ASN Nephrology Workforce Report

The second report from the ASN Workforce came out last week.

Mark Parker, from Maine Medical Center, is the chair of the ASN Workforce Committee. Mark is also @KidneyFuture, a name almost as hokey as @Kidney_boy, and he is doing a TweetChat on Tuesday, January 13th at 9PM EST. I spoke with him about the report and mission of the Workforce Committee.

Click the pic to grab the PDF

Dr. Topf

I remember seeing you speak at a previous Kidney Week talking about the shortage of nephrologists. Seeing the lack of job opportunities that fellows are reporting, have you changed your position? Do you still think we are heading to a shortage?

Dr. Parker

In a nutshell, yes, I guess you could say my position has changed. I would rather say “evolved.” I spoke again at the most recent Kidney Week during the joint ASN-RPA public policy session about workforce issues. Dr. Baron from ABIM gave the Blagg lecture during that session. In my own talk, I leaned pretty heavily on data from Part 1 of the ASN-GWU report, which was really simply a more sophisticated composite of the data resources that many of us had already looked to in recent years. I think my message was a little different from a few years ago. A few years back, a number of us saw the following:

  1. Decline in fellowship interest, particularly among US medical grads.
  2. Increasing CKD/ESRD population projections.
  3. Students and residents expressing negative feelings about a career as a nephrologist.
  4. A decrease in interest in becoming nephrology researchers.

This informed our mission and we developed strategies to improve nephrology recruitment. Our interventions really focused early in the medical education pipeline, primarily targeting US medical students.

The recent issues with the nephrology job market for fellows and the abysmal performance of nephrology in the match over the last few cycles has spurrred some urgency and reevaluation of the assumptions and strategies.

With the caveat that the ASN-GWU Part 2 report is our first fellow survey (more are planned) and had a suboptimal response rate, I think the survey responses, combined with the anecdotal observations of program directors support the concept that the current nephrology job market is soft.

There could still be a component of maldistribution that we are missing, but it is hard to argue that we do not or will not have enough nephrologists in the near term. Does this mean that long-term concerns about shortages are invalid? I hesitate to swing the pendulum of opinion all the way in that direction. The CKD/ESRD population remains a significant component of the people that nephrologists serve and projections about the growth of these populations remain robust and have held fairly true over the past few decades. The wild card is really who will care for these patients and how will we continue to define the rest of what a nephrologist does. If we are going to seed the core functions of the care of kidney patients to primary care physicians and hospitalists while continuing to allow other elements of our domain to erode (less involvement with AKI, hypertension, procedures, etc), then sure, why would we need more nephrologists?

On the other hand, if our intent is to strengthen our hold on our domain, prepare for a still growing core population, and most important, attract quality candidates who deliver high quality care and participate in investigation and innovation, then I think we need to continue to focus on recruitment, regardless of whether we perceive a long term shortage or not.
I asked Dr. Parker what drove the 50% expansion in fellowship spots over the last 2 decades, he said, “You know, it’s really interesting. I don’t quite get it either. The balanced budget act of 1997 capped fed money for GME yet nephrology managed to do this. I think maybe we managed to get control of unused slots from other disciplines at various institutions. I also think that service needs, rather than education, drove it. It was not systematically planned.

Few people would argue with the concept that we offer too many fellowship positions currently and I concur with many that we need an acceptable method to reduce them. But even if we reduce the total by say, 25% or more, I worry that we will still have an inadequate pipeline of high quality applicants. It will impact our ability to do research and our ability to deliver the type of care that has contributed to the historical reputation of nephrologists as the smart docs.

Dr. Topf

I am seeing competent hospitalists doing more and more of what nephrologists were consulted to do in the past (routine CKD care, dealing with electrolyte abnormalities, etc). Could this be decreasing hospital consults, tightening practice incomes and preventing nephrology practices from hiring? Is the shrinking scope of practice leading to lower than anticipated employment opportunities?

Dr. Parker

I think there are big issues around defining our scope of practice and maintaining the traditional preeminence of the nephrologist in these areas should be a priority for the field. On the other hand, with regard to your comments about hospitalists, while there are many competent hospitalists with a decent handle on kidney issues, they populate a high turnover, high burnout field, and they don’t spend 2+ years focusing their training exclusively on the kidney. We need to remember that we did and make sure others remember it, too. How will we define ourselves going forward and what steps will we take to retain our domain?

Dr. Topf

What did you find most surprising about the fellow survey?

Dr. Parker

How really, really hard it is to find a satisfactory post-graduate position right now if you are an IMG (particularly because of visa issues). I sort of knew, but the quantified results are stark. And when you consider that IMGs make up the majority of our trainees right now, that is a problem.

Page 13 of the report.

Dr. Topf

How are fellowship programs responding to the most recent match results?

Dr. Parker

Not sure yet. Individual programs may still be trying to fill open spots, though I think that ship has sailed for the most part. Some programs will probably make an independent decision to reduce their number of positions for next year, I think, but I am guessing that is still a small number. The ASN nephrology match task force, populated with Training Program Directors (TPD), division chiefs, Council members, and others will begin meeting soon and probably make specific recommendations to the community in March.

Dr. Topf

You guys have been doing a lot of creative work building interest in nephrology. what can you tell us about KidneyTreks and the Kidney Mentor programs? Are you guys tracking how well that works to convert med students and residents to the fold?

I worry about preaching to the choir. I know that I had already committed to nephrology when ASN put $800 in my pocket to go the Kidney Week in 1998, and a three or four years ago I spoke with a med student at Kidney Week on the ASN’s dime who had already committed to going to MBA school after graduating from Northwestern.

Dr. Parker

Mount Desert Island Biologic Laboratories

We have gone back and forth on who to target for these programs. For the past few years, we have made efforts to target “undifferentiated” trainees for both TREKS (a week of renal physiology experience at MDIBL for med students followed by a longitudinal nephrologist mentor pairing at school) and STARS (the Kidney Week program for residents and students). The latest Match results have given us pause and made us reconsider focusing on partially differentiated (i.e., an established interest) trainees — perhaps we should nurture them and solidify their career intentions given our precarious applicant numbers. It is an ongoing topic of discussion in the workforce committee. As for tracking, yes, we are following people as they move from med school to residency and beyond. The TREKS program is still young. Most of the initial cohorts are still in medical school.

Dr. Topf

What are the future Workforce Reports going to be about and when can we expect read them.

Dr. Parker

Ed Salsberg and his colleagues at GWU are going to continue to survey the fellows annually for the next few years, under a contract with ASN. In addition, they are doing some focus groups in the near future with practicing nephrologists — I think the questions will deal with some of the scope of care issues, marketplace concerns, and views of employment and hiring, to name a few. Should be interesting and useful.

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