The results of the most recent ASN/Hopkins survey among nephrology fellows are not all that surprising. Like many industries in and out of health care dealing with the desires and demands of millennials coming into the workforce for the first time, nephrology is feeling the impact. Lifestyle, according to the survey, is the overall key factor in the decision-making process for this age group when looking for that first job. Based on the results of this survey, for example, limits on weekend and weekday call rotations is the most important factor to fellows coming out of training.
While this may be the case for the fellows who responded to the survey, it is also important to note that the results may be skewed by additional factors. The authors of the report did indicate a wide variance between international medical graduates (IMGs) with student loans ($0 median) and American medical graduates ($225,000 median) who responded to the survey. It would be reasonable to expect income and debt assistance to be a priority for the American medical graduates. A large percentage of IMGs must deal with visa assistance, either with J1 or H1b visas. With 64.5% of nephrology fellows being international medical graduates who responded to the survey and 45% of them requiring visa assistance, their main focus for finding a job is going to be different as well. IMGs who are on visas have to deal with finding positions in locations that are underserved for J1 visa requirements and meet specific requirements as H1b visa candidates. Their choice of geographic locations may have to be limited in order to meet those requirements. While call rotation may be the highest factor for all nephrology fellows, the realities of student debt and meeting visa requirements creates a differing focus for many IMGs.
Location was another major factor according to the survey in choosing an opportunity; 64% of fellows indicating there were “too few” or “far too few” opportunities within 50 miles of their programs. Some of the reasons for this dissatisfaction is a result of the majority of training programs being located in nine states. It should not be surprising that more than 50% of nephrologists out of fellowship are in those states (43% of fellows completing training chose to stay within the same state of their training program sites). But a key factor that may be limiting job opportunities in those states is that the populations are not growing as rapidly as they have in the past (New York, New Jersey, Pennsylvania, Illinois and Ohio are five of the nine states; they grew 1.3% or less in population during the last 8 years vs. a national average of 6%). These slowdowns in population growth combined with the increase in physicians wanting to remain in those states makes procuring a position difficult.
Another factor that plays into the unattractive position close to the training programs is that many of those schools are in metro areas, which are highly competitive for jobs and where tax rates and cost-of-living are high. These factors all impact salaries, which in these locations are not necessarily as competitive with national averages. Between the number of opportunities available and the inadequate compensation, it forces a number of nephrology fellows to accept hospitalists or internal medicine positions in the communities where they want to stay. As a hospitalist, their initial salaries will be substantially higher than those of a first-year nephrologist and the week-on/week-off schedules can be attractive. The downside is that you are not practicing nephrology (which is the reason for going through the fellowship) and there is limited long-term growth potential.
It should also be noted that more than 48% of the respondents in the survey are in their first year of training. There is a strong possibility that their attitudes and plans may change after fellowship. There is minimum exposure during training to how to go about looking for employment. As a result, as the fellows go through their interviews, they are exposed to factors they may not have considered in responding to a survey question a year in advance and may alter their priorities and responses.
In summation, while the survey provides insight into key factors fellows utilize in determining their post fellowship plans, the results can be misleading if the motivations of the respondents are not considered.
Martin Osinski, MBA, CVA
division of American Medical Consultants Inc.
Palmetto Bay, Florida
Nephrology News & Issues Editorial Advisory Board member