The Future Nephrology Workforce: There Will Be One

In 2011, the introduction of the American Society of Nephrology (ASN) Workforce Committee was heralded by a Public Policy Series article titled, “The Future Nephrology Workforce: Will There Be One?” (¹). The title was intended to evoke concern over a precipitous drop in nephrology fellowship applications, particularly by US medical school graduates (USMGs). Perceived sources of disenchantment included daunting complexity of kidney physiology, unattractive lifestyle, inadequate income relative to work effort, and monolithic pace of discovery and change in the field (¹,²). Over the next decade, the committee advanced initiatives and developed programs to increase appeal of the field. Although several new programs gained traction, it became evident that assurance of workforce stability was more complex than simple recruitment. Nephrologists have explored the size and quality of fellowship programs, the role and distribution of advanced practice providers, the need to stimulate innovation and rapid advancement in disease management, and the scope of nephrology care. Ten years after the advent of the workforce committee, what has been accomplished?

The Nephrologist Pipeline Problem

Projections about the growth of CKD and kidney failure populations have shaped workforce conversations while health care delivery and reimbursement models have evolved. Integration and growth of advanced practice providers into the nephrology workforce has mitigated some concerns but competition with other disciplines and dropout limits this resource (³). Physician pipeline remains a fundamental exigency.

In the 2011 nephrology Match, there were 104 (26%) fewer USMG fellowship applications than in 2002. The total number of available fellowship positions grew by 200 (28%) in the same decade (⁴). Though international medical graduate (IMG) applications initially remained substantial, that pipeline soon diminished too. Consequently, the ratio of filled to available positions in the Match fell from 1.3 in 2011 to 0.6 in 2016. The ratio has fluctuated from 0.6 to 0.7 since 2016. Most open positions have been filled by “scramble.” Some have worried about declining quality of fellowship graduates, pointing to falling board certification pass rates from 90% in 2016 to 74% in 2019 (³). Board pass rates bounced back mildly to 80% in 2020—a rise of uncertain significance.

Efforts at Improving the Pipeline and Educator Environment

The ASN Workforce Committee directed initial efforts toward those elements of the pipeline problem that seemed most malleable: stimulating interest and developing educators. Ideas to rekindle student and resident interest culminated in two sustained core programs: Kidney Students and Residents (STARS) and Tutored Research and Education for Kidney Scholars (TREKS) (Figure 1). STARS recruits undeclared career path residents along with medical and graduate students to attend ASN Kidney Week. Mentored activities enhance the experience. Attendance records at ASN Kidney Week in 2019 identified 300 participants. The most recent STARS program survey saw 92% of residents expressing strong interest in nephrology training after Kidney Week (ASN Workforce and Training Committee, personal communication). TREKS invites 60 medical and graduate students per year to attend a week-long summer experience—either an origins of kidney physiology course at Mount Desert Island Biological Laboratories in Maine or an exposure to contemporary clinical nephrology experiences at the University of Chicago. Mentorship pairings are then created at home institutions to maintain longitudinal connection to nephrology (⁵). A medical school nephrology interest pilot program, Kidney Mentoring and Awareness Program for Students, centered on community kidney disease screening activities was modeled on a successful college program, Kidney Disease Screening and Awareness Program (⁶). Although Kidney Mentoring and Awareness Program for Students was not expanded, the pilot sites still thrive (⁷).

Figure 1.: Past challenges, present programs, and future signs of the health of the nephrology workforce. ASN, American Society of Nephrology; STARS, Students and Residents; TREKS, Tutored Research and Education for Kidney Scholars; MAPS, Kidney Mentoring and Awareness Program for Students.

While focusing on pipeline was a key feature of workforce development, equally important was stimulating the skills of educators who could mentor these trainees. Faculty development efforts began with a nephrology educators’ listserv that evolved into an ASN Community, a series of medical education special sessions at Kidney Week, and the establishment of the William and Sandra Bennett Clinical Scholars Program grant to facilitate early career development of nephrologists pursuing paths as medical education researchers. Seven Bennett awards have been provided to date, supporting such projects as nephrology curriculum development in undergraduate medical education and pencast videos to enhance kidney learning among internal medicine residents. And finally, the Innovations in Kidney Education contest, entering its sixth cycle in 2021, aims to foster interest in nephrology and promote faculty development of creative tools to teach nephrology in engaging ways.

Outcomes of Our Efforts and Next Steps Forward

Has there been a clear association between these efforts and individual decisions to pursue nephrology fellowship? It is easy to survey participants immediately after program participation—these results have been favorable (⁵). However, tracking students through medical school and residency has proved challenging. In 2019, the ASN fellowship survey asked fellows if they had participated in ASN recruitment programs, and 60% of fellows stated that they had attended Kidney Week STARS (⁸). Three percent of fellows had attended TREKS—not an insignificant proportion considering that TREKS began in 2013 and targeted early year medical students. These were likely the first TREKS graduates to enter nephrology fellowships.

Two other efforts informed workforce strategy. A “Best Practices” project described medical schools and residencies that produced high numbers of eventual nephrologists. Early and consistent exposure to nephrology experiences and faculty were identified as key attributes (⁹). Additionally, ASN conducted annual surveys to query key aspects of a fellow’s current educational experience and future job activities. The first survey in 2014 was discouraging. Only 72% of respondents said they would recommend the field to others; perceptions of inadequate job opportunities were high—35% for USMG and 56% for IMG. By 2019, though, “would recommend” rose to 80% and “inadequate job opportunities” fell to 12% (USMG) and 20% (IMG) (⁸).

Although conditions have improved, hurdles remain. Despite a suggestion in 2015 that fellowship position number should be contracted to enhance competition and quality (¹⁰), the total number of available positions remains essentially unchanged. Perceptions of insufficient compensation and unappealing lifestyle remain challenging (¹¹). Social, cultural, and economic factors complicate the equation. Real concerns exist about gender imbalance, gender disparity in compensation, inadequate ethnic diversity, diminished nephrologist role in hospital settings, and workload (³).

Still, there are positive signs. In 2021, the best rate of filled Match positions was achieved since 2014. Graduating fellows' perceptions of job opportunities have markedly improved. They are recommending the field to others. The past decade has yielded molecular discovery and new treatment breakthroughs, from elucidation of Klotho protein to discovery of anti-phospholipase A2 receptor antibody, and from the benefits of sodium-glucose transport 2 inhibitors to the promise of hypoxia inducing factor–proline hydroxylase inhibitors. The ASN Kidney Health Initiative and the Innovation Accelerator (KidneyX) public-private funding partnership have boldly charted paths to rapid change in prevention, diagnosis, and treatment of kidney diseases. The Advancing American Kidney Health Executive Order has focused attention on patients with kidney diseases. In this milieu, the current ASN Workforce and Training Committee will summit this year to re-envision the workforce, tackling topics such as right-sizing fellowship positions, improving diversity, recruiting incompletely tapped pools (e.g., osteopaths), alternative work structures (e.g., job sharing), and nephrology subspecialization. Invariably, these factors and the targeted ASN workforce recruitment programs will sustain the physician pipeline.

Medical specialists of the kidney clearly will be needed long into the future. The question is no longer, “Will there be a workforce?” There will be one. The question is, “How will the future nephrology workforce discover, innovate, and deliver high value care?”

Disclosures

All authors have nothing to disclose.

Funding

None.