With the most recent delta variant – and the potential for others to follow – the coronavirus has made hospitalization rates and high death tolls a way of life.
There is nothing in the foreseeable future that makes one believe things will get back to normal anytime soon, and that has had an impact on the nephrology workforce.
As has been previously documented in numerous articles and reports, the nephrology workforce has had a shortfall of physicians going into the specialty for several decades. Besides the usual explanations – low pay compared with other medical specialties, dealing with a complex and chronic disease, too much time between multiple offices, dialysis units and hospitals, and long hours – the fact is fewer residents are going into this specialty.
Nephrology has one of the lowest match rates of any subspecialty and has the lowest pass rates for any subspecialty board after completion of training.1 The biggest impact, however, on workforce is fewer fellows coming out of training are going into private practice.
Utilizing the Fellowship and Residency Electronic Interactive Database, which is managed by the AMA, it is evident that private practice in nephrology does not hold the same appeal as it did 10 years ago. The percentage of fellows completing training who chose who choose private practice has gone down substantially from 70.3% in 2011 to 45.9% in 2020.2 Although these numbers are not absolute (only 87.3% of fellows reported their plans in 2020), the figures provide a good indicator of the decrease in private practice interest.
COVID-19 further exacerbated these issues. Data are hard to come by, as many of the usual resources that track trends in fellowship training have been delayed or canceled during the past 18 months. The following is what we do know for most of the second and third quarters of 2020:
- interviews in person with fellows looking for a job came almost to a complete standstill;
- physician candidates for positions and the hiring parties were prohibited from getting together due to travel restrictions, quarantine issues, lockdowns and safety concerns;
- for the first couple of months after the pandemic hit, many private practices and fellowship programs were slammed with more work than they could handle;
- many programs put a freeze on travel or insisted on quarantining after travel; and
- interviews (if these took place at all) were done online for the first time.
Zoom, Skype or FaceTime meetings quickly became the tool of choice to interview for jobs. These work well if candidates are familiar with the geographic area where they are interviewing but do little to introduce them to a new community where they may be looking to spending the next part of their lives.
For the fellows coming out of medical school in June 2020, most of them knew where they were going 4 months earlier (when lockdowns occurred). The 2021 class, however, was limited on interviews through their first 6 months of second-year training.
COVID-19 made it more difficult for those nephrology fellows who were contemplating going into private practice to be able to identify and interview for positions.
Instead, they stayed in place. From personal experience and conversations with several nephrology-focused recruiters, it is apparent that more fellows stayed on to do an additional year of training through transplant, critical care and interventional fellowships. In addition, some stayed in their current locations after completing training but chose to work as a hospitalist or internist (if competitive nephrology opportunities were not available locally).
Things have improved since December 2020, when vaccinations became available for physicians and health care workers. Physicians who were in practice were not constrained as much as fellows by timeframe and were able to interview and travel as lockdowns ceased and things opened up across the United States. Those who moved seemed to be fewer in number than in the period before COVID-19.
More fellows should be coming out of training programs next summer than in the last 2 years, as students doing additional years of fellowship finally complete their training. For private practice as an option, there will be an increase in opportunities available due to retirements, along with an end to hiring freezes. Likewise, physicians who were contemplating moving – but held off due to some of the reasons previously mentioned – are now ready to go. Finally, starting compensation has seen significant improvement as the shortage of candidates persists.
As a result, there will be more movement among physicians in the coming year. While this will be a positive step in fulfilling needs in the workforce, the shortage of nephrologists will continue until the specialty does more to attract residents into nephrology and, in addition, make stronger efforts to keep those who have trained in the specialty to stay in the profession.
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