These days, it is common to hear about challenges facing nephrology: the burgeoning end-stage renal disease (ESRD) population, concerns over bundled reimbursement and pay for performance in dialysis care, and the relative lack of effective interventions for halting the progression of chronic kidney disease are a few examples that come to mind.
One of the most concerning issues, though, is that in the face of these difficulties and others, interest in nephrology careers among medical students and residents seems to be waning.
Mark Parker, MD, Chair of the American Society of Nephrology (ASN) Workforce Committee, and coauthors detailed this decline in US medical graduates entering nephrology fellowships in a manuscript published in the Clinical Journal of the American Society of Nephrology.1 Ours is the only subspecialty besides geriatrics to see a downturn in interest, which occurred despite the creation of 200 new fellowship positions.
Why is this happening, and what can be done? We intend to explore one aspect that may play a significant role: shifts in physician views of work-life balance and the importance of a so-called controllable lifestyle, characterized by regular and predictable work hours.
Nearly ten years ago, E. Ray Dorsey, MD, MBA, and colleagues published an article in the Journal of the American Medical Association that explored changing specialty choices by medical students from 1996 to 2002, concluding that much of the variance was due to perception of controllable lifestyle.2
Examination of the surgical literature reveals an alarming rate of attrition among surgical residents—up to 25% in some cases—most of which is explained by lifestyle reasons.3,4 These trends are starting to affect internal medicine as well, not only influencing initial career choices but also practice models and mid-career changes.5,6
In contrast, interest in controllable-lifestyle fields such as anesthesiology, emergency medicine, and dermatology is on the rise. This is particularly true among medical students graduating from highly ranked medical schools.7
Some of the factors driving this change are related to major demographic shifts in society. Research into the Millennial generation—a term coined for those born after 1980, which encompasses nearly all current medical students—has revealed a group that prizes controllable lifestyle and time with family to a greater extent than previous generations did.
US medical graduates share similar goals and may be less interested in forming long-term relationships with patients, which may also explain the declining interest in careers in primary care.1,8,9
While nephrology is fortunate to have attracted many highly qualified international medical graduates, these graduates have similar attitudes toward lifestyle and career choice as US medical graduates do, suggesting that the problem of reduced interest in nephrology is not confined to those educated in this country.8
International graduates, who already face considerable difficulty obtaining US residency and fellowship positions in light of more demanding visa requirements and application processes, have decreased their applications to nephrology fellowships by nearly 20% in the past five years.10
Many nephrologists may initially be attracted to the field by its basic science aspects and are subsequently discouraged by clinical practice's increasing focus on protocol-driven issues, such as dialysis adequacy and core measures for chronic kidney disease.
Residents considering nephrology generally have cited exposure to patient care in areas like electrolyte disturbances and kidney transplantation as piquing their interest, while experience with ESRD is viewed negatively.1,11
This revelation comes at an inopportune time, as extrapolations from the United States Renal Data System suggest that nephrologists are now caring for twice as many dialysis patients as they did 15 years ago, and, given trends in ESRD incidence, this imbalance will only worsen with time.10
Nephrologists are widely thought of as some of the busiest physicians, and the perceived number of hours worked may lead doctors to seek careers outside of nephrology.1,11
There is some evidence that trainees' negative perceptions of careers in nephrology may reflect reality. A study looking at career satisfaction among 6,500 US physicians ranked nephrology 40th out of 42 specialties, and controllability of lifestyle seemed to be a major factor in this lack of satisfaction.12
Despite these challenges, about 90% of nephrology fellows responding to a recent survey were satisfied with their career choice, suggesting that careers in nephrology are still interesting and fulfilling to a number of up-and-coming physicians.13
Room for Change
Medical students choose internal medicine for reasons that are predominantly not lifestyle-oriented; most of us might agree that this pattern is likely true for nephrology as well. Regardless, believing that national trends in physician specialty choice will not further affect interest in nephrology training is probably naïve.
Medical graduates increasingly have viewpoints that may be at odds with seeking nephrology careers in the current environment, and, whether or not we agree, this pressure is likely to result in changes to practice models over time.
We pose that a major challenge facing all of us in nephrology is to think of ways to change our practice that not only address the burgeoning numbers of patients needing our care but also the desire of future physicians to have more control over their lifestyle.
These potential shifts must be carefully considered so they do not compromise patient care. Nephrology practices run a particular risk of unintended consequences if they fail to implement adjustments in work-life balance proactively and instead are forced into making changes to attract new fellowship graduates.
Such proactive changes are already happening throughout the country; examples include the increasing role of nurse practitioners and physician assistants in providing dialysis care and of hospitalists in admitting dialysis patients.10,14
If nephrology is to remain a competitive and vital field of medicine capable of attracting the best and the brightest practitioners, it must reinvent itself—not only in terms of what we do to take care of patients, but how we take care of ourselves.
1. Parker MG, Ibrahim T, Shaffer R, Rosner MH, Molitoris BA. The future nephrology workforce: will there be one? Clin J Am Soc Nephrol
2. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA
3. Dodson TF, Webb AL. Why do residents leave general surgery? The hidden problem in today's programs. Curr Surg
4. Naylor RA, Reisch JS, Valentine RJ. Factors related to attrition in surgery residency based on application data. Arch Surg
5. Bylsma WH, Arnold GK, Fortna GS, Lipner RS. Where have all the general internists gone? J Gen Intern Med
6. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA
7. Patel MS, Katz JT, Volpp KG. Match rates into higher-income, controllable lifestyle specialties for students from highly ranked, research-based medical schools compared with other applicants. J Grad Med Educ
8. West CP, Drefahl MM, Popkave C, Kolars JC. Internal medicine resident self-report of factors associated with career decisions. J Gen Intern Med
10. Mehrotra R, Shaffer RN, Molitoris BA. Implications of a nephrology workforce shortage for dialysis patient care. Semin Dial
11. Lane CA, Healy C, Ho MT, Pearson SA, Brown MA. How to attract a nephrology trainee: quantitative questionnaire results. Nephrology
12. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res
13. Parker MG, Owens S, Rosner MH. Nephrology as a career choice: an ASN fellow membership survey (Abstract #SA-PO2868). Paper presented at: American Society of Nephrology Renal Week; Oct. 31, 2009; San Diego, CA.
14. Gesensway D. Admitting dialysis patients. Today's Hospitalist
. March 2012: 22–25.