Is There a Nephrologist in the House?

Lackluster Interest Among U.S. Fellows and Government Restrictions Could Spell Disaster for Nephrology Specialty
By Martin H. Osinski and Michael J. Kirschner

Introduction
After years of hearing about having the highest mortality rate in the world, renal care in the United States finally received some good news this year, courtesy of the l997Annual U.S. Renal Data System Report. It appears that the incidence rate, or new starts for patients on dialysis, is decreasing. And, patients who are on dialysis are showing improved survival rates from years past. Changes in the dialysis prescription-better KtlVs, hematocrits, and longer dialysis times may be having an impact.

While the news presents a brighter picture of U.S. renal care, it creates a dilemma for the nephrologists in charge of caring for patients now on dialysis. The fellowship programs in this country are not producing enough nephrologists to meet current or future needs. There is a lack of interest among internal medicine residents, especially those with medical school training in the United States, to consider going into the specially. Lastly, the supply of international medical graduates who enter nephrology may be in jeopardy. If these three areas are not addressed shortly, a crisis will occur for nephrologists, and even more so for the patients who need their services.

A Look at Current Numbers
According to the American Medical Association' s 1997 Physician Masterfile, there are 4,778 physicians who identify themselves as nephrologists (i.e., list nephrology as their primary specialty), excluding current fellows. This number includes both direct patient (84. 1 %) and non-patient care (15.9%). Almost 4% are over the age of65 and another 17% are approaching (within 10 years) retirement age. With over 215,000 patients currently on dialysis and approximately 75,000 renal transplant patients, nephrologists on average are treating 60 dialysis and 21 post transplant patients. These numbers, although manageable, are close to capacity, especially in a single physician practice.

There are numerous job opportunities for every well--trained fellow coming out of training. The authors' own
experiences indicate a strong need for nephrologists, substan-tially greater than other internal medicine subspecialties. Approximately 250 fellows complete their training each year. Close to 100 either go into research, academics, or are foreign-born physicians required to return to their homeland. The remainder goes into direct patient care.

Major university teaching centers are under tremendous pressure to increase the number of generalists and decrease the number of specialists they produce. Cuts can be expected in the number of programs. The recently approved Balanced Budget Act of 1997 will insure that there will be financing only for a number of slots equal to the current number; however, it includes a floating average format that will eventually result in a decrease in funding if the numbers drop.

A potentially bigger problem for nephrology is the Third Report recommendation of the Council on Graduate Medical Education. This includes the so-called 1 10% rule. It states, "the total number of entry residency positions should be limited to the number of U.S allopathic and osteopathic medical school graduates plus 10%." A more recent proposal was a consensus statement issued jointly by the American Medical Association, American Osteopathic Association, the Association of American Medical Colleges, the National Medical Association, the Association of Academic Health Centers, and the American Association of Colleges of Osteopathic Medicine. This consensus statement ties the number of residency positions more closely to the number of U.S medical and osteopathic school graduates.

Why American Grads Aren't Interested
A major emphasis needs to be placed on attracting Ameri-can medical graduates to go into nephrology who until now have been reluctant to do so. Whereas 28% of the U.S. physician population consists of International Medical Graduates, nephrology is closer to 37% - and increasing. In discussion with hundreds of nephrologists, both in training and in practice along with internal medicine residents who have chosen to go into other subspecialties, we found several points continually raised as to why nephrology is not as attractive to many American graduates.

• Residents don't feel comfortable with the more complex physiology and chemistry that nephrology requires. It is an extremely intellectually challenging specialty and many resi-dents are not comfortable or prepared to handle situations that come up. Eric Neilson, MD, the Nephrology Program Direc-tor at the University of Pennsylvania in Philadelphia, said, "Nephrology is only for a few brave and daring souls."
• Most internal medicine rotations in nephrology introduce the physicians to only the most complex chronic patients. In many instances they see the less savory and non-compliant patients, i.e., a high percentage of HIV-infected patients and drug addicts. As one nephrology fellow stated, "These are people not willing to help themselves and yet we are there to help them live, many times taking abuse on top of it. It is not a pretty sight." Thomas Hotstetter, MD, director of nephrology at the University of Minnesota, reinforced this position by stating, "Most of our residents' exposure is to complications in dialysis and not to the dialysis patients who are doing well."
• During the rotation, residents will often see the same patients; not as interesting, they say, compared to what they see in other rotations.
• There are high mortality rates in dialysis. Nephrology is not a specialty where patients get better, and it isn't a "glamour specialty" like cardiology.
• There are not a lot of interesting procedures, like in gastroenterology.
• The financial potential is limited in nephrology. The average Nephrologist coming out of fellowship programs is offered somewhere in the $120,000 range. A general internist coming out of training without the fellowship is offered approximately the same amount.
• Graduates see little hope for facility ownership in an era
of consolidation. A practicing nephrologist with a single specialty group that recently sold his dialysis facility said there will be fewer and fewer opportunities for nephrologists coming out of training to own their own facilities.
• Many comments were made regarding how busy the nephrologists were while the residents were going through their rotation. One resident who chose to go into nephrology stated that the nephrologists she trained with were busier than any of the other rotations that she went through. Michael Choi, MD, Program Director of Nephrology at Johns Hopkins, echoed this feeling when he said, "I was told (by rotating internal medicine residents) that I am paged more during rounds than anyone else they follow." The call appeared heavier then most other specialties as well.
• There is also the perception that nephrology is a closed shop. If a Nephrologist wanted to go into a specific geographic location and the dialysis facilities were already locked up, there would be no way to practice in that community. Patient referrals are already established and it is very hard to break into an area.
• Hours are too long.

Views, Priorities Change
On this last point, our experience from thousands of interviews over the past 14 years shows a changing mindset among physicians. Whereas a decade ago they looked at partnership tracks and owning their own practices, many residents today coming out of training are looking for a four-day work week, outpatient only practices, and salaried posi-tions. Lifestyle appears to be of greater importance, and the exposure they get to nephrology through their residency rotation does not entice them to look favorably toward the specialty.

Fellows and practicing physicians who were attracted to nephrology gave the following reasons.

• Intellectual challenge.
• It is a subspecialty field where the nephrologist can be the primary caregiver (it is the authors' opinion that this will not be an option in the future except in larger urban areas where an oversupply of the specialty exists).
• One sees a wide variety of patients.
• The complexity of the specialty makes it stimulating.
• Numerical aspects (i.e., chemistry and physiology of nephrology).

Steps to Take
A concerted effort needs to be made to attract residents into the field of nephrology. Steps have been taken by the Ameri-can Society of Nephrology (ASN) to introduce the specialty to internal medicine residents by offering financial assistance for them to attend the annual ASN meeting. This must continue, along with a well-orchestrated marketing campaign to increase awareness of the need for nephrologists. A bro-chure developed by the ASN that is being distributed to Internal Medicine residents describes the shortage in nephrol-ogy and the opportunities. Additionally, slides are being- provided to program directors reinforcing the need for addi-tional nephrologists. Whether this will have a positive effect on the numbers is yet to be determined.

Nephrology is one of the few internal medicine subspecialties where fellows coming out of training will be doing the vast majority of their practice in their specialty. During the internal medicine resident' s nephrology rotation, practicing nephrologists, either at the teaching center or in the community, must arrange for the residents to come see dialy-sis patients at a dialysis center outside of the tertiary care facilities they work in. This will introduce many of them to the positive aspects of the specialty. According to Wadi Suki, MD, president-elect of the American Society of Nephrology, "Internal medicine programs are now mandated to have residents spend 25% of their time in ambulatory settings. It is important that this takes place and that residents get an opportunity to see the positive sides of nephrology. The way things are now," he adds, "when the house staff rotates in nephrology, it is an inpatient specialty. We need to change that perception."

Suki also noted the importance of nephrologists "capturing back some of their procedures." Although counter to the projected demands and changes in nephrology practices, this has the potential to make the specialty more attractive to many residents and enhance interest.

The Balanced Budget Act of 1997 creates an even greater urgency to insure that every fellowship slot available is filled. In addition, that same law instructs the Secretary of Health and Human Services to establish a method to measure and report the quality of renal dialysis services provided under Medicare. Although this does not directly affect the physician and is geared more toward the dialysis facility, it is not going to make things easier. Suki indicated that efforts are being made on several fronts to raise the awareness of key members of Congress to the shortage problem, as well as with the Health Care Financing Administration, The Institute of Medicine, and the American College of Physicians (in addition to other organizations). Only time will tell the effectiveness of these efforts and their impact on the future nephrology physician levels.

Conclusion
As previously stated, there are numerous changes occurring that will alter the way nephrologists practice medicine in this country. In order to ensure continuity of quality care, efforts need to be established and maintained to increase the number of nephrologists coming out of training programs. As one frustrated nephrologist put it, "The real issue is who speaks for the patients - and we are not talking about those currently on dialysis but rather those who don't even know they have a problem yet. There is an overall lowering of the bar at the patient's expense. We cannot afford to let this happen."

Originally published in the the November 1997 issue of Nephrology News & Issues