The purpose of our study was to elucidate the factors that influence residents’ decision-making process in regard to their choice of specialty, and in particular, to understand the reasons driving them away from nephrology. There are three major findings in our study. 1) Female gender was the only factor associated with the choice of a less desirable fellowship. 2) Despite a positive perception of nephrology that aligns with reported resident priorities, three major deterrents appear to drive residents away from our specialty: perception of inadequate financial compensation, broad scope of the clinical practice, and a complex patient population. 3) There is a gap in both exposure to and quality of nephrology education during clinical years of medical school.
Gender and choice of specialty
Gender was the only demographic factor that influenced the choice of specialty, as females chose less desirable fellowships more often than males (Table 5). Both males and females valued the intellectual challenge equally. However, females seemed to favor specialties that are predominantly ambulatory and offer a good work-life balance; while males favored procedural-based specialty with high prestige and high financial compensation (shown in Fig. 3A). It has long been postulated that specialties with a controllable lifestyle13 are more appealing to females who may be trying to balance family and career responsibilities.14 However, this approach is somewhat simplistic as gender inequity in medicine is a multifaceted issue that has been linked to gender bias and discrimination in the workplace.15 Its complexity warrants a multilayered approach that our survey was not designed to evaluate.
None of the other demographic factors reported in Table 5 were associated with choosing a highly desirable specialty. Notably, and despite common misconceptions, the location of the medical school (United States vs. International) was not associated with choosing a highly desirable fellowship. The number of USMGs interested in nephrology was noted to be low as early as 200916 and has remained low since then. However, this seems to reflect a general decrease in nephrology interest rather than an issue related to the medical school per se.
Why not nephrology? Analysis of resident perceptions
Overall, nephrology was perceived positively and aligned well with the top three factors influencing residents’ choice in a career specialty, namely: intellectual challenge, work-life balance and ability to make a difference in patients’ lives. However, in light of the profession’s struggle to fill its training positions, negative factors appear to outweigh the positives. Those negative factors consist in a perception of poor financial compensation, job stress, complex patient population, and broad scope of clinical practice (shown in Fig. 2B).
Not enough money or too much work?
Economic concerns are known to influence career choices of trainees17 and low-income specialties tend to have lower fill rates than high-income specialties.18 However, is this perception of inadequate nephrologist compensation true? According to the MedScape Physician Compensation report of 2020, the average annual compensation of nephrologists falls in the middle tier and in the same category as pulmonary-critical care and oncology.19 Additionally, the ASN Adult Nephrology Workforce report shows that 72% of nephrologist aged over 55 reported their financial status to be “excellent” or “very good” as opposed to 5.5% considering their financial status as “fair” or “poor”.20 This raises the question as to whether or not the problem is related to income per se rather than to Relative Value Unit (RVU), or in other words, adequate compensation for the amount of work done. The latter appears to tie into burnout. Indeed, burnout is becoming increasingly prevalent among nephrologists, with 49% of them reporting burnout symptoms and ranking third most severe among 24 other specialties.21 The reasons for this burnout are numerous but have recently been linked to the restructuring of the health care system stripping away the three major pillars of intrinsic motivation: competence, relatedness and autonomy.22 While all specialties face these issues, the profound lack of control over time and schedule seems to be particularly worse for nephrologists, whose heavy work load emphasizes frequent in-person visits to dialysis units23,24 thus requiring significant time and effort, notably driving from one dialysis unit to the other.
Given the known impact of burnout and the desire for a controllable lifestyle on the specialty choice of trainees,13,25 we hypothesize that it is not the financial compensation per se that is driving residents away from nephrology, but rather the RVU of the work done. Indeed, it is widely believed that current RVUs are unfairly valued to favor procedure-based specialties over specialties requiring actual face time with complex patients, such as in nephrology.26 This was clearly shown in a 2018 report for the Medicare payment advisory commission,27 which analyzed physician total cash compensation per work RVU, and found that nephrologists get less compensation per RVU than primary care physicians. Thus, despite a satisfying annual income, nephrologists need to work harder than their colleagues in other specialties.
Medical complexity or inadequate representation?
The majority of respondents reported finding the nephrology population challenging, and this is not surprising as our patients are among the most medically complex in terms of number of co-morbidities, number of medications prescribed, and mortality risk.28 In an Australian study, trainees even cited distress from negative patient interactions, particularly when caring for patients on dialysis.29 While it is certainly true that nephrologists take care of dialysis patients, they also manage a multitude of intellectually challenging and stimulating pathologies in the ambulatory setting. However, the nephrology exposure of residents appeared to be largely limited to inpatient nephrology as only 32.8% of respondents reported an ambulatory nephrology experience. This could skew residents’ perception of the specialty, by exposing them to sick, potentially non-adherent dialysis patients. We hypothesize that this negative perception could be balanced by providing trainees with a more comprehensive nephrology exposure that includes more ambulatory interactions, including home dialysis and transplant patients.30
Spectrum of clinical practice and the need to subspecialize
Another poorly recognized factor that could deter people from pursuing nephrology is the broad scope of the clinical practice. This has traditionally been perceived as a key attraction to nephrology with the underlying idea that nephrologists “never get bored”.31 However, in our study, while the majority of our respondents recognized that nephrology has a broad scope of practice and offers a wide breadth of pathology (shown in Fig. 2A), they also cited those factors as deterring them from pursuing the profession (show in Fig. 2B). This appears to be in line with results reported in the rheumatology field, where a narrow practice scope was favored by the practicing physicians.32 As the world of medicine continues to head into more advanced subspecialty, our results seem to suggest that nephrology may benefit from doing the same and developing more advanced subspecialty fields such as interventional nephrology, onco-nephrology, glomerular disease as examples.
Exposure to nephrology and quality of education
Our findings unveil a possible gap in nephrology exposure and education (shown in Fig. 1). Indeed, both the quality and exposure appeared to be robust in pre-clinical years of medical school and in residency. However, during clinical years of medical school, we observed a decline in the number of students exposed to nephrology in general and in the perceived quality of that exposure. We suspect this decline to be relevant in steering careers away from nephrology. Indeed, clinical rotations have been shown to be among the most important factors determining career choices.33,34 This is consistent with our findings, which show that choosing a specialty is associated with rotating in this specialty, specifically during the clinical years of medical school (Table 3). Of utmost importance as well is the fact that a significant portion of respondents (35%, the largest) pursuing fellowship training reported deciding on their specialty choice during the clinical years of medical school. We believe this gap could represent an opportunity for improving the impact of nephrology on trainees and potentially reinvigorating the nephrology pipeline.
Study Strengths and limitations.
The main strength of our study is its solid methodological design. First, this is one of the very few studies that is grounded in a well-established theoretical framework, which is crucial to substantiate the importance and significance of the work.35 Second, to our knowledge, it is the only study that was preceded by a qualitative assessment, which allowed us to base our questions on the residents’ input rather than the investigators’ perceptions. Third, rather than focusing on nephrology physicians and fellows, our study focuses on internal medicine residents (the majority of which were USMGs), and this population is of particular interest because these trainees constitute the main pipeline for the specialty.
Our study has several limitations. First, and though we reached out to all ACGME-accredited internal medicine programs in the US, only 26 agreed to participate in our survey. We also note that the majority of the respondents come from midwestern programs, and that could affect our representation of the national population. However, our respondents’ demographic characteristics appear to mirror those of internal medicine residents nationally, with 56.6% males in our dataset versus 57% males nationally.36 Our race and ethnicity distributions are also similar with a comparable representation of African Americans, Hispanics and Asians (respectively 5.1%, 6.3% and 24.3% in our dataset versus 4.7%, 6.7% and 24.1% nationally).37 Second, we recognize that our response rate of 21%, is average for a web-based survey study. Indeed, web-based surveys usually yield a response rate that is on average 10% lower than mail surveys and ranges around 20–30%.38 Furthermore, the number of nonrespondents does not correlate with the probability of nonresponse bias.39,40 Thus, our survey’s findings, while subject to the same limitations of survey designs, can be trusted to the extent of that design. Third, the RedCap survey platform displays clearly on mobile devices but the potential for incorrect responses still exists. Finally, despite a solid methodology along with numerous efforts to ensure the validity of the data collected, it is possible that some responses did not accurately measure the characteristics that we were seeking.
In summary, our study sheds light on factors that account for the declining interest in the nephrology specialty and identifies potential targets for improvement. Impacting some of those factors such as RVU-based compensation may require national policy changes; influencing other elements, such as moving the nephrology field towards sub-specialization, could be addressed at a systemic level with help from the different nephrology societies. Most importantly, as individual nephrologists, we have an opportunity to impact trainees’ perceptions of nephrology by improving their hands-on experience during the clinical years of medical school and broadening their exposure during residency to include more ambulatory settings. This requires our increased involvement in and commitment to the education of trainees.