The future of nephrology training: A fellow’s perspective

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Much is being said about the steady and dramatic decline in applications to nephrology training programs. The recent match shows a continuation of this trend: 67.9 percent of offered positions filled, leaving 50% of US programs unfilled on match day. The writing is on the wall: the number nephrology training positions needs to shrink. However, there is going to be no agreeable and easy way to decide which program should reduce size or close its doors. Should we let programs decide what to do individually or should we defer decisions to some governing body? Should programs that go unfilled be forced to reduce numbers or shut down, the so-called “survival of the fittest” model? Or should we create an algorithm to decide how to reduce positions more equitably?

Tejas Desai posted a paper that describes a more equitable model by allocating training positions according to ESRD prevalence in US states/jurisdictions. In his model, he estimates that fewer jurisdictions would reduce in size under an equitable model compared to the “survival of the fittest” model. An “equitable” process using an algorithm is attractive because it would distribute the allocation of positions based on some objective measure, like ESRD prevalence. This would benefit training programs that have a harder time recruiting. An equal proportions model may “share the pain” so certain regions are not affected disproportionately than others, thus retaining program directors and training infrastructure for when applications rebound (assuming they will).

As a fellow in training, I worry that any algorithmic approach to this problem will be focused too heavily on the needs of the training program and not the applicants. In that sense, the “survival of the fittest” model is more oriented to a fellow’s actual needs. Program desirability is likely driven by a mix of perceived program quality and factors unrelated to quality like geographic region, cost of living, or job opportunities for spouses, for example. In this thin market with so few applicants, program quality is not as much of a distinguishing factor. I think it’s safe to assume that fellows will work hard everywhere and that training program directors and faculty truly care about fellow education at all programs. In that sense, these factors not directly related to program quality will likely influence an applicant’s decision. I think it’s safe to assume that if these factors matter today, then they will likely be valued again by applicants in future years. If we are truly on board with a mission to increase interest in nephrology, we can start by paying attention to where people want to train and why. The NRMP Match rank list is a reasonable way to understand this.

Simply allocating positions based on ESRD prevalence or any other equitable algorithm favors at-risk programs, but it does not take into account trainee preferences. Many trainees desire specialized training in transplantation, glomerulonephritis, interventional nephrology, clinical research, basic science research, medical education, quality improvement, or health informatics. Some programs are more desirable because they can provide these individualized opportunities for career development. Access to one of these programs might be more limited through an algorithmic approach to training position allocation. Who knows, if word got out that positions have been weighted to regions based on ESRD prevalence alone, it may perpetuate the stereotype among residents that nephrologists are nothing more than dialysis technicians, missing the breadth and depth of actual practice. If fewer positions are made available in highly desirable programs, then it would be wrong to assume an applicant will be just as happy or available to train elsewhere. Given that some applicants desire certain locations due to factors like job opportunities for spouses, reducing positions in those desirable locations may be enough to convince the applicant to choose an alternative career like hospital medicine for example, where opportunity is abundant.

The nephrology community should remember that the primary issue is lack of interest. Efforts to increase interest should be at the center of the discussion. Deciding how to reduce positions will be controversial and it will be tough to find agreement. Maybe the best solution will need to consider everyone’s needs equally: considering applicant choices/preferences and also minimizing program dissolution. One model for position allocation could be based on an incentive for producing more nephrology applicants: You get fellowship training positions if you contribute to the applicant pool by mentoring/developing the residents and students at your institution. This would actually address the underlying problem wouldn’t it? I applaud Dr. Desai for starting this conversation. Even if some final complex algorithm is required, I just hope that applicant and fellow preferences are not ignored.


  1. Everyone here is missing the MAIN reason why there are so less residents choosing Nephrology- REIMBURSEMENTS.

    Over the years medicare has cut the reimbursements a lot. Unless you go to a rural area where is a dearth of nephrologists- it is hard to compare the salaries to Cardiology, GI, Oncology, Critical Care and even Rheumatology. Reimbursements for nephrology are one of the lowest. Compare for an injection of zolandronate medicare reimburses an oncologist 180$ and for 4 dialysis visits (including a comprehensive visit + patients care plan) we get 240$.

    I don't think people are not choosing nephrology as there is a lack of interest. nephrology has been one of the most interesting and intriguing specialty of medicine. Also most of the fellowship programs do a good job in training fellows. As a fellow I did not have much exposure to outpatient dialysis. When I started private practice did not have any i but highly problem and never felt under trained in dialysis.

    If we do want the specialty to survive- we do need to open up to discussion about reimbursements. It is the hard truth- nobody wants to do nephrology because our patients are complex and reimbursement is one of the lowest.

  2. Does the Medical Education Institute (MEI), which Dori Schatell heads, have an education product to teach nephrologists about dialysis?

    Until everyone is completely open about their financial and organizational interests, an honest and productive dialogue about fixing dialysis/nephrology is unlikely.

  3. I am struck by what is missing in this blog post–any reference apart from population to the PATIENTS with kidney disease that a freshly-minted nephrologist will care for. Nephrology is, like endocrinology, an IM subspecialty that is highly complex, and therefore attracts some of the best and brightest. But, for years, the ABIM certification exam has been a mismatch for clinical nephrology practice–and, thus, fellowship training programs have been a mismatch as well. The ABIM exam has 240 items–and only a dozen (5%!) focus on ANY aspect of dialysis, which occupies as much as 60% of the time of practicing nephrologists. Don Berwick points out that systems are designed to obtain the results that they get. We have a system of nephrology training designed to develop chairs of academic nephrology departments at universities who can attract NIH research dollars–not take care of PEOPLE. Since there are so few dialysis questions on the exam, it's easy for training programs to ignore it entirely. I'm told that of the 140 or so training programs, just 10 require a hands-on chronic dialysis rotation. (Imagine if oncologists were not trained in chemotherapy!) Is it possible that one reason nephrology is no longer attracting fellows is the LACK of focus on taking care of people? Isn't caring for people the reason many people enter the field of medicine in the first place? The ASN is now offering dialysis coursework, and my understanding is that the new chair of the ABIM is looking at better fitting the exams to clinical practice. Perhaps steps like these will help to make nephrology practice more appealing to future physicians.

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