This year's nephrology fellowship match numbers are out, and here is the take away: meh.
Although the big career day for physicians is Match Day, a spring ritual for 4th year students, fellowship programs run separate "matches" and these latest numbers come from this month's nephrology match -- run by the National Resident Matching Program, the same folks that run the spring Match Day.
According to numbers released Wednesday by the American Society of Nephrology (ASN), there were 467 nephrology fellowship positions offered in the match for 2017, of which 284, or 60.8%, were filled. This is similar to last year, when 59.2% of nephrology slots were filled through the match.
To those looking for good news, here it is: the 2017 number represents an end to the steady decline in the fill rate that occurred since 2009, when 94.8% of the 367 nephrology slots in the match were filled.
Those numbers, however, have to be placed into context, according to , data science officer at the ASN, in Washington. "Many of these [unfilled] positions are filling in the scramble (or post-Match period)," he wrote in an email to 乌鸦传媒. For example, "For the current academic year, there were 466 positions offered in the Match, of which 190 were left unfilled. However, on July 1, 2016, 435 1st-year nephrology fellows began training."
Reasons for a Decline
Nephrology, of course, is not the only specialty that has trouble filling slots. In the 2016 academic year, only 65% of infectious disease fellowship slots were filled and just half of headache medicine slots.
Nonetheless, nephrology educators say that interest in their specialty is not necessarily where they would like it to be. The low fill rate "has been going on for years," , a nephrologist at Duke University in Durham, N.C., said in a phone interview. "I think that we're almost perpetuating the problem [by] talking about it so much ... I'm confident things will turn around, but I don't know what the magic bullet is, and I think there will be multiple things we have to do."
One reason that fewer residents may be choosing a nephrology fellowship is the advent of the hospitalist, a position that doesn't require a fellowship and often pays more -- at least initially -- than a nephrologist who is just starting out, an attractive option for residents burdened with student loan debt.
"The hospitalist movement started when we were seeing the decline; most people think that was a huge reason for the decline in numbers," Sparks said. "It particularly affects [specialties that] aren't compensated as well as cardiology, hematology/oncology, and GI. We're just vulnerable. And the acuity of patients we see [in nephrology] is a little higher than in those fields."
However, things even out income-wise later on, he added. "Hospitalists might get out of training and make $200,000 a year, but their cap is about $220,000, whereas a nephrologist could go from $170,000 to ... $270,000" or possibly more as he or she may become a partner in a practice, own a medical building or infusion center, and other business/professional opportunities usually not available to hospitalists.
Even so, being a hospitalist just seems like an easier path for many, said , vice chair for education and academic affairs at the NYU School of Medicine, in New York City.
"It's pretty clear that residents finishing residency are well-trained to be hospitalists, because one-third to two-thirds of all residency training programs are inpatient," he said in a phone interview. So it's easy to say, 'It's easy for me to be a hospitalist next year -- it's a lot like being a resident but less work, and I can double my pay.' It's an easy out for people who want to start working, pay off their debt, and do something they're comfortable doing. If you do a fellowship, you're resigning yourself to 2-4 years of pay marginally more than what you were getting as a resident, and you're probably going to be working harder, at least as a first-year fellow."
And, "as medical school debt rises, starting salaries for cardiology and GI and critical care are substantially greater than for people in less procedural specialties of internal medicine, like rheumatology, nephrology, infectious diseases, and endocrinology," Stern said. "They just aren't paying as much."
In addition to that, "Nephrology used to be an area where some of [the] most interesting research [was being done] in physiology and metabolism -- even inflammation was a huge growing area. So people who were interested in lupus might just as well be nephrologists as anything else -- it's a disease of the whole body but affects the kidneys substantially. Now, of course, the [interesting] research going on is in GI and pulmonary disease and cardiology."
Lifestyle Issues
, a nephrologist in Detroit, said he suspects the cause is multi-factorial. "It may be due to lower reimbursement, it may be due to profoundly ill patients, it may be due to the complex physiology [of the kidney]. I think you can find a number of plausible explanations."
But nephrology also has drawbacks that some other non-procedural specialties such as endocrinology don't, like lifestyle issues, Sparks pointed out. "I think the lifestyle is much better [for endocrinology] -- no emergencies and no weekend rounding -- but they don't make as much money as nephrologists."
There is also a geographic issue. Although patients may be willing to drive a little ways for infrequent visits with their endocrinologist or cardiologist, "people dialyze where they live, and so there are jobs available [in underserved areas] because nephrologists need to be near those people, but nobody wants to live in those areas," said Sparks.
Nonetheless, nephrology educators are optimistic that the nephrology fellowship numbers will eventually go back up, said , chair of the ASN training program executive directors committee. "I think the specialty, through the ASN, is doing a lot to increase the pipeline, but the projects ASN has worked on focused on medical students and early residents, so that's a long lead time and we haven't yet seen the benefits of those activities."
"We hope that some of the other kidney societies besides ASN will participate in helping find solutions to this," continued Adams, who is also chief of nephrology at the University of Connecticut, in Farmington. For example, to help take care of patients in rural areas, "One of the activities of ASN ... is to recognize that remotely served patients and some patients doing remote home dialysis may benefit from new technological changes such as telemedicine and telehealth, and [to figure out] how to implement that."
New Models of Care
A few institutions have been experimenting with a nephrologist hospitalist model, including a nocturnist, she said. And "a few very, very busy large urban training programs have a night float rotation of a few weeks a year for their fellows that has very much improved the quality of the experience for fellows working during the day, and ... there are also a few nephrology subspecialties such as transplant nephrology which may attract people."
In the end, it may turn out that some of those new nephrology fellows are former hospitalists, said , dean and provost of the Southern Illinois University School of Medicine, in Springfield. "One thing we have seen ... is that some graduates of internal medicine become hospitalists for some number of years and then go back and do their fellowships. We've definitely seen people do 2, 3, 4, 5, or 6 years as a hospitalist and then say, 'Now I'm going to do my fellowships.'"
Overall, the longer-term trend in the supply of nephrologists is unclear, according to a issued this year by the George Washington University Health Workforce Institute. However, the report also delivered some good news: "Despite this uncertainty on the number of trainees in the coming years, the basic trend in total supply is clear: continued growth for the foreseeable future. Based on recent levels of entrants and estimates of historical rates of retirements, the number of full-time equivalent (FTE) adult nephrologists is projected to grow 76% between 2016 and 2030."