How to make opposites attract: Work/life balance needed to attract fellows to nephrology
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It has become clear that the wants and needs of nephrology fellows looking for employment in general, and specifically in the private practice sector, have changed in the past 40 plus years that I have been recruiting in the profession.
When I first started, the primary objective of a fellow coming out of training was to either start a practice with the assistance of an income guarantee sponsored by a local hospital (to help establish themselves in a community) or to join an existing practice with the idea of becoming a partner.
Nephrology is not an easy specialty to master – a chronic illness like end-stage kidney disease can make patient management challenging and time-consuming. That was understood if you joined this profession as a fellow years ago.
Today and for the better part of the past decade, work/life balance has become the major priority to fellows when discussing practice opportunities. It is not limited solely to nephrology; it is a priority with fellows in other specialties and probably for many people entering the workforce in general. A survey conducted by the American Psychological Association in 2023 showed that 92% of workers reported working for an organization that values their emotional and psychological well-being is very or somewhat important.
According to results from the 2022 Nephrology Fellows Survey published by the American Society of Nephrology, the top four factors influencing a fellow’s decision in considering an employment offer (rated either extremely or very important to the fellows interviewed) were weekend call frequency, overnight call frequency, desired location and workday length. These were followed closely by predictable workday and compensation.
Demanding specialty
The problem the nephrology world faces is that work/life balance and practicing nephrology in a private practice setting are counterintuitive. A shortage of nephrologists since the start of the specialty has always put extra workloads on those practicing. Remember the projections of potential patients and costs in 1972 when Congress approved Medicare for dialysis payment? Legislators did not anticipate that the Medicare entitlement would grow to treat older, sicker patients and assumed younger patients would all get transplants and go back to work. Twenty-five years later in 1997, it was clearly stated again in an ad hoc committee report co-written by representatives of various nephrology and transplant associations, including the ASN and the Renal Physician Association.
Today, partly through Medicare funding aimed at slowing the progression of chronic kidney disease, the annual growth in the number of patients with ESKD has slowed (the high mortality rate among patients with kidney disease who contracted COVID-19 also depleted the prevalent population).
According to quarterly updates released by the U.S. Renal Data System, 136,196 patients were newly diagnosed with ESKD in 2021. That number decreased to 131,216 in 2022 and, if the pattern of quarterly counts continues, new cases will be approximately 130,930 in 2023.
Still 808,000 prevalent patients had ESKD in the United States at the end of 2021. More significantly, more than 37 million Americans have some form of CKD. Back in 1997, when the ad hoc committee report was released, the ESKD population was less than 300,000. The total nephrology physician population at that time was around 4,800; today it is closer to 12,600.
Attracting fellows
The nephrology community has tried to address these numbers by expanding the number of fellowship programs and the number of fellows completing those programs (see table).
Even with the additional programs today, the most recent match results are alarming: Overall, 52% of the training tracks for nephrology (of which there are 180) filled completely. Likewise, 66% of positions in those tracks were filled (321 of a possible 488 nephrology open positions).
While better than fill rates during 2010 to 2019, the numbers have been trending downward since 2020. Of the major internal medicine specialties, the majority achieved fill rates in the 2024 match in excess of 95%. Nephrology joined geriatrics and infectious disease at less than 66%.
Why does this happen? Internal medicine residents going through rotations in nephrology see that nephrologists tend to manage the sickest of patients, work longer hours and have the added component of having to go to visit patients in dialysis facilities (in order to collect the monthly capitated payment) in addition to maintaining an office and hospital practice. The complexity of the specialty and the stress and ramifications of decisions is not always something that all residents want to deal with. Compensation is an issue as well.
Looking at the most recent Physician Starting Salary Survey put out by the Medical Group Management Association, the mean starting salaries for nephrologists first year post fellowship were the fifth lowest among 60 specialties reporting. The median starting salary ranked better but was still in the lower 25th percentile.
While the sample size for this survey is small, it can be used conceptually to compare with other specialties. Somehow, the nephrology community must do a better job of increasing these starting numbers to help attract residents to the specialty.
Changes in productivity
Nephrology is impacted by all these factors: the shortage, the long hours, complexity/difficulty of the specialty, and the lower compensation. Also, for a multitude of reasons, those fellows are not going to be as productive as those physicians already in practice. In a recent interview in NEJM Catalyst, Daniel Varga, MD, chief physician executive for Hackensack Meridian Health System, said, “The problem is that the ones (doctors) they’re replacing are two X of them, and we’re going to have to figure how to redesign the care model in a way that allows those doctors to be the good doctors they are, but at the same time provide the same access to care that we’re providing today, if not more.”
He goes on to describe this as a generational change — a good change but one that needs to be addressed. It is not just a matter of replacing bodies, it is a matter of replacing productivity.
To facilitate work/life balance in nephrology, all these issues need to be dealt with. Some options include the following:
- develop a better utilization of physician extenders in nephrology practices;
- improve the coordination of responsibilities within the practice;
- minimize driving time and increase face time with patients;
- utilize telehealth when possible and appropriate; and
- develop protocols that can be applied to all aspects of practice that will make the physicians more productive.
The recent advancements seen with AI also have the potential to be a game changer; however, its use must be approached cautiously. AI “presents unprecedented opportunities to enhance patient care, improve diagnostics, streamline workflows and facilitate more precise treatment decisions ... [it] can also be used in the applications in diagnosis, risk prediction, treatment optimization and patient monitoring,” Francesco Bellocchio, MD, PhD, and colleagues wrote in Frontiers in Nephrology. “While the potential of AI in nephrology is immense, its implementation comes with challenges and ethical considerations.”
Without making changes, the specialty of nephrology will continue to have difficulty attracting new fellows and meeting the needs of the kidney community.
- References:
- AMA database. Medical Marketing Services. https://static1.squarespace.com/static/58c9b895414fb537a75ee36b/t/601c7ec93d12c8463a46066b/1612480202227/MMS_AMA_info.pdf. Accessed June 6, 2024.
- Bellocchio F, et al. Front Nephrology. 2023; doi: 10.3389/fneph.2023.1270769.
- Neilson EG, et al. J Am Soc Nephrol.1997. https://www.scholars.northwestern.edu/en/publications/the-ad-hoc-committee-report-on-estimating-the-future-workforce-an. Accessed June 6, 2024.
- Medical Group Management Association. 2024 Provider Compensation Report. https://www.mgma.com/data-report-provider-comp-2024. Accessed June 6, 2024.
- Work in America Survey: Workplaces as engines of psychological health and well-being. https://www.apa.org/pubs/reports/work-in-america/2023-workplace-health-well-being. Accessed June 6, 2024.
- On Deck: Results from the 2022 ASN nephrology fellow survey. https://data.asn-online.org/posts/2022_fellow_survey/. Accessed June 6, 2024.
- U.S. Renal Data System: 2023 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. https://usrds-adr.niddk.nih.gov/2023. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2023.
- For more information:
- Martin Osinski, MBA, CVA, is president of NephrologyUSA and based in Jacksonville, Florida. He is also a Healio | Nephrology News & Issues Editorial Advisory Board Member. He can be reached at mo@nephrologyusa.com.
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