Where Have All the Nephrologists Gone? Long Time Passing!

We are seeing a continual increase in the number of US patients with CKD and ESRD. The epidemic of obesity, and resultant diabetes and hypertension, has not abated and will continue to swell the ranks of patients needing care from nephrologists. Add to this the incredible improvement in the survival rate of ESRD patients over the last decade and the extended availability of medical care to the uninsured thanks to the Affordable Care Act, and we are indeed on the brink of a tidal wave of kidney patients. These facts should be a wake-up call to health policy-makers, especially in light of the shocking statistics from the most recent Medical Specialties Matching Program (MSMP)(1). For appointment year 2013, MSMP indicates that nearly a quarter of nephrology fellowship programs had unfilled positions, the worst of all medical subspecialties. Only 25 percent of positions were filled by US graduates overall and only 21 percent of clinical nephrology positions are filled by US graduates—the lowest of any medical subspecialty.

So what happened to nephrology? Why has it lost its allure for the best and the brightest US graduates? KD Jhaveri and colleagues recently tried to answer this question by surveying internal-medicine subspecialty fellows(2). They found more than one-third of those surveyed considered nephrology the most difficult physiology to learn. Two of the key findings for why nephrology was not chosen were the complexity of ESRD patient care and the lack of mentors.

It is worth exploring the issue of the difficulty of the subject matter, since this issue was addressed in an important study by MP Hoenig et al(3). The American Society of Nephrology conducted a survey of US medical students and found that experiences in renal pathophysiology courses during medical school were important determinants of the decision not to pursue nephrology. Teaching techniques used, such as videotaped lectures, plus the lack of social-media integration and the use of volunteer teachers all tended to reinforce a lack of vitality to the subject matter. The Hoenig study proposed creative teaching approaches to reverse this trend.

Similarly, experiences during the medical-residency years do not nurture a strong interest in nephrology. Nephrology faculty is often not excited about the specialty, and particularly about patient care focused on CKD/ESRD. Nephrology electives are heavily weighted toward inpatient consultations and critical care, and don’t expose residents to the full breadth of experience in nephrology(4). Mentors are few are far between.

Perhaps we should take solace in the fact that the loss of attractiveness of nephrology as a specialty is not confined to the United States. Recent publications from Spain and elsewhere document the same trend(5), and many of the factors outlined above for the United States apply in Spain, as well. (Ironically, nephrology in Spain attracts a high number of non-Spanish physicians, which is considered an important indicator in that country.)

We need to address these issues from two perspectives. First, we need to make nephrology the high-profile, challenging, rewarding, desirable specialty it once was. This needs to start in medical school and continue into internship and residency. Creative approaches to teaching renal physiology and—most importantly—exposure to the outpatient practice of nephrology are key. Second, and overriding all of this, is the development of a group of mentors—people who are role models, who love the discipline of nephrology and who are passionate about keeping it vibrant, something that is sorely lacking today. Partnerships among our academic and clinical-practice societies are critical in the development of this equivalent of a speaker’s bureau, and could focus on development of basic and clinical scientists as well as committed clinicians.

In the meantime we need to take accountability for ensuring that the new CKD/ESRD patients flooding into the system receive the care they need and deserve. As a discipline, we must embrace and expand the use of physician extenders as well as fully develop coordinated care models to deliver needed services. Partnerships with primary-care physicians will be increasingly important, while careful attention to the continued improvement of clinical outcomes will be critical(6,7).

So, to the nephrologists reading this, what are you going to do to ensure the viability of nephrology? Who will you mentor? Who will be able to look to you as a role model? We owe it to ourselves, to our discipline and, most importantly, to our current and future patients to step up and do our part.

As Albert Schweitzer said, “One thing I know; the only ones among you who will be really happy are those who will have sought and found how to serve.” 

1. http://www.nrmp.org/fellow/match_name/msmp/stats.html. Accessed March 4, 2013.
2. Jhaveri KD et al. Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows. Am J Kidney Dis. In press, 2013.
3. Hoenig MP et al. Lessons Learned from the ASN Renal Educator Listserv and Survey. Clin J Am Soc Nephrol. In press, 2013.
4. Jhaveri KD et al. Enhancing Interest in Nephrology Careers During Medical Residency. Am J Kidney Dis 60(3):350–353, 2012.
5. Suarez FO et al. What Happens to the Specialty of Nephrology? Nefrología 32(4):435–436, 2012.
6. Shah AP, Mehrotra R. Searching for New Care Models for Chronic Kidney Disease. Kidney International 82:621–623, 2012.
7. Mehrotra R et al. Implications of a Nephrology Workforce Shortage for Dialysis Patient Care. Seminars in Dialysis 24:275–277, 2011.