The pediatric nephrology workforce is in crisis
Key takeaways:
- Projections show fewer pediatric nephrology trainees and an aging workforce.
- Education debt is high and remuneration low.
- Children’s health care is underfunded.
Pediatric nephrology is facing a looming workforce shortage. Concern initially developed within the community via anecdotal evidence and water cooler conversations at national meetings. More recently, alarm has heightened substantially due to the advent of more objective data.
Workforce projections demonstrate a dwindling pipeline of trainees interested in the specialty, an aging workforce and poor retention with substantial exodus from the specialty. Although reasons for the decline remain varied and complex, a common underpinning is economic disincentives both personal and at a structural level. Without substantial changes to renumeration policies, it is likely the strain on the pediatric nephrology workforce will negatively impact our ability to adequately care for children with kidney disease.
Fewer trainees choose fellowship
The 2024 pediatric nephrology fellowship match was one of the most dismal to date in a series of worrisome statistics. During an 8-year period, from 2014 to 2022, pediatric nephrology ranked the lowest of all 15 pediatric subspecialties with a fill rate of only 66%. The most recent fellowship applicants were down by nearly 30%, with only 29 trainees matching, for a fill rate of 37%.
This discouraging news comes just after one of the most brutal general pediatrics residency matches to date, in which nearly one-third of pediatric residencies went unfilled. As general pediatrics serves as the gateway to future subspecialty matches, it is likely that all pediatric subspecialties will continue to suffer the ill effects of a stagnant pipeline. Although adult nephrology has encountered similar workforce issues, the most recent match shows a glimmer of hope with a 13% rise in adult nephrology appointments for July 2025, with a fill rate of 73%.
Global trends demonstrate similar prognosis in Canada and much of Europe, with substantial shortfalls of pediatric nephrologists and dialysis nurses predicted. Interestingly and in stark contrast to the U.S. system, in the United Kingdom, where physician salaries are on the same national scale of the National Health Service, pediatric nephrology was the second most competitive pediatric subspecialty after endocrinology, with 3.5 applicants per training position in 2023.
Current pediatric nephrology training programs in the United States are 3 years in duration, although globally most are 2 years, as is adult nephrology. One of the liveliest discussions within the community is debating the merits of a 2-year vs. 3-year training pathway. There is now perhaps a begrudging acknowledgement that current recruitment efforts would likely benefit from transitioning to a shorter duration that may allow optional extended training for certain career pathways.
Such efforts will take time and energy to get right and will require concerted efforts between programs and credentialing bodies. Educators and training program directors must now start to envision rebuilding programs and curricula that optimize learning in a more compressed timeline without sacrificing the quality of education to ensure trainees are competent and ready for independent practice.
Education debt high, remuneration low
Another cause of the lack of interest in pursuing pediatric nephology is likely related to the substantial opportunity cost involved with pursing subspecialty education, particularly in the light of soaring medical education debt. The median debt for a graduating medical student is now around $200,000 or more. Pediatricians already make on average about 25% less than their adult counterparts, with subspecialists making substantially less than general pediatricians.
Opportunities for private practice are extremely limited or nonexistent for pediatric nephrology, and practices are generally limited to large academic centers or stand-alone children’s hospitals. The projected difference in lifetime earnings between an adult and pediatric nephrologist is around $1.2 million during a 30-year career. Perhaps it is not surprising that a medical student may find choosing a career in pediatric nephrology a daunting prospect even if initially drawn to the specialty for the intellectual challenges and rewarding long-term patient interactions, given the relatively high workload with far fewer financial returns.
Ongoing efforts to mitigate the substantial financial burdens incurred by pediatric nephrology trainees should continue to be a focus. Loan mitigation programs represent a potential solution. After years of lobbying, the Pediatric Subspecialty Loan Repayment Program was finally authorized by Congress and funded $10 million in the 2023 omnibus government spending package and provides up to $100,000 in loan repayment per individual. Unfortunately, the implementation of the program added a serious unexpected challenge with a requirement of at least 36 weekly hours of patient face-to-face time, which thereby disqualified most pediatric subspecialists from applying to the program. Ongoing conversations with the Health Resources and Services Administration are crucial to modify eligibility criteria so that the legislation serves to revitalize the pediatric nephrology pipeline.
At a systems level, the traditional payment model deriving from work relative value units (wRVU) is a fundamentally flawed payment system that contributes substantially to the pediatric subspecialty workforce crisis. Although a detailed discussion of the wRVU system and the profoundly negative downstream consequences on nephrology reimbursement is beyond the scope of this article, the relative devaluing of the “cognitive-based” specialties, such as pediatric nephrology, has been well described in the literature.
Worth noting is that pediatric nephrology is somewhat unique among specialties with balanced practices between inpatient and ambulatory settings. Most programs are small with one to four partners, which leads to high call burdens for nights and weekends. Although the balance of settings may be a welcome reprieve from the monotony of the day, it also results in an explosion of non-billable clinical work outside of face-to-face time from both inpatient and outpatient spheres. More often than not, this is not accounted for in job descriptions of clinical full-time equivalents (cFTE), particularly in academic settings where productivity in education, research and administrative tasks is also expected (though rarely funded). The unrealistic workload expectations and poor work-life balance are often cited as a key driver of burnout among pediatric nephrologists.
Children’s health underfunded
One of the most important yet daunting tasks is related to making changes in the mechanisms by which pediatric health care is financed. The truth is stark but simple: Our society does not appropriately prioritize or value children’s health.
The U.S. has a higher rate of childhood poverty than other industrialized nations or even middle-income countries, with the lowest health care spending per child of nearly all industrialized countries. Most of children’s health is paid for by Medicaid, state-run programs that uncommonly achieve, or even approach, parity with Medicare. Nationwide, Medicaid pays $0.72 to the dollar compared with Medicare. The general public, nay, most physicians are unaware of this simple fact.
On the whole, pediatric health care organizations fare worse financially than their adult counterparts, ultimately impacting the ability to remain solvent. Perhaps it should be no surprise that between 2008 and 2018, nearly one in five U.S. hospitals closed their pediatric units. Additionally, most pediatric nephrology positions remain in academic medical centers, which carry additional vital missions of education, advocacy and research that are not tied to clinical revenue streams and therefore usually remain unsupported, adding even more financial strain.
Pediatric nephrology was recently granted a potentially pivotal opportunity to demonstrate to policymakers the importance of appropriately valuing pediatric care for the unique expertise and resource expenditure required with the Transitional Pediatric ESRD Add-On Payment Adjustment (TPEAPA) program. The program implements a 30% add-on payment per treatment for pediatric dialysis treatments, starting Jan. 1, 2024, and effective for a period of 3 years.
The purpose of this adjustment is to address equity concerns and to improve access to and quality of care for pediatric patients with ESKD, as CMS recognizes that pediatric patients with ESKD account for 40% higher costs than adult patients, while current payment adjusters account for only about 10% higher costs. This program may serve as a model for other underserved pediatric subspecialties caring for children with complex medical conditions to demonstrate to policymakers and key legislative stakeholders the appropriate value and resources needed for pediatric subspecialty care.
Pediatric nephrology at a crossroads
We are at a crossroads where key action is necessary to mitigate the threats to the already vulnerable pediatric nephrology workforce. While there may not be any quick fixes, multidimensional solutions with collaboration between multiple stakeholders are necessary. Progressive compensation models that appropriately value the intellectual and cognitive skills necessary to provide medical care for children with kidney disease are sorely needed to retain top talent in our specialty, as well as appeal to the youngest generation of newly minted physicians.
All hope is not lost. The alarm has been sounded, and key professional organizations and government partners are now strategizing action plans and implementing task forces designed to enact meaningful change. Such groups must approach their mission with determination, consensus building and staunch advocacy on behalf of its members and the children we serve.
References:
Ashoor I, et al. J Pediatr. 2021;doi:10.1016/j.jpeds.2021.03.033.
American Society of Nephrology 2024 Fellows Survey Report. https://data.asn-online.org/posts/2024_fellow_survey/. Published Oct. 14, 2024. Accessed Jan. 15, 2025.
Catenaccio E, et al. Pediatrics. 2021;doi:10.1542/peds.2020-027771.
National Academies of Sciences, Engineering, and Medicine. 2023. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. Washington, DC: The National Academies Press. https://doi.org/10.17226/27207.
National Resident Matching Program. Specialty Match Program Results: 2020-2024. https://www.nrmp.org/match-data/2024/02/specialty-match-program-results-2020-2024/. Published Feb. 13, 2024. Accessed Jan. 10, 2025.
Soranno DE, et al. Pediatr Nephrol. 2024;doi:10.1007/s00467-024-06410-9.
Vinci RJ, et al. J Pediatr. 2021;doi: 10.1016/j.jpeds.2021.02.004.
Weidemann DK, et al. Front Pediatr. 2022;doi:10.3389/fped.2022.849826.
Weidemann DK, et al. Pediatrics. 2024;doi:10.1542/peds.2023-063678P.
For More Information:
Darcy Weidemann, MD, MHS, is a Healio | Nephrology News & Issues Editorial Board Member. She is associate professor in the department of pediatrics, division of nephrology at Children’s Mercy Kansas City. She can be reached at dkweidemann@cmh.edu.
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