This summer I was really optimistic. I was riding a #Flozin high that was being further buoyed by the successes of finerenone. Long dormant fields were yielding fresh life. How long has it been since we’ve had this much investigation into glomerulonephritis? So many trials. So many agents.
This is how I started a letter of rec I wrote this summer:
Can you feel it? Can you smell it? Yup, the winds of change have reached nephrology. Just as the most optimistic and sanguine nephrologists predicted, the new diagnostics, new therapies, and new hopes have blown in fresh enthusiasm for nephrology as a career. I am seeing more interns express interest in nephrology, more seniors asking for letters of recommendation, and more general interest for our specialty than I have seen in a score of years. Yes, the gains in the match results have been meager but change is coming and Dr. XXXXXX is a flag bearer for this renewed renal enthusiasm.
Well I was wrong. The winds of change were blowing us backward. After a good year for 2023’s starting class, this year’s match was a dud.
All those unfilled positions often make the training harder for the fellows that do match.
And residents see how hard the training is.
And they see the long and unpredictable hours.
And hospitalist looks better and better.
I love nephrology. I want nephrology to be a vibrant, attractive specialty, but what we are doing, isn’t working.
We have added training capacity like mad without building the demand for the positions. Look at the number of people matching every year (yellow). It is pretty flat since 2014. But the number of positions, and unfilled positions has grown steadily (blue).
This graph from Brian Carmody is interesting. Look where rheumatology and endocrinology are. Two specialties that are not lucrative. But they fill. Reliably and competitively. Lifestyle is important. This has been neglected in nephrology. We work hard, long, hours for sick patients. This should be an area we work on to remodel the specialty around new visions of work. Do we need to train nephro-hospitalists? Consider a one year fellowship with a focus on ICU and inpatient nephrology. Less clinic. Less GN. Less chronic dialysis. And this could be paired with an outpatient nephrology fellowship. Also one year. Modeled after endo or rheumatology with a clinic based schedule. Time dedicated to learning the skills and procedures to create and maintain dialysis access. If we removed the burden of inpatient rounding, fellows could master outpatient nephro and outpatient dialysis in a single year.
Splitting the roles would make the job easier and less chaotic.
Now look at ID the other end of the graph. ID and nephrology. Two specialties that can’t draw fellows. We need to fix this. This is an existential moment for the field.
Updates from Twitter
I tend to agree with Joel. [this is the most important part] The discussion around compensation is valid but doesn’t explain the strong demand for lower-paying specialties. Besides, as an entrepreneurial nephrologist in private practice a 500-600k salary is not unusual. Money is not everything. Nephrology in the way we currently practice it is not attractive. And trainees see that. Let me explain:
Nephrologists remain proud generalists in an era of ever more complex diagnostic and treatment options. Other than dialysis, for the most part, we don’t own anything that our patients need. We need to beg other specialties to help us with fistula, catheter, biopsy, imaging, infusions, pheresis, and invasive volume assessment. Had we shown some pride, ownership, and support for clinical research as cardiology did, we would have now branched into several subspecialties and be more attractive, given the diverse opportunities catering to different preferences. Still, we also would have likely been more inventive in driving progress. Again, using cardiology as an example, cardiac imaging has advanced because cardiologists understand the clinical problems and have content expertise in finding technical solutions. Cardiac MR or CT wouldn’t be where it was if it were for the radiologists who are busy with 60 different body parts and would remain unaware of questions that would have never been asked.
But rather than creating a subspecialty track, nephrology dwells in the nostalgia of being a generalist. In 2023 still talking about the same electrolyte and acid base problems from 60 years ago with formulas validated in 10 med students.
We are risking to become a profession of mediocre generalists. The average rheumatologist is better at treating lupus nephritis than the average nephrologist. Not because they are the better doctors but because the nephrologist also has to master peritoneal dialysis, CRRT in ICU, post-transplant renal care, hypoNa with seizure, and on and on. How do we expect trainees observing us (jacks of all trades and master of none) and getting inspired??
Nephrology as a specialty needs to have either a radical makeover or will diminish and perish, with endo taking over electrolyte management, rheum autoimmune disorders, cardiology volume and BP, critical care CRRT, and so on. Some say that would be good so. Because it would be better for the patients.
And though this was not in response to this essay it is a good thought