What Is Ailing Nephrology?

As we return from another American Society of Nephrology (ASN) meeting brimming with new knowledge and excited by the range of advances in therapies, there is no better time to be a nephrologist. So, why does nephrology remain unattractive to medical students and residents?

Ten years ago, Jeff Berns and colleagues¹ noted declining interest in nephrology among medical students and residents and identified an urgent need to better define the subspecialty and its scope of practice and to rethink fellowship training programs and training requirements. However, not much has changed, as an editorial by Farouk and Sparks² points out, and the basic structures and limitations of nephrology training endure.

The nephrology brand is still dominated by the idea that most clinicians focus on treating dialysis patients, and that these patients are complicated and difficult, leading to drudge work. In short, the life of a clinical nephrologist is exhausting and very different from the life of a cardiologist or an oncologist. Newer super-subspecialities of nephrology, such as critical care nephrology, onco-nephrology, and interventional nephrology, have emerged over the past decade or so, but have not caught the eye of would-be nephrology trainees. Nor has the approval of many new, exciting treatments to keep patients off dialysis increased interest in nephrology. At my hospital, the Brigham and Women’s Hospital in Boston, Massachusetts, the most popular subspecialties remain cardiovascular medicine, oncology, and gastroenterology. (In some hospitals, dermatology is part of internal medicine and in others it is not, so I haven’t listed it in my top three.)

Some evidence from the Kidney Disease Screening and Awareness Program³ suggests that an effort to increase awareness among medical students might help change the situation. The 10-year review of this program by Jiang and colleagues⁴ is encouraging and worth consideration. For several years, the ASN, National Kidney Foundation, and National Institutes of Health have committed to supporting young investigators in pursuing a career in nephrology.

There is also a global perspective to consider. Sozio and colleagues⁵ recently reported on the global crisis in the nephrology workforce. In the US and Europe, they estimated that there are about 25 nephrologists per 1 million in the population. In South Asia, the number is one per 1 million and in sub-Saharan Africa it is estimated to be 0.5 per 1 million. The disparity is stunning as kidney disease is rampant in South Asia and sub-Saharan Africa, in large from the impact of type 2 diabetes, which is in epidemic proportions, and CKD of unknown origin, where exposure to regional environmental factors may be significant.

While the developed world must consider attracting more trainees to nephrology, we also need to think globally. North America and Europe must contribute to training nephrologists in the developing world in a way that does not exacerbate the dire nephrology workforce situation there. Organizations like the World Bank and the United States Agency for International Development must have nephrology workforce issues on their radar. Our national and international societies can help by bringing this to their attention. Solutions can include incentivizing trainees to return to their country of origin so that the massive shortage of nephrologists in South Asia and Africa is not worsened by a nephrology “brain drain.” Local funding to South Asian and African countries like what the Gates Foundation has done in maternal health could spur innovation in low- to middle income countries. These innovations can include reducing the need for nephrologists and focusing instead on training physician extenders. This has been done successfully in many centers in the United States.

Turning to the developed world, what ails nephrology? Part of the problem is the nephrology brand—the way trainees think about our specialty. We need to change the brand by infusing in our trainees the excitement we all feel about recent advances in nephrology. The treatments that until now were unthinkable are becoming a reality and have been transformational for our patients. These treatments will keep patients off dialysis!

With respect to caring for dialysis patients and changing the negative impression of this work, we need more innovation. In several editorials published here, I have waxed lyrical about the US government funding a “Dialysis Moonshot” like the Biden Cancer Moonshot. The surge in funding for innovations in dialysis is well overdue. Large and midsized dialysis providers are focused on the business aspects of dialysis—ensuring financial returns to their shareholders. Surely, it is the government’s role to fund research into better ways to treat dialysis patients. These new strategies will likely reduce mortality and improve the quality of life for our patients.

As Winston Churchill said, “To improve is to change; to be perfect is to change often.” The workforce challenges, branding issues, and innovation in our specialty are inextricably linked. We need to tackle all three, while also taking a global view of this problem. Simply fixing the problems in our own backyard is not enough.

References

1. Berns JS, Ellison DH, Linas SL, Rosner MH. Training the next generation’s nephrology workforce. Clin J Am Soc Nephrol. 2014;9(9):1639-1644. doi:10.2215/CJN.00560114
2. Farouk SS, Sparks MA. Reenvisioning the adult nephrology workforce: the future of kidney care in the United States. Adv Chronic Kidney Dis. 2020;27(4): 279-280. doi:10.1053/j.ackd.2020.08.006
3. Hsiao LL, Wu J, Yeh AC, et al. The Kidney Disease Screening and Awareness Program (KDSAP): a novel translatable model for increasing interest in nephrology careers. J Am Soc Nephrol. 2014;25(9):1909-1915. doi:10.1681/ASN.2013090928
4. Jiang M-Y, Song R, Chen R, Tuot DS, Heung M, Hsiao L-L. Addressing the nephrology workforce shortage via a novel undergraduate pipeline program: the Kidney Disease Screening and Awareness Program (KDSAP) at 10 years. Kidney Int. 2021;100(6):1174-1178. doi:10.1016/j.kint.2021.10.007
5. Sozio SM, Pivert KA, Caskey FJ, Levin A. The state of the global nephrology workforce: a joint ASN–ERA–EDTA–ISN investigation. Kidney Int. 2021;100(5):995-1000. doi:10.1016/j.kint.2021.07.029

The opinions expressed in this column are the contributor’s own and do not represent those of Nephrology Times.