Editorial

Choosing Nephrology—Or Not

Related Article, p. 540

Why does a trainee choose to become a nephrolo-gist? Why does he or she remain a nephrolo-

gist? These are important questions, and understand-ing the answers will help us ensure that nephrologycontinues to attract and retain intelligent and talentedtrainees. Recently, we and others have been askingquestions of nephrology fellows1,2 and working neph-rologists3,4 in order to better understand recruitmentand retention in our specialty. Similarly, others havequeried medicine residents5-8 and medical students inan effort to understand how people decide their futurecareers. As future nephrologists derive from the poolof internal medicine and pediatrics residents, Jhaveriand colleagues9 questioned fellows who chose otherinternal medicine subspecialties on their thoughtsabout nephrology and why they did not choose it.

Jhaveri and colleagues report that 26% of the 710non-nephrology internal medicine subspecialty fel-lows surveyed (with a survey response rate of 11%)considered pursuing nephrology, but most found an-other field that captured their interest. Some respon-dents felt that long work hours or poor monetarybenefits in nephrology were reasons to select anotherdiscipline, while others cited the complexities of ne-phrology patients or a perceived lack of mentors orrole models. Many felt that nephrology was a difficultsubject in medical school. Jhaveri et al also note thatthe number of nephrology applicants has had a steepdecline relative to the number of positions availableover the 5 years that nephrology has participated inthe match (2008-2012); however, these data also incor-porate an increase in the number of first-year positionsfrom 372 to 419 from 2005 to 2010. Critically, thenumber of practicing nephrologists has increased 43%over the past decade.10

How do we reconcile this information with what wealready know about career choices in medicine? Garib-aldi et al5 reported in 2005 that the number of medi-cine residents electing for careers in primary care hadseen a consistent decrease; however, more recent datasuggest that, while most subspecialties have seen anincrease in applicants, some have experienced a de-crease.11 The recent interest in hospitalist careerscounteracts subspecialization and may siphon off resi-dents interested in subspecialties that incorporate sub-stantial acute hospital patient care, such as nephrol-ogy.8 One can argue that hospitalists seem to come in2 varieties: those transiently choosing hospital medi-cine to gain experience, make money and pay debts,

or obtain a green card, and those who become career

Am J Kidney Dis. 2013;61(4):529-531

hospitalists. We need data on the former; if they seekfellowships, are they successful in obtaining them,satisfied with the experience, and committed to thefield upon board certification?

Beginning in 2012, the subspecialty match forpositions starting in July was moved to December,just 6 months prior to the start date. This change led toconcerns among nephrology training program direc-tors about reductions in applicant numbers. As nephrol-ogy has a high proportion of international medicalgraduates,10 many of whom have J-1 visas, this subsetof applicants may be particularly vulnerable if theyfail to match. Accordingly, they may choose visawaiver positions, which are available earlier in theacademic year than the match, thus postponing subspe-cialty training. Preliminary data from the 2013 matchsuggest that a reduced number of applicants resultedin a rise in unmatched nephrology positions.12 Thismay be the first evidence of a decrease in applicationsfrom international medical graduates, which supportsthe concern of nephrology program directors,13 ormay reflect a broader decrease in applicants to allsubspecialty fellowships.

What do other data tell us about nephrologists’preferences? Garibaldi et al5 and West et al8 bothreported that nephrologists value long-term patientcare. Redesigning nephrology rotations for studentsand residents to include exposure to ambulatory officepractice and dialysis continuity may permit trainees tosee these rewarding aspects of our specialty.1,14 OneCanadian study noted that intellectual stimulation wasdeemed highly important for all medicine residentsselecting subspecialties7 and for those choosing aca-demic practice.15 In contrast, Jhaveri and colleagues9

report that one concern of other subspecialty fellowswas the perception that nephrology subject matter isdifficult. Accordingly, the tension in recruiting tonephrology rests between recognizing the discipline’sintellectual challenge and choosing to work in adifficult field. This tension requires that teachers ofrenal pathophysiology and clinical nephrology beclear and make the discipline more accessible. Specifi-cally, the breadth of subject material, which spansacid-base disorders, glomerular diseases, dialysis, and

Address correspondence to Nancy Day Adams, MD, Universityof Connecticut Health Center, Division of Nephrology, Departmentof Medicine, 263 Farmington Ave, Farmington, CT 06030-1405.E-mail: adams@nso.uchc.edu

© 2013 by the National Kidney Foundation, Inc.0272-6386/$36.00

http://dx.doi.org/10.1053/j.ajkd.2013.02.003

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Nancy Day Adams

transplantation, requires these teachers to identifythemes and unifying concepts both in the classroomand in the clinic.

Criticisms of nephrology as a subspecialty from thepresent survey’s response group include long workhours and relatively low remuneration.9 Many factorsenter into “lifestyle” decisions for trainees and stu-dents when choosing their medical specialty.5,7,8,13

West and colleagues describe time with family andtime for nonwork activities as being important formany trainees.8 Additionally, some trainees want morecontrolled work hours, fewer weekend and night calls,and the opportunities for part-time work for yearswhen other obligations, such as young children, de-mand significant time.13 This need may draw sometrainees away from nephrology, as this career is per-ceived to be demanding.

Data about the importance of doing procedures aredifficult to interpret in the context of these otherfactors in career decisions. For those entering cardiol-ogy and gastroenterology fellowships, procedures seemto trump work hours, perhaps with better remunera-tion as the counterweight.5,7,8 Nephrology has someprocedures,16 but fewer than interventional cardiol-ogy or electrophysiology. In the study by West et al,procedures were less important among internationalmedical graduates, a group drawn to nephrology.8

Notably, one facet of our discipline, interventionalnephrology, has become procedure oriented; this as-pect of nephrology needs to be more broadly recog-nized by medical students and residents, who mightfind more procedures attractive.

In their literature review, Borges and colleaguesidentified the presence of role models and mentors asimportant features that attract people to academicmedicine.15 Minorities and, in particular, women mayneed role models so that they see others “do it” and doit in a way that mirrors their hopes in order to envisionthemselves going into the field. Horn et al found thatwomen residents looked to women professionals inselecting a subspecialty,7 while West and colleaguesidentified role models as an important factor for futurenephrologists in selecting our field.8 Changes thathave occurred within national nephrology organiza-tions (ie, increased numbers of women leaders, award-ees, moderators, and speakers) may enable studentsand residents exploring nephrology to find role mod-els; however, some medical schools may not offer adiverse array of teaching faculty, especially in the first2 years. Nephrology has a lower proportion of women(23.5%) than either parent discipline (�34% in inter-nal medicine and �58% in pediatrics).17 Similarly,African American, Native American, Alaskan Native,and Hispanic physicians, groups who are underrepre-

sented in medicine overall, tend to gravitate to pri-

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mary care rather than subspecialty care.17 Accord-ingly, the problem of a lack in role models applieseven more to underrepresented minority students andresidents. The summative effect of these factors is alack of role models for the vast majority of medicalstudents.

As described by Lane and colleagues, exposure tonephrology is also an important factor.6 McMahonand colleagues identified a nephrology elective inmedical school as influential in career selection for62% of academic nephrologists and 55% of nonaca-demic nephrologists.4 Unfortunately, only 30% ofmedical students have a nephrology rotation in theirfourth year of medical school,18 which further reducesthe availability of role models. Both Borges et al15

and McMahon et al4 identify early research experi-ence (as a student or a resident), funding, and mentor-ing as valuable in deciding on an academic or researchcareer. Mentoring is a broader issue, perhaps more soin nephrology than other disciplines,1,2,8,19 and ongo-ing mentoring for students, residents, nephrology fel-lows, and junior faculty or new-to-practice physiciansshould be a priority for the nephrology community.

Critically, teachers and practitioners cannot be posi-tive role models for potential nephrologists if they aredissatisfied with their work. Leigh et al,3 who sur-veyed practicing physicians in 2004-2005, noted that,in contrast to surveys from the late 1990s, nephrolo-gists were not satisfied with their careers. Non-nephrology fellows responding to Jhaveri and col-leagues’ survey9 would have been senior medicalstudents or first-year residents at the time of the Leighet al survey and working with those dissatisfied physi-cians; importantly, this is the time at which traineesare drawn to a subspecialty.2 While a survey ofAmerican Society of Nephrology members conductedin 2009 documents that respondents generally hadhigh satisfaction with their work, a higher percentageof younger versus older nephrologists (13.9% vs 8.3%)regretted choosing nephrology.4 Taken together, thesedata compel us to rethink how we distribute our workas practicing nephrologists and faculty, how fellow-ships organize rotations with heavy clinical responsi-bility and opportunities for education and scholarship,and how we mentor new practitioners. The impact ofregulatory and payment policies for dialysis care onsatisfaction among nephrologists should also be evalu-ated. Billing for maintenance dialysis changed signifi-cantly in 2004.20 This may well have influenced theLeigh et al response group, as noted previously.

Recognizing these issues, in 2010, the AmericanSociety of Nephrology charged its Workforce Commit-tee to do 3 things: 1) implement strategies for increas-ing interest in nephrology among US medical gradu-

ates and current residents and for increasing the

Am J Kidney Dis. 2013;61(4):529-531

Editorial

diversity of the nephrology workforce; 2) highlightthe positive aspects of nephrology careers, includingthrough the use of social media; and 3) enhanceeducational efforts at all levels, including studentteaching, faculty development, and career guidance.13

A subgroup of this committee is focusing on medicalstudent education, especially preclinical renal patho-physiology teaching, with a recent report document-ing several innovations being shared among renaleducators.21

In sum, as Jhaveri et al report, the impressions oftrainees outside of nephrology can shed light on areaswe should explore in more depth.9 These insights andothers provide foci for further study as we strive tomeet recruitment goals for fellowship training andworkforce replenishment. In the meantime, in ourdaily work, we must remember that we are the face ofnephrology for our students and trainees. We mustproject our enthusiasm for the discipline, our dedica-tion to the care of our patients, and the excitement wefind in solving nephrology problems.

Nancy Day Adams, MDUniversity of Connecticut Health Center

Farmington, Connecticut

ACKNOWLEDGEMENTSSupport: None.Financial Disclosure: The author declares that she has no

relevant financial interests.

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