, a reduced number of both international and US applicants, and a large number of applicants simultaneously applying to other subspecialties, including pulmonary, cardiology, critical care, and gastroenterology. These findings raise concerns for (1) training program expectations to meet patient or work needs versus the opportunity to train and educate a trainee; (2) a reduced presence and awareness of nephrology as a field/concentration/specialization at early stages of education in science, technology, engineering, and mathematics fields; (3) regional differences in applicant numbers/positions available, favoring more urban centers of the country; and (4) regional differences in training expertise in specific areas of nephrology, such as genetic kidney medicine, nephrolithiasis, critical care nephrology, home dialysis, and vascular access. Taken individually or in combination, these issues contribute to a reduced number of physicians entering training in nephrology (1,2,29,30).

A risk analysis performed during the ASN retreat revealed a challenging environment for training programs and a significantly reduced eligible training and applicant pool. However, we should also understand that there are a number of factors and developments that enhance nephrology as a subspecialty. There are a significant number of highly qualified teachers and academic leaders in the field of nephrology. Many fellowship training programs are strategically moving to a less service- and more education-based approach using a variety of strategies. Two examples are incentivizing faculty members who round independently without fellows, and utilization of advanced practice providers on services where educational opportunities are reduced. This permits more focused educational opportunities and greater attending-fellow interaction. The development of nephrology-hospitalist services that include house staff and fellows may have increased earlier exposure to nephrology. Institutional support for nephrology faculty exposure to medical students, interns, and residents (general medicine rounding, morning report, internal medicine residents coming to outpatient clinics, and debates with other subspecialties as part of the conference schedule) has increased local resident applications to a few nephrology fellowship programs. Sub-subspecialization opportunities have increased interest and awareness in nephrology. Importantly, these efforts are not standardized nationally and remain local to specific programs.

Opportunities exist through earlier exposure to nephrology, for undergraduate students, medical students, and residents, early in their training where leadership in the field of nephrology is important. Importantly, creating core requirements for advanced practice providers with certification in nephrology is critical. Merging hospitalist programs with nephrology and creating ACGME-approved combined accelerated pathways with subspecialization certification could enhance interest.

There are specific recommendations that should be implemented as soon as possible. It is highly recommended that an advanced practice nurse and physician’s assistant nephrology care certification program be developed for advanced practice providers taking care of patients with underlying kidney disease. Certificate programs in areas of subspecialization in nephrology similar to what is now available for hypertension should also be developed and approved at training programs with the correct expertise. Short tracking into nephrology should be approved by the ACGME and implemented at institutions that are willing to consider this. Medical schools should revise their curricula regarding clinical nephrology and kidney physiology to increase exposure for medical students, interns, and residents. Medical students and residents who express interest in nephrology must be identified by their program directors so that mentorship opportunities with nephrology faculty can be developed.

In the future, we need to (1) optimize nephrology compensation through CMS/ASN exchange to promote a better understanding of the complexity in care of the patient with CKD or kidney failure; (2) address geographical deficiencies regarding lack of training expertise by building regional training programs in specific components of nephrology and providing small training centers appropriate support; and (3) establish an accurate estimate of the minimum number of board-certified nephrologists needed to lead the field of nephrology, understanding that with appropriately trained and certified advanced practice providers’ support, this may be substantially fewer than the number currently being trained.

As we look to the future, the growing number of patients with kidney diseases will ultimately dictate the need for expanding the number of nephrologists in the future. During this expansion, it is vital to ensure that nephrology is valued within health systems. Recommendations by the division chiefs are summarized in Table 2. We will need to ensure that nephrologists are well trained and leaders in new and creative programs, such as cardionephrology (4), onconephrology (36), critical care nephrology (9), and interventional nephrology (37,38). By doing so, primary physicians will continue to consult nephrologists for traditional nephrology clinical management problems, such as fluid and electrolytes, acid-base imbalance, or AKI. In the intensive care unit, nephrologists will continue to provide expertise in continuous RRT. We must continue to remind hospital administrators of the vital contribution that nephrology makes to the overall health system. Lastly and importantly, we must ensure that we create a profession that is distinctive and diverse with optimal work-life balance. We must push forward in support of kidney care innovation and also create new and audacious programs to invigorate current and future nephrologists and ensure the success of our specialty.

Disclosures

A. Chapman reports grants and other from Reata, grants and other from Sanofi, and personal fees from Janssen Pharmaceuticals, outside the submitted work. D.H. Ellison reports serving as a councilor for the American Society of Nephrology; reports other from the American Heart Association, the American Physiological Society, the American Society of Nephrology, Asian Pacific Congress of Hypertension, Department of Veterans Administration, Fondation LeDucq, National Defense University of Taiwan, the National Institutes of Health (NIH), Ninth Oriental Congress of Nephrology, Oregon Health and Science University, University of Colorado, and UpToDate; and reports receiving grants from Department of Veterans Affairs, Fondation LeDucq, and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), outside the submitted work. C.A. Gadegbeku reports serving as a site investigator for Akebia Therapeutics, as a site investigator and on the advisory committee for Bristol-Myers Squibb and Duke Clinical Research Institute, as an NIH grants coinvestigator, as a Fresenius Medical Care Episcopal Hospital Dialysis Medical Director (Philadelphia, PA), and as a councilor for the American Society of Nephrology; reports receiving grants from Akebia, Fresenius, and the NIDDK; and reports nonfinancial support from the American Society of Nephrology during the conduct of the study. P. Igarashi reports receiving travel support from American Society of Nephrology during the conduct of the study. He also reports receiving consulting fees from Otsuka America Pharmaceutical Inc.; employment from University of Minnesota and University of Minnesota Physicians; grants from National Institutes of Health; honoraria and travel support from Yale University, University of Alabama Birmingham, UT Southwestern, Harvard, and Northwestern University; royalties from Elsevier; travel support from Association of American Physicians and Federation of American Societies for Experimental Biology; and equity from Crispr Therapeutics, Editas Medicine, Johnson and Johnson, Medtronic, Merck, Pfizer, Gilead, and Allergan. E. Kelepouris reports personal fees from Relypsa, personal fees from Reata Pharmaceuticals, personal fees from UpToDate, and grants from Mallinkrodt, outside the submitted work. M.D. Okusa reports receiving honoraria from UpToDate; reports honoraria and travel from Continuous Renal Replacement Therapy Taipei and India, Hong Kong Society of Nephrology, Japanese Society of Nephrology, Johns Hopkins, Mount Sinai, Northwestern, Tokyo University, University of Alabama O’Brien, University of Florida, University of Maryland, Yale O'Brien, and Yale University; reports grants from Am Pharma/Pfizer and the John Bower Foundation; reports travel support from American Physiological Society, Federation of American Societies for Experimental Biology, and Keystone during the conduct of the study; reports other from Adenosine Therapeutics, LLC; and reports serving on the Yale O'Brien External Advisory Committee. T.J. Plumb reports other from DaVita, Fresenius Medical Care, Nebraska Department of Health and Human Services, and Outset Medical. S.E. Quaggin reports receiving grants and other from Mannin Research; reports serving as a consultant for AstraZeneca, Genentech, Janssen, Lowy Medical Research Institute–Lowy Board of Scientific Governor's, and Roche, outside the submitted work; and reports serving as an advisor for AstraZeneca, Disease Models & Mechanisms, Journal of Clinical Investigation, Lowy Medical, Lowy Medical Research Foundation, Mannin Research, Stem Cells; as an American Diabetes Association mentor; and as the NIH Pathobiology of Kidney Disease Study Section Chair. D.J. Salant reports receiving grants from Sanofi Genzyme and Pfizer CTI; consulting and advisory board fees from Advance Medical, Chugai, Pfizer, Visterra, and University of Virginia; and honoraria from the Japanese Society of Nephrology and several US academic institutions. In addition, he has a patent Diagnostics for Membranous Nephropathy with royalties income through Boston University and royalty payments from UpToDate, Inc. for authorship of four topic cards. S. Somlo is a founder, shareholder, scientific advisory board member, and consultant for Goldfinch Bio. He has also received honoraria from Otsuka Pharmaceuticals. All remaining authors have nothing to disclose.

Funding

None.