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The US Pediatric Nephrology Workforce: A Report Commissioned by the American Academy of Pediatrics
Special Report The US Pediatric Nephrology Workforce: A Report Commissioned by the American Academy of Pediatrics William A. Primack, MD,1 Kevin E. Meyers, MD,2 Suzanne J. Kirkwood, MS,3 Holly S. Ruch-Ross, ScD, Carrie L. Radabaugh, MPP,3 and Larry A. Greenbaum, MD, PhD4 The US pediatric nephrology workforce is poorly characterized. This report describes clinical and nonclinical activities, motivations and disincentives to a career in pediatric nephrology, future workforce needs, trainee recruitment, and possible explanations for personnel shortages. An e-mail survey was sent in 2013 to all identified US-trained or -practicing pediatric nephrologists. Of 504 respondents, 51% are men, 66% are US graduates, and 73% work in an academic setting. About 20% of trained pediatric nephrologists no longer practice pediatric nephrology. Among the 384 respondents practicing pediatric nephrology full or part-time in the United States, the mean work week was 56.1 6 14.3 hours, with time divided between patient care (59%), administration (13%), teaching (10%), clinical research (9%), basic research (6%), and other medical activities (3%). Most (.85%) care for dialysis and transplantation patients. The median number of weeks annually on call is 16, and 29% work with one or no partner. One-third of US pediatric nephrologists (n 5 126) plan to reduce or stop clinical nephrology practice in the next 5 years, and 53% plan to fully or partially retire. Almost half the division chiefs (47%) report inadequate physician staffing. Ongoing efforts to monitor and address pediatric nephrology workforce issues are needed. Am J Kidney Dis. -(-):---. ª 2015 by the National Kidney Foundation, Inc. INDEX WORDS: Pediatric nephrology; workforce; physician shortage; staffing adequacy; health services needs; health care worker maldistribution; work-life balance; workload; physician motivation; medical career; fellowship training; fellows; American Academy of Pediatrics (AAP).
BACKGROUND Serious concerns exist about the adequacy of the American pediatric nephrology workforce due to a high number of potential retirees and difficulty recruiting trainees. According to American Board of Pediatrics (ABP) data, pediatric nephrologists are the oldest group of pediatric subspecialists, with a mean age of 57.8 years as of the end of 2013.1 The last decade has seen a significant increase in the number of pediatric nephrology trainees, with an average of 43 third-year fellows over the last 3 years versus 19 third-year fellows during the 3-year period ending in 2004. However, partially due to an increase in fellowship programs, 43% of first-year fellowship positions were unfilled in the subspecialty resident match between 2010 and 2014.2 Thus, there may not be adequate qualified trainees available to address the aging workforce. Similar workforce issues, especially a marked decrease in trainee applicants, are of great concern to internal medicine nephrology.2-6 A 2008 survey of pediatric nephrology fellows found that workload, faculty dissatisfaction, and poor financial compensation were perceived as negative elements to a career in pediatric nephrology.7 A 2012 survey of pediatric subspecialty fellows who chose subspecialties other than nephrology found that a lack of positive mentoring and the perception of nephrology as a challenging subject, especially among women trainees, were primary disincentives to Am J Kidney Dis. 2015;-(-):---
pursuing nephrology.8 Women, who presently make up .70% of pediatric residency trainees, are less likely than men to choose a subspecialty or a research career and more likely to prefer part-time work.9 Workforce adequacy concerns are compounded by the growing demand for pediatric nephrology services as care becomes more sophisticated and children with chronic conditions survive kidney-related complications.10,11 Consequently, a need exists to accurately characterize the pediatric nephrology workforce, obtain data on workload, and identify the perceived strengths and weaknesses of a pediatric nephrology career. The American Academy of Pediatrics (AAP) conducts periodic workforce surveys of pediatric medical subspecialists and surgical specialists; however, the AAP had previously not studied pediatric nephrology.
From the 1University of North Carolina Kidney Center, Chapel Hill, NC; 2Children’s Hospital of Philadelphia, Philadelphia, PA; 3 American Academy of Pediatrics, Elk Grove Village, IL; and 4Emory University and Children’s Healthcare of Atlanta, Atlanta, GA. Received December 17, 2014. Accepted in revised form March 6, 2015. Address correspondence to William Primack, MD, CB 7155, University of North Carolina, Chapel Hill, NC 27599. E-mail: [email protected] 2015 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.03.022 1
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The AAP Division of Workforce and Medical Education Policy, the AAP Section on Nephrology (SONp), and the American Society of Pediatric Nephrology (ASPN) collaborated to develop and analyze this survey, which is the first comprehensive survey of the American pediatric nephrology workforce.
SURVEY METHODOLOGY Questions common to pediatric subspecialists were developed by the AAP Division of Workforce and Medical Education Policy. These address training, clinical practice, and demographic characteristics and are being asked of many pediatric subspecialty groups in order to characterize the larger pediatric subspecialty workforce and allow comparisons between subspecialties. We created 44 additional questions specifically for pediatric nephrologists (Item S1, available as online supplementary material). These questions were reviewed and refined by members of the Workforce Committee of the ASPN and the Executive Committee of the AAP SONp. Some questions, including queries about physician staffing, hiring plans, and number of ancillary division staff, were asked only of division directors or solo practitioners. Surveys were sent in spring 2013 to anyone with an active e-mail address who was ever ABP board eligible in pediatric nephrology or was a member of the ASPN or the AAP Section on Nephrology at the time of the survey. Current trainees were not included. Four reminder e-mails over 2 months were sent to nonresponders. Data analysis was performed using SPSS, version 18.0 (IBM). Descriptive statistics, including frequency distributions and measures of central tendency, were used to summarize all responses to the survey. Bivariate relationships were tested for statistical significance using c2, Fisher exact, or t test, as appropriate. Results are expressed as count with percent or mean 6 standard deviation. The survey was deemed exempt by the Institutional Review Board of the AAP because survey respondents were anonymous.
RESULTS AND DISCUSSION
80% 70% 60% 50% 40% 30%
male female
20% 10% 0%
>30 years
2
<15 years
Years from medical school graduaon Figure 1. Pediatric nephrologists by sex and years since medical school graduation.
($25% of the time). Based on postal codes, 384 practice in the United States; 14, in Canada; and the rest, outside North America. Twelve respondents practice primary care pediatrics .75% of their time. Pediatric Nephrology Practice The mean reported work week for the 384 USbased pediatric nephrologists is 56.1 6 14.3 hours, with a median of 60 hours (Table 1). Men work a mean of 56.5 6 16.4 hours, and women, 53.0 6 13.8 hours (P 5 0.01). Pediatric nephrologists are on call a median of 16 weeks and 14 weekends annually. Most (58%) take call alone, and the rest, with a fellow either all (16%) or part (26%) of the time. US pediatric nephrologists work in the outpatient clinic a median of 3 (interquartile range, 2-5) half-days weekly. Table 2 summarizes the activities of the 384 US pediatric nephrologists who were practicing at least part-time ($25% of the time). Nearly all pediatric nephrologists (98%) participate in patient care. Most teach (88%), do administrative work (80%), and perform clinical research (63%). A minority participate in basic science research (14%) and health Table 1. Pediatric Nephrology Practice
Overview of Survey Participants The survey was sent to 766 physicians, and 504 surveys were completed fully or in part (65.8% response rate). Fifty-one percent of respondents are men; however, women are the majority (62%) of those who graduated from medical school within the last 15 years (Fig 1). Seventy percent are Caucasian, 21% are Asian, and 4% are black. Most (66%) are US medical school graduates and 79% are ABPcertified in pediatric nephrology. There are 409 respondents who are involved in some aspect of pediatric nephrology at least part-time
15-30 years
Hours worked weekly Group sizea Weeks on call per year (Monday-Friday) Weekends on call per year Half-day clinics weekly
No. Responding
Mean
Q1
Q2
Q3
381 369 352
56.1 4 18.2
50 2 10
60 4 16
60 6 26
355 376
17.2 3.4
10 2
14 3
23 5
Note: Based on 384 pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time) in the United States. Abbreviation: Q, quartile. a Number of pediatric nephrologists in the practice. Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce Table 2. Activities of Pediatric Nephrologists
Activity
No. Engaging in Activity
Patient care Teaching Administrationa Clinical research Basic research Health services research Other medical activitiesb
377 337 309 241 53 13 182
Proportion of Work Hours Taken by Activity Mean
Q1
Q2
Q3
58.3% 40% 60% 80.0% 11.1% 5% 10% 14.5% 15.1% 5% 10% 20.0% 14.4% 5% 10% 17.5% 40.7% 15% 40% 65.0% 7.0% 5% 5% 7.5% 6.3% 4% 5% 5.0%
Note: Based on 384 pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time time) in the United States. The percentages refer only to the pediatric nephrologists who report engaging in that activity. Abbreviation: Q, quartile. a Administration includes activities related to planning or managing services in hospitals or other health facilities. b Other medical activities not including direct patient care, such as committees or consulting.
services research (3%). The time spent in each activity varies markedly among individuals (Table 2). On average, pediatric nephrologists divide their time between patient care (59%), administration (13%), teaching (10%), clinical research (9%), basic research (6%), and other medical activities (3%). Most US pediatric nephrologists (73%) work in an academic setting such as a medical school or teaching hospital. The rest work in a pediatric, specialty, or multispecialty group practice (17%), community hospital (4%), solo private practice (1%), or another setting (5%). About half (49%) were in a program that teaches pediatric nephrology fellows. Median group size is 4 pediatric nephrologists, although nearly 10% are the sole pediatric nephrologists at their locations and 19% practice with only one partner (Table 1; Fig 2). Primary care pediatrics is practiced part-time by 54 (14%) responding US pediatric nephrologists.
Figure 2. Group size of pediatric nephrologists. Based on pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time) in the United States. Am J Kidney Dis. 2015;-(-):---
Peritoneal dialysis patients are followed up by 88% of practicing US pediatric nephrologists; 29% care for more than 10 patients, while 26% follow 0 to 4 patients. Similarly, 87% follow hemodialysis patients, 32% care for more than 10 patients, and 32% follow 0 to 4 patients. About 56% of respondents follow hemodialysis patients in a unit that serves only children; the rest care for hemodialysis patients in a unit that cares for adults and children. Pediatric nephrologists manage the continuous renal replacement therapy programs in 91% of their hospitals’ pediatric intensive care units and nearly all the acute peritoneal dialysis in their pediatric and newborn intensive care units. Kidney transplant recipients are followed up by 94% of US pediatric nephrologists, with 78% working in programs that perform pediatric kidney transplantation. Respondents report working in programs that perform a mean of 12.2 and a median of 10 pediatric kidney transplantations per year (interquartile range, 5-17). Most (79%) respondents report performing kidney biopsies during the previous year, with 87% reporting that pediatric nephrologists perform most of the kidney biopsies in their hospital. Radiologists perform the majority of the remaining biopsies. In summary, most pediatric nephrologists participate in a broad range of activities related to the care of children with kidney disease, including maintenance peritoneal dialysis, maintenance hemodialysis, continuous renal replacement therapy, acute peritoneal dialysis, kidney transplantation, and kidney biopsies. Most work in small groups in academic settings and are frequently on call. Pediatric nephrology is changing from a male- to a female-dominated specialty (Fig 1). This correlates well with ABP data showing that 53 of the 80 (66%) pediatricians who took the pediatric nephrology certifying examination in 2012 were women, which is similar to the 73% of current pediatric residents who are women.1 There are workforce implications of this trend because 8 of these 53 women plan to work parttime compared to 0 of the 27 men.1 Male pediatric nephrologists report working a longer work week (56.5 hours) than female pediatric nephrologists (53.0 hours). Our survey did not address how many pediatric nephrologists are working or would like to work part-time. Employment in part-time work is common among recent pediatric residency graduates working in general pediatrics.12 Creating and promoting the availability of part-time work in pediatric nephrology is a potential strategy in increasing interest in fellowship training and retention of trained pediatric nephrologists. Only a small percentage of pediatric nephrologists (14%) report participating in basic science research, 3
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although most pediatric nephrologists work in academic institutions and at least 1 year of research training is required by the ABP for certification. This is of great concern because basic science research is critical for developing future translational and clinical research efforts. The explanation is likely multifactorial and may include challenges such as the difficulty securing National Institutes of Health funding, high levels of medical school debt precluding trainees from devoting extra time to basic science training during fellowship, and physician shortages, which may require researchers to prioritize clinical care. Most of the limited number of pediatric nephrologists performing basic research devote only a minority of their time to basic research (Table 2), further supporting the hypothesis that basic scientists have inadequate time to succeed in a basic science career. This issue demands further analysis. Sixty-five percent of US respondents report that they compete with other pediatric nephrologists in their service area for patients, and 14% compete for patients with adult nephrologists. Of those reporting competition, 25% report practice changes, including working extra hours, adding support staff including advanced practice nurses, and hiring additional pediatric nephrologists. Pediatric Nephrology Division Staffing Of the 102 US division directors and 25 solo pediatric nephrologists who responded, 52% believe that their physician staffing is adequate, 47% consider it to be insufficient, and one thinks it is excessive. At the time of the survey, 66 of these respondents anticipated having 79 new positions for pediatric nephrologists available in the next 3 years. Of these, 24 positions were to replace retirees and 12 were to replace nephrologists leaving their practices. Thirty-three programs reported having a total of 60 current openings, including 47 primarily clinical and 13 primarily research positions. Support staff, excluding those who are attached to the dialysis programs, are reported to include a total of 69.3 full-time equivalent (FTE) nurse practitioners working in 46 (36%) pediatric nephrology programs, 191.1 FTE clinical nurses in 90 (71%) programs, 63.5 FTE social workers in 65 (51%) programs, and 64.9 FTE dieticians in 67 (53%) programs. Nearly half the division directors believe they have inadequate physician staffing. Many programs do not appear to have the full team of nephrologist, clinical nurse, social worker, and dietician considered optimal for the care of children and adolescents with kidney disease.13 Physician extenders are an important part of the pediatric nephrology workforce. Nurse practitioners and clinical nurses are being used in many of the pediatric nephrology programs in the United States. 4
Our study did not specifically query whether physician assistants are working in these programs; however, a recent report from the American Academy of Physician Assistants identified no physician assistants working in pediatric nephrology.14 It will be important to track whether the use of physician extenders changes over time and to understand how they are being used. Their roles and the quality of the care they provide should also be evaluated, as well as data regarding recruitment and retention. To improve quality of care, since 2013, the ASPN has sponsored annual educational conferences for ancillary pediatric nephrology staff, with an average attendance of 80. The increasing trend toward team-based care and the recent availability of reimbursement for physician extender visits in the dialysis unit may to a limited extent decrease the need for pediatric nephrologists in larger programs. Unfortunately, most physician extenders do not take call, and one of the biggest challenges in pediatric nephrology is the high frequency of call for the many physicians in small groups. Why Do Pediatric Nephrologists Leave the Subspecialty? Of the 384 currently practicing US pediatric nephrologists, 126 (33%) reported that they plan to reduce or stop pediatric nephrology clinical activities during the next 5 years, while 9% plan to increase their clinical activities. Twenty-six percent plan to increase research activities and 19% plan to increase administrative activities. The most frequently reported reasons for reducing clinical activities were plans to fully or partially retire (53%), a desire to spend more time in nonclinical activities (37%), and family responsibilities (10%). A follow-up question asked of those who were planning on decreasing clinical activities for reasons other than retirement showed that dissatisfaction with work-life balance (45%), compensation (11%), or geographic location (4%) were factors in their plans. Fifty-three (10.5%) of all respondents report that they do not practice pediatric nephrology. Of this group, 21% have retired. However, an additional 21% report an inability to find a suitable position, 19% report a desire to work as a general pediatrician, and 19% report choosing a career in industry or government. Other given reasons included financial or family considerations. Would You Choose Pediatric Nephrology Again? When asked, “Based on your professional and personal experiences, if you were completing residency and selecting a subspecialty today, would you choose pediatric nephrology as your subspecialty?” the majority (64%) of all respondents indicate that Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce Table 3. Selection of Pediatric Nephrology as a Career Today Frequency (Percent)
Definitely Probably Maybe Maybe not Definitely not
174 119 63 64 35
(38.2) (26.2) (13.8) (14.1) (7.7)
Note: N 5 455. The survey asked, “Based on your professional and personal experiences, if you were completing a residency and selecting a subspecialty today, would you chose pediatric nephrology?”
they would “definitely” or “probably” choose pediatric nephrology again (Table 3). However, just more than a third are less than sure that they would make the same choice. Pediatric nephrologists who graduated fewer than 15 years ago are more likely to state that they would “definitely not” or “maybe not” again choose nephrology compared with those who graduated more than 15 years ago (27.7% vs 18.8% [P 5 0.04]). This is similar to data for current internal medicine nephrology fellows recently reported by the American Society of Nephrology (ASN), which shows that 72% would recommend a nephrology career to medical students or residents.6 A follow-up open-ended question in our survey, “Why might you not choose pediatric nephrology today?” received Table 4. Pediatric Nephrologist Ratings of Different Aspects of their Profession Subgroups Rating Higher
Mean 6 SD
Intellectual stimulation Teaching opportunity Transplantation Critical care nephrology Academic setting Maintenance dialysis Leadership opportunity Research opportunity Job opportunities
6.53 6 0.76 6.03 6 0.98 5.94 6 1.10 5.94 6 1.04 5.59 6 1.24 5.59 6 1.27 5.07 6 1.38 5.04 6 1.51 4.81 6 1.54
Prestige Administrative Geographic distribution
4.71 6 1.41 4.64 6 1.29 4.27 6 1.50
Hours worked Work-life balance Compensation
4.06 6 1.74 3.85 6 1.65 3.61 6 1.56
— — Women
— —
Women US medical graduate US medical graduate Men; US medical graduate
— —
Not recent graduatea; US medical graduate Recent graduatea Men
—
Note: Data were collected on a 7-point Likert scale (7, completely positive aspect; 4, neutral; 1, completely negative aspect). Means are compared using t tests; only statistically significant differences at P , 0.05 (or better) are reported in the table. Abbreviation: SD, standard deviation. a Recent graduate is defined as fewer than 15 years since medical school graduation. Am J Kidney Dis. 2015;-(-):---
125 responses, with some respondents giving several reasons. Financial compensation was listed by 70; workload, by 38; insufficient institutional support, by 18; difficulty finding a satisfactory position, by 12; and work-life balance, by 12. What Motivates a Pediatric Nephrologist? Table 4 shows how responding pediatric nephrologists rate various aspects of their profession on a 7-point Likert scale. All respondent groups find intellectual stimulation (6.53) and teaching opportunities (6.03) to be the most positive aspects of a career in pediatric nephrology, with compensation (3.61) and work-life balance (3.85) the most negative aspects. International medical graduates seem to have more difficulty finding appropriate jobs and rate research opportunities less favorably than US medical graduates. Although hours worked and work-life balance are seen as negative aspects by most pediatric nephrologists, physicians fewer than 15 years from medical school graduation found hours worked less problematic. Women view work-life balance and job opportunities more negatively than men. Trained pediatric nephrologists who have left the clinical specialty rate compensation (P 5 0.5), caring for maintenance dialysis patients (P 5 0.006), and job opportunities (P 5 0.05) significantly lower than practicing pediatric nephrologists. All respondent groups find intellectual stimulation, teaching opportunities, and critical care nephrology to be the most positive aspects of a career in pediatric nephrology. Nevertheless, only w64% of responding pediatric nephrologists would definitely or probably choose this subspecialty if they had the opportunity to start over. A 2009 survey of ASN members found that the intellectual aspect of nephrology was the principal motivating factor to choose the specialty of nephrology (9% of respondents reported being trained in pediatric nephrology).5 Compared to our finding that 22% of responding pediatric nephrologists would “definitely not” or “maybe not” again choose this specialty, the 2009 ASN survey found that 6.7% of academic and 18.4% of nonacademic nephrologists “regret choosing nephrology.” Because 73% of our respondents work in an academic setting compared with 43% in the ASN survey, the relative lack of nonacademic positions may explain in part the large number of trained pediatric nephrologists who have left the specialty. It is worrisome that the more recent graduates from both adult and pediatric programs would be less likely to choose nephrology as a career. Lack of enthusiasm for the subspecialty may be communicated to pediatric residents and decrease interest. Because mentorship has been demonstrated to be a very important factor in career choice,4,7,8 the presence of unenthusiastic 5
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younger nephrologists may hinder recruitment and retention of physicians to both pediatric and adult nephrology. The lowest rated aspects of pediatric nephrology are compensation, workload, recognition, geographic job location, work-life balance, and academic-only opportunities. These observations must be interpreted cautiously because there was no comparison group of physicians in other specialties. Nevertheless, it would be useful to explore the specific factors that have led 20% of trained pediatric nephrologists to leave clinical practice. The role of these issues in trainee recruitment demands scrutiny, especially considering that between 2010 and 2014, only 57% of pediatric nephrology fellowship openings filled in the US National Resident Matching Program (NRMP).2 This worrisome trend continues because only 36% of 61 available positions filled in the 2015 match for firstyear pediatric nephrology fellows and open slots remained in 79% of the 45 certified training programs.2 Compensation is likely to be a major concern for many residents given large medical school debts and data estimating that career earnings for pediatric nephrologists are potentially $750,000 less than those of a general pediatrician.15 The impression of nephrology as a difficult subject, inadequate mentorship, work-life balance concerns, and lack of job opportunities in desirable areas, especially for international medical graduates, are other potential deterrants.6-8 Similar issues affect adult nephrology, which has experienced a marked decrease in the number of residents applying for fellowship, especially among US medical school graduates.2,4,6,7 The 2014 ASN survey of internal medicine nephrology fellows found that lack of job opportunities, especially for international medical graduates, and work-life balance concerns were most frequently mentioned reasons not to recommend nephrology as a career.6 Thirty-two percent of all responding practicing pediatric nephrologists plan to decrease their clinical activity in the next 5 years. It is not surprising that 16% plan to retire because as of December 2013, a total of 287 (35.6%) of all nephrologists ever certified by the ABP were between 61 and 75 years old.1 However, it is very concerning that another 16% of the active pediatric nephrology workforce who do not anticipate retirement plan to decrease clinical activities in the next 5 years, with the principal stated reason (reported by 45% of respondents) being dissatisfaction with work-life balance (only 11% listed salary as a consideration). Conversely, low compensation is the most frequently mentioned reason that pediatric nephrologists might not select this subspecialty if they could choose again. 6
It seems counterintuitive that there is an apparent shortage of pediatric nephrologists, yet some have left the specialty because they thought they could not find an adequate position, and more than half report competing with other pediatric nephrologists in their geographic area. Maldistribution of pediatric subspecialists is a long-standing issue.16,17 ABP data indicate that at the end of 2013, there were 5 states that had no pediatric nephrologists and 8 that had very few, with ratios varying from 1:27,000 children to 1:785,000 children.1 Similar data obtained by Ku et al18 using the 2008 American Medical Association Masterfile data show that 7 states had no pediatric nephrologists and 6 had 1:500,000 children or less. Because pediatric kidney disease is relatively rare, a large population base and the resources of a tertiary medical center are typically necessary to support a clinical practice. Consequently, most practicing pediatric nephrologists are in academic centers, which tend to be clustered in urban areas, largely explaining the maldistribution and reported competition. Similarly, if a physician’s preferences or circumstances preclude work in an academic center or an urban area, finding a pediatric nephrology position can be very difficult.
LIMITATIONS Our study has a number of limitations. Although we had a high response rate, trained pediatric nephrologists who have left the subspecialty may have been less likely to respond to this survey. Their perceptions of a career in pediatric nephrology may be different from those who continue to practice. An additional limitation is that no reference data are available to assess whether the career satisfactions and dissatisfactions of pediatric nephrologists are different from those of other physicians, although the attitudes, experiences, and concerns of pediatric nephrologists and internal medicine nephrologists as reported in the 2009 and 2014 ASN surveys are similar. Additional data may become available in the next few years as other pediatric subspecialties report results of their AAP-sponsored survey.
CONCLUSIONS This survey provides an overview of the US pediatric nephrology workforce. Pediatric nephrologists predominantly practice in academic settings and spend a significant amount of their time in nonclinical activities such as teaching and research. Although it is very difficult to predict future workforce needs, our data support the concern that the potential exists for a workforce shortage in this field. Serious efforts to recruit qualified trainees into the subspecialty are needed and may need to address issues including loan repayment, work-life balance, compensation, mentorship, and part-time work. Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce
The potential impact of physician extenders on the pediatric workforce needs to be followed closely.
ACKNOWLEDGEMENTS Drs Adam Weinstein and Coral Hanevold assisted in the development of the questionnaire. Phuong (Julia) Le helped categorize and quantitate the free text comments. Susan Hogan provided very helpful editorial insight. Support: The AAP Division of Workforce and Medical Education Policy and Section on Nephrology provided funding for this project. Ms Kirkwood and Ms Radabaugh are employed by the AAP. Ms Ruch-Ross is a consultant to the AAP. Financial Disclosure: The authors declare that they have no other relevant financial interests.
SUPPLEMENTARY MATERIAL Item S1: Survey questions. Note: The supplementary material accompanying this article (http://dx.doi.org/10.1053/j.ajkd.2015.03.022) is available at www.ajkd.org
REFERENCES 1. The American Board of Pediatrics. Workforce data: 20132014. https://www.abp.org/sites/abp/files/pdf/workforcebook.pdf. Accessed February 6, 2015. 2. National Resident Matching Program. Results and Data: Specialties Matching Service, 2015 Appointment Year. Washington, DC: National Resident Matching Program; 2015. 3. Lane CA, Brown MA. Nephrology: a specialty in need of resuscitation? Kidney Int. 2009;76(6):594-596. 4. Parker MG, Ibrahim T, Shaffer R, Rosner MH, Molitoris BA. The future nephrology workforce: will there be one? Clin J Am Soc Nephrol. 2011;6(6):1501-1506. 5. McMahon GM, Thomas L, Tucker JK, Lin J. Factors in career choice among US nephrologists. Clin J Am Soc Nephrol. 2012;7(11):1786-1792. 6. Salsberg E, Masselink L, Wu X. The US nephrology workforce: development and trends. https://www.asn-online.org/ education/training/workforce/Nephrology_Workforce_Study_Report. pdf. Accessed February 25, 2015.
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7. Weinstein AR, Reidy K, Norwood VF, Mahan JD. Factors influencing pediatric nephrology trainee entry into the workforce. Clin J Am Soc Nephrol. 2010;5(10):1770-1774. 8. Ferris M, Iglesia E, Ko Z, et al. Wanted: pediatric nephrologists!—why trainees are not choosing pediatric nephrology. Ren Fail. 2014;36(8):1340-1344. 9. Spector ND, Cull W, Daniels SR, et al. Gender and generational influences on the pediatric workforce and practice. Pediatrics. 2014;133(6):1112-1121. 10. Althouse LA, Stockman JA 3rd. Pediatric workforce: a look at pediatric nephrology data from the American Board of Pediatrics. J Pediatr. 2006;148(5):575-576. 11. Althouse LA, Stockman JA. The pediatric workforce: an update on general pediatrics and pediatric subspecialties workforce data from the American Board of Pediatrics. J Pediatr. 2011;159(6): 1036-1040. 12. Cull WL, Caspary GL, Olson LM. Many pediatric residents seek and obtain part-time positions. Pediatrics. 2008;121(2): 276-281. 13. Stapleton FB, Andreoli S, Ettenger R, Kamil E, Sedman A, Chesney R. Future workforce needs for pediatric nephrology: an analysis of the nephrology workforce and training requirements by the Workforce Committee of the American Society of Pediatric Nephrology. J Am Soc Nephrol. 1997;8(5)(suppl 9): S5-S8. 14. American Academy of Physician Assistants. 2013 AAPA annual survey report. https://www.aapa.org/WorkArea/Download Asset.aspx?id52902. Accessed February 25, 2015. 15. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2011;127(2):254-260. 16. Mayer ML, Skinner AC. Influence of changes in supply on the distribution of pediatric subspecialty care. Arch Pediatr Adolesc Med. 2009;163(12):1087-1091. 17. Stockman JA 3rd, Freed GL. Adequacy of the supply of pediatric subspecialists: so near, yet so far. Arch Pediatr Adolesc Med. 2009;163(12):1160-1161. 18. Ku E, Johansen KL, Portale AA, Grimes B, Hsu CY. State level variations in nephrology workforce and timing and incidence of dialysis in the United States among children and adults: a retrospective cohort study. BMC Nephrol. 2015;16(1):2.
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BACKGROUND Serious concerns exist about the adequacy of the American pediatric nephrology workforce due to a high number of potential retirees and difficulty recruiting trainees. According to American Board of Pediatrics (ABP) data, pediatric nephrologists are the oldest group of pediatric subspecialists, with a mean age of 57.8 years as of the end of 2013.1 The last decade has seen a significant increase in the number of pediatric nephrology trainees, with an average of 43 third-year fellows over the last 3 years versus 19 third-year fellows during the 3-year period ending in 2004. However, partially due to an increase in fellowship programs, 43% of first-year fellowship positions were unfilled in the subspecialty resident match between 2010 and 2014.2 Thus, there may not be adequate qualified trainees available to address the aging workforce. Similar workforce issues, especially a marked decrease in trainee applicants, are of great concern to internal medicine nephrology.2-6 A 2008 survey of pediatric nephrology fellows found that workload, faculty dissatisfaction, and poor financial compensation were perceived as negative elements to a career in pediatric nephrology.7 A 2012 survey of pediatric subspecialty fellows who chose subspecialties other than nephrology found that a lack of positive mentoring and the perception of nephrology as a challenging subject, especially among women trainees, were primary disincentives to Am J Kidney Dis. 2015;-(-):---
pursuing nephrology.8 Women, who presently make up .70% of pediatric residency trainees, are less likely than men to choose a subspecialty or a research career and more likely to prefer part-time work.9 Workforce adequacy concerns are compounded by the growing demand for pediatric nephrology services as care becomes more sophisticated and children with chronic conditions survive kidney-related complications.10,11 Consequently, a need exists to accurately characterize the pediatric nephrology workforce, obtain data on workload, and identify the perceived strengths and weaknesses of a pediatric nephrology career. The American Academy of Pediatrics (AAP) conducts periodic workforce surveys of pediatric medical subspecialists and surgical specialists; however, the AAP had previously not studied pediatric nephrology.
From the 1University of North Carolina Kidney Center, Chapel Hill, NC; 2Children’s Hospital of Philadelphia, Philadelphia, PA; 3 American Academy of Pediatrics, Elk Grove Village, IL; and 4Emory University and Children’s Healthcare of Atlanta, Atlanta, GA. Received December 17, 2014. Accepted in revised form March 6, 2015. Address correspondence to William Primack, MD, CB 7155, University of North Carolina, Chapel Hill, NC 27599. E-mail: [email protected] 2015 by the National Kidney Foundation, Inc. 0272-6386 http://dx.doi.org/10.1053/j.ajkd.2015.03.022 1
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The AAP Division of Workforce and Medical Education Policy, the AAP Section on Nephrology (SONp), and the American Society of Pediatric Nephrology (ASPN) collaborated to develop and analyze this survey, which is the first comprehensive survey of the American pediatric nephrology workforce.
SURVEY METHODOLOGY Questions common to pediatric subspecialists were developed by the AAP Division of Workforce and Medical Education Policy. These address training, clinical practice, and demographic characteristics and are being asked of many pediatric subspecialty groups in order to characterize the larger pediatric subspecialty workforce and allow comparisons between subspecialties. We created 44 additional questions specifically for pediatric nephrologists (Item S1, available as online supplementary material). These questions were reviewed and refined by members of the Workforce Committee of the ASPN and the Executive Committee of the AAP SONp. Some questions, including queries about physician staffing, hiring plans, and number of ancillary division staff, were asked only of division directors or solo practitioners. Surveys were sent in spring 2013 to anyone with an active e-mail address who was ever ABP board eligible in pediatric nephrology or was a member of the ASPN or the AAP Section on Nephrology at the time of the survey. Current trainees were not included. Four reminder e-mails over 2 months were sent to nonresponders. Data analysis was performed using SPSS, version 18.0 (IBM). Descriptive statistics, including frequency distributions and measures of central tendency, were used to summarize all responses to the survey. Bivariate relationships were tested for statistical significance using c2, Fisher exact, or t test, as appropriate. Results are expressed as count with percent or mean 6 standard deviation. The survey was deemed exempt by the Institutional Review Board of the AAP because survey respondents were anonymous.
RESULTS AND DISCUSSION
80% 70% 60% 50% 40% 30%
male female
20% 10% 0%
>30 years
2
<15 years
Years from medical school graduaon Figure 1. Pediatric nephrologists by sex and years since medical school graduation.
($25% of the time). Based on postal codes, 384 practice in the United States; 14, in Canada; and the rest, outside North America. Twelve respondents practice primary care pediatrics .75% of their time. Pediatric Nephrology Practice The mean reported work week for the 384 USbased pediatric nephrologists is 56.1 6 14.3 hours, with a median of 60 hours (Table 1). Men work a mean of 56.5 6 16.4 hours, and women, 53.0 6 13.8 hours (P 5 0.01). Pediatric nephrologists are on call a median of 16 weeks and 14 weekends annually. Most (58%) take call alone, and the rest, with a fellow either all (16%) or part (26%) of the time. US pediatric nephrologists work in the outpatient clinic a median of 3 (interquartile range, 2-5) half-days weekly. Table 2 summarizes the activities of the 384 US pediatric nephrologists who were practicing at least part-time ($25% of the time). Nearly all pediatric nephrologists (98%) participate in patient care. Most teach (88%), do administrative work (80%), and perform clinical research (63%). A minority participate in basic science research (14%) and health Table 1. Pediatric Nephrology Practice
Overview of Survey Participants The survey was sent to 766 physicians, and 504 surveys were completed fully or in part (65.8% response rate). Fifty-one percent of respondents are men; however, women are the majority (62%) of those who graduated from medical school within the last 15 years (Fig 1). Seventy percent are Caucasian, 21% are Asian, and 4% are black. Most (66%) are US medical school graduates and 79% are ABPcertified in pediatric nephrology. There are 409 respondents who are involved in some aspect of pediatric nephrology at least part-time
15-30 years
Hours worked weekly Group sizea Weeks on call per year (Monday-Friday) Weekends on call per year Half-day clinics weekly
No. Responding
Mean
Q1
Q2
Q3
381 369 352
56.1 4 18.2
50 2 10
60 4 16
60 6 26
355 376
17.2 3.4
10 2
14 3
23 5
Note: Based on 384 pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time) in the United States. Abbreviation: Q, quartile. a Number of pediatric nephrologists in the practice. Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce Table 2. Activities of Pediatric Nephrologists
Activity
No. Engaging in Activity
Patient care Teaching Administrationa Clinical research Basic research Health services research Other medical activitiesb
377 337 309 241 53 13 182
Proportion of Work Hours Taken by Activity Mean
Q1
Q2
Q3
58.3% 40% 60% 80.0% 11.1% 5% 10% 14.5% 15.1% 5% 10% 20.0% 14.4% 5% 10% 17.5% 40.7% 15% 40% 65.0% 7.0% 5% 5% 7.5% 6.3% 4% 5% 5.0%
Note: Based on 384 pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time time) in the United States. The percentages refer only to the pediatric nephrologists who report engaging in that activity. Abbreviation: Q, quartile. a Administration includes activities related to planning or managing services in hospitals or other health facilities. b Other medical activities not including direct patient care, such as committees or consulting.
services research (3%). The time spent in each activity varies markedly among individuals (Table 2). On average, pediatric nephrologists divide their time between patient care (59%), administration (13%), teaching (10%), clinical research (9%), basic research (6%), and other medical activities (3%). Most US pediatric nephrologists (73%) work in an academic setting such as a medical school or teaching hospital. The rest work in a pediatric, specialty, or multispecialty group practice (17%), community hospital (4%), solo private practice (1%), or another setting (5%). About half (49%) were in a program that teaches pediatric nephrology fellows. Median group size is 4 pediatric nephrologists, although nearly 10% are the sole pediatric nephrologists at their locations and 19% practice with only one partner (Table 1; Fig 2). Primary care pediatrics is practiced part-time by 54 (14%) responding US pediatric nephrologists.
Figure 2. Group size of pediatric nephrologists. Based on pediatric nephrologists who were practicing at least part-time pediatric nephrology ($25% of the time) in the United States. Am J Kidney Dis. 2015;-(-):---
Peritoneal dialysis patients are followed up by 88% of practicing US pediatric nephrologists; 29% care for more than 10 patients, while 26% follow 0 to 4 patients. Similarly, 87% follow hemodialysis patients, 32% care for more than 10 patients, and 32% follow 0 to 4 patients. About 56% of respondents follow hemodialysis patients in a unit that serves only children; the rest care for hemodialysis patients in a unit that cares for adults and children. Pediatric nephrologists manage the continuous renal replacement therapy programs in 91% of their hospitals’ pediatric intensive care units and nearly all the acute peritoneal dialysis in their pediatric and newborn intensive care units. Kidney transplant recipients are followed up by 94% of US pediatric nephrologists, with 78% working in programs that perform pediatric kidney transplantation. Respondents report working in programs that perform a mean of 12.2 and a median of 10 pediatric kidney transplantations per year (interquartile range, 5-17). Most (79%) respondents report performing kidney biopsies during the previous year, with 87% reporting that pediatric nephrologists perform most of the kidney biopsies in their hospital. Radiologists perform the majority of the remaining biopsies. In summary, most pediatric nephrologists participate in a broad range of activities related to the care of children with kidney disease, including maintenance peritoneal dialysis, maintenance hemodialysis, continuous renal replacement therapy, acute peritoneal dialysis, kidney transplantation, and kidney biopsies. Most work in small groups in academic settings and are frequently on call. Pediatric nephrology is changing from a male- to a female-dominated specialty (Fig 1). This correlates well with ABP data showing that 53 of the 80 (66%) pediatricians who took the pediatric nephrology certifying examination in 2012 were women, which is similar to the 73% of current pediatric residents who are women.1 There are workforce implications of this trend because 8 of these 53 women plan to work parttime compared to 0 of the 27 men.1 Male pediatric nephrologists report working a longer work week (56.5 hours) than female pediatric nephrologists (53.0 hours). Our survey did not address how many pediatric nephrologists are working or would like to work part-time. Employment in part-time work is common among recent pediatric residency graduates working in general pediatrics.12 Creating and promoting the availability of part-time work in pediatric nephrology is a potential strategy in increasing interest in fellowship training and retention of trained pediatric nephrologists. Only a small percentage of pediatric nephrologists (14%) report participating in basic science research, 3
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although most pediatric nephrologists work in academic institutions and at least 1 year of research training is required by the ABP for certification. This is of great concern because basic science research is critical for developing future translational and clinical research efforts. The explanation is likely multifactorial and may include challenges such as the difficulty securing National Institutes of Health funding, high levels of medical school debt precluding trainees from devoting extra time to basic science training during fellowship, and physician shortages, which may require researchers to prioritize clinical care. Most of the limited number of pediatric nephrologists performing basic research devote only a minority of their time to basic research (Table 2), further supporting the hypothesis that basic scientists have inadequate time to succeed in a basic science career. This issue demands further analysis. Sixty-five percent of US respondents report that they compete with other pediatric nephrologists in their service area for patients, and 14% compete for patients with adult nephrologists. Of those reporting competition, 25% report practice changes, including working extra hours, adding support staff including advanced practice nurses, and hiring additional pediatric nephrologists. Pediatric Nephrology Division Staffing Of the 102 US division directors and 25 solo pediatric nephrologists who responded, 52% believe that their physician staffing is adequate, 47% consider it to be insufficient, and one thinks it is excessive. At the time of the survey, 66 of these respondents anticipated having 79 new positions for pediatric nephrologists available in the next 3 years. Of these, 24 positions were to replace retirees and 12 were to replace nephrologists leaving their practices. Thirty-three programs reported having a total of 60 current openings, including 47 primarily clinical and 13 primarily research positions. Support staff, excluding those who are attached to the dialysis programs, are reported to include a total of 69.3 full-time equivalent (FTE) nurse practitioners working in 46 (36%) pediatric nephrology programs, 191.1 FTE clinical nurses in 90 (71%) programs, 63.5 FTE social workers in 65 (51%) programs, and 64.9 FTE dieticians in 67 (53%) programs. Nearly half the division directors believe they have inadequate physician staffing. Many programs do not appear to have the full team of nephrologist, clinical nurse, social worker, and dietician considered optimal for the care of children and adolescents with kidney disease.13 Physician extenders are an important part of the pediatric nephrology workforce. Nurse practitioners and clinical nurses are being used in many of the pediatric nephrology programs in the United States. 4
Our study did not specifically query whether physician assistants are working in these programs; however, a recent report from the American Academy of Physician Assistants identified no physician assistants working in pediatric nephrology.14 It will be important to track whether the use of physician extenders changes over time and to understand how they are being used. Their roles and the quality of the care they provide should also be evaluated, as well as data regarding recruitment and retention. To improve quality of care, since 2013, the ASPN has sponsored annual educational conferences for ancillary pediatric nephrology staff, with an average attendance of 80. The increasing trend toward team-based care and the recent availability of reimbursement for physician extender visits in the dialysis unit may to a limited extent decrease the need for pediatric nephrologists in larger programs. Unfortunately, most physician extenders do not take call, and one of the biggest challenges in pediatric nephrology is the high frequency of call for the many physicians in small groups. Why Do Pediatric Nephrologists Leave the Subspecialty? Of the 384 currently practicing US pediatric nephrologists, 126 (33%) reported that they plan to reduce or stop pediatric nephrology clinical activities during the next 5 years, while 9% plan to increase their clinical activities. Twenty-six percent plan to increase research activities and 19% plan to increase administrative activities. The most frequently reported reasons for reducing clinical activities were plans to fully or partially retire (53%), a desire to spend more time in nonclinical activities (37%), and family responsibilities (10%). A follow-up question asked of those who were planning on decreasing clinical activities for reasons other than retirement showed that dissatisfaction with work-life balance (45%), compensation (11%), or geographic location (4%) were factors in their plans. Fifty-three (10.5%) of all respondents report that they do not practice pediatric nephrology. Of this group, 21% have retired. However, an additional 21% report an inability to find a suitable position, 19% report a desire to work as a general pediatrician, and 19% report choosing a career in industry or government. Other given reasons included financial or family considerations. Would You Choose Pediatric Nephrology Again? When asked, “Based on your professional and personal experiences, if you were completing residency and selecting a subspecialty today, would you choose pediatric nephrology as your subspecialty?” the majority (64%) of all respondents indicate that Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce Table 3. Selection of Pediatric Nephrology as a Career Today Frequency (Percent)
Definitely Probably Maybe Maybe not Definitely not
174 119 63 64 35
(38.2) (26.2) (13.8) (14.1) (7.7)
Note: N 5 455. The survey asked, “Based on your professional and personal experiences, if you were completing a residency and selecting a subspecialty today, would you chose pediatric nephrology?”
they would “definitely” or “probably” choose pediatric nephrology again (Table 3). However, just more than a third are less than sure that they would make the same choice. Pediatric nephrologists who graduated fewer than 15 years ago are more likely to state that they would “definitely not” or “maybe not” again choose nephrology compared with those who graduated more than 15 years ago (27.7% vs 18.8% [P 5 0.04]). This is similar to data for current internal medicine nephrology fellows recently reported by the American Society of Nephrology (ASN), which shows that 72% would recommend a nephrology career to medical students or residents.6 A follow-up open-ended question in our survey, “Why might you not choose pediatric nephrology today?” received Table 4. Pediatric Nephrologist Ratings of Different Aspects of their Profession Subgroups Rating Higher
Mean 6 SD
Intellectual stimulation Teaching opportunity Transplantation Critical care nephrology Academic setting Maintenance dialysis Leadership opportunity Research opportunity Job opportunities
6.53 6 0.76 6.03 6 0.98 5.94 6 1.10 5.94 6 1.04 5.59 6 1.24 5.59 6 1.27 5.07 6 1.38 5.04 6 1.51 4.81 6 1.54
Prestige Administrative Geographic distribution
4.71 6 1.41 4.64 6 1.29 4.27 6 1.50
Hours worked Work-life balance Compensation
4.06 6 1.74 3.85 6 1.65 3.61 6 1.56
— — Women
— —
Women US medical graduate US medical graduate Men; US medical graduate
— —
Not recent graduatea; US medical graduate Recent graduatea Men
—
Note: Data were collected on a 7-point Likert scale (7, completely positive aspect; 4, neutral; 1, completely negative aspect). Means are compared using t tests; only statistically significant differences at P , 0.05 (or better) are reported in the table. Abbreviation: SD, standard deviation. a Recent graduate is defined as fewer than 15 years since medical school graduation. Am J Kidney Dis. 2015;-(-):---
125 responses, with some respondents giving several reasons. Financial compensation was listed by 70; workload, by 38; insufficient institutional support, by 18; difficulty finding a satisfactory position, by 12; and work-life balance, by 12. What Motivates a Pediatric Nephrologist? Table 4 shows how responding pediatric nephrologists rate various aspects of their profession on a 7-point Likert scale. All respondent groups find intellectual stimulation (6.53) and teaching opportunities (6.03) to be the most positive aspects of a career in pediatric nephrology, with compensation (3.61) and work-life balance (3.85) the most negative aspects. International medical graduates seem to have more difficulty finding appropriate jobs and rate research opportunities less favorably than US medical graduates. Although hours worked and work-life balance are seen as negative aspects by most pediatric nephrologists, physicians fewer than 15 years from medical school graduation found hours worked less problematic. Women view work-life balance and job opportunities more negatively than men. Trained pediatric nephrologists who have left the clinical specialty rate compensation (P 5 0.5), caring for maintenance dialysis patients (P 5 0.006), and job opportunities (P 5 0.05) significantly lower than practicing pediatric nephrologists. All respondent groups find intellectual stimulation, teaching opportunities, and critical care nephrology to be the most positive aspects of a career in pediatric nephrology. Nevertheless, only w64% of responding pediatric nephrologists would definitely or probably choose this subspecialty if they had the opportunity to start over. A 2009 survey of ASN members found that the intellectual aspect of nephrology was the principal motivating factor to choose the specialty of nephrology (9% of respondents reported being trained in pediatric nephrology).5 Compared to our finding that 22% of responding pediatric nephrologists would “definitely not” or “maybe not” again choose this specialty, the 2009 ASN survey found that 6.7% of academic and 18.4% of nonacademic nephrologists “regret choosing nephrology.” Because 73% of our respondents work in an academic setting compared with 43% in the ASN survey, the relative lack of nonacademic positions may explain in part the large number of trained pediatric nephrologists who have left the specialty. It is worrisome that the more recent graduates from both adult and pediatric programs would be less likely to choose nephrology as a career. Lack of enthusiasm for the subspecialty may be communicated to pediatric residents and decrease interest. Because mentorship has been demonstrated to be a very important factor in career choice,4,7,8 the presence of unenthusiastic 5
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younger nephrologists may hinder recruitment and retention of physicians to both pediatric and adult nephrology. The lowest rated aspects of pediatric nephrology are compensation, workload, recognition, geographic job location, work-life balance, and academic-only opportunities. These observations must be interpreted cautiously because there was no comparison group of physicians in other specialties. Nevertheless, it would be useful to explore the specific factors that have led 20% of trained pediatric nephrologists to leave clinical practice. The role of these issues in trainee recruitment demands scrutiny, especially considering that between 2010 and 2014, only 57% of pediatric nephrology fellowship openings filled in the US National Resident Matching Program (NRMP).2 This worrisome trend continues because only 36% of 61 available positions filled in the 2015 match for firstyear pediatric nephrology fellows and open slots remained in 79% of the 45 certified training programs.2 Compensation is likely to be a major concern for many residents given large medical school debts and data estimating that career earnings for pediatric nephrologists are potentially $750,000 less than those of a general pediatrician.15 The impression of nephrology as a difficult subject, inadequate mentorship, work-life balance concerns, and lack of job opportunities in desirable areas, especially for international medical graduates, are other potential deterrants.6-8 Similar issues affect adult nephrology, which has experienced a marked decrease in the number of residents applying for fellowship, especially among US medical school graduates.2,4,6,7 The 2014 ASN survey of internal medicine nephrology fellows found that lack of job opportunities, especially for international medical graduates, and work-life balance concerns were most frequently mentioned reasons not to recommend nephrology as a career.6 Thirty-two percent of all responding practicing pediatric nephrologists plan to decrease their clinical activity in the next 5 years. It is not surprising that 16% plan to retire because as of December 2013, a total of 287 (35.6%) of all nephrologists ever certified by the ABP were between 61 and 75 years old.1 However, it is very concerning that another 16% of the active pediatric nephrology workforce who do not anticipate retirement plan to decrease clinical activities in the next 5 years, with the principal stated reason (reported by 45% of respondents) being dissatisfaction with work-life balance (only 11% listed salary as a consideration). Conversely, low compensation is the most frequently mentioned reason that pediatric nephrologists might not select this subspecialty if they could choose again. 6
It seems counterintuitive that there is an apparent shortage of pediatric nephrologists, yet some have left the specialty because they thought they could not find an adequate position, and more than half report competing with other pediatric nephrologists in their geographic area. Maldistribution of pediatric subspecialists is a long-standing issue.16,17 ABP data indicate that at the end of 2013, there were 5 states that had no pediatric nephrologists and 8 that had very few, with ratios varying from 1:27,000 children to 1:785,000 children.1 Similar data obtained by Ku et al18 using the 2008 American Medical Association Masterfile data show that 7 states had no pediatric nephrologists and 6 had 1:500,000 children or less. Because pediatric kidney disease is relatively rare, a large population base and the resources of a tertiary medical center are typically necessary to support a clinical practice. Consequently, most practicing pediatric nephrologists are in academic centers, which tend to be clustered in urban areas, largely explaining the maldistribution and reported competition. Similarly, if a physician’s preferences or circumstances preclude work in an academic center or an urban area, finding a pediatric nephrology position can be very difficult.
LIMITATIONS Our study has a number of limitations. Although we had a high response rate, trained pediatric nephrologists who have left the subspecialty may have been less likely to respond to this survey. Their perceptions of a career in pediatric nephrology may be different from those who continue to practice. An additional limitation is that no reference data are available to assess whether the career satisfactions and dissatisfactions of pediatric nephrologists are different from those of other physicians, although the attitudes, experiences, and concerns of pediatric nephrologists and internal medicine nephrologists as reported in the 2009 and 2014 ASN surveys are similar. Additional data may become available in the next few years as other pediatric subspecialties report results of their AAP-sponsored survey.
CONCLUSIONS This survey provides an overview of the US pediatric nephrology workforce. Pediatric nephrologists predominantly practice in academic settings and spend a significant amount of their time in nonclinical activities such as teaching and research. Although it is very difficult to predict future workforce needs, our data support the concern that the potential exists for a workforce shortage in this field. Serious efforts to recruit qualified trainees into the subspecialty are needed and may need to address issues including loan repayment, work-life balance, compensation, mentorship, and part-time work. Am J Kidney Dis. 2015;-(-):---
The US Pediatric Nephrology Workforce
The potential impact of physician extenders on the pediatric workforce needs to be followed closely.
ACKNOWLEDGEMENTS Drs Adam Weinstein and Coral Hanevold assisted in the development of the questionnaire. Phuong (Julia) Le helped categorize and quantitate the free text comments. Susan Hogan provided very helpful editorial insight. Support: The AAP Division of Workforce and Medical Education Policy and Section on Nephrology provided funding for this project. Ms Kirkwood and Ms Radabaugh are employed by the AAP. Ms Ruch-Ross is a consultant to the AAP. Financial Disclosure: The authors declare that they have no other relevant financial interests.
SUPPLEMENTARY MATERIAL Item S1: Survey questions. Note: The supplementary material accompanying this article (http://dx.doi.org/10.1053/j.ajkd.2015.03.022) is available at www.ajkd.org
REFERENCES 1. The American Board of Pediatrics. Workforce data: 20132014. https://www.abp.org/sites/abp/files/pdf/workforcebook.pdf. Accessed February 6, 2015. 2. National Resident Matching Program. Results and Data: Specialties Matching Service, 2015 Appointment Year. Washington, DC: National Resident Matching Program; 2015. 3. Lane CA, Brown MA. Nephrology: a specialty in need of resuscitation? Kidney Int. 2009;76(6):594-596. 4. Parker MG, Ibrahim T, Shaffer R, Rosner MH, Molitoris BA. The future nephrology workforce: will there be one? Clin J Am Soc Nephrol. 2011;6(6):1501-1506. 5. McMahon GM, Thomas L, Tucker JK, Lin J. Factors in career choice among US nephrologists. Clin J Am Soc Nephrol. 2012;7(11):1786-1792. 6. Salsberg E, Masselink L, Wu X. The US nephrology workforce: development and trends. https://www.asn-online.org/ education/training/workforce/Nephrology_Workforce_Study_Report. pdf. Accessed February 25, 2015.
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7. Weinstein AR, Reidy K, Norwood VF, Mahan JD. Factors influencing pediatric nephrology trainee entry into the workforce. Clin J Am Soc Nephrol. 2010;5(10):1770-1774. 8. Ferris M, Iglesia E, Ko Z, et al. Wanted: pediatric nephrologists!—why trainees are not choosing pediatric nephrology. Ren Fail. 2014;36(8):1340-1344. 9. Spector ND, Cull W, Daniels SR, et al. Gender and generational influences on the pediatric workforce and practice. Pediatrics. 2014;133(6):1112-1121. 10. Althouse LA, Stockman JA 3rd. Pediatric workforce: a look at pediatric nephrology data from the American Board of Pediatrics. J Pediatr. 2006;148(5):575-576. 11. Althouse LA, Stockman JA. The pediatric workforce: an update on general pediatrics and pediatric subspecialties workforce data from the American Board of Pediatrics. J Pediatr. 2011;159(6): 1036-1040. 12. Cull WL, Caspary GL, Olson LM. Many pediatric residents seek and obtain part-time positions. Pediatrics. 2008;121(2): 276-281. 13. Stapleton FB, Andreoli S, Ettenger R, Kamil E, Sedman A, Chesney R. Future workforce needs for pediatric nephrology: an analysis of the nephrology workforce and training requirements by the Workforce Committee of the American Society of Pediatric Nephrology. J Am Soc Nephrol. 1997;8(5)(suppl 9): S5-S8. 14. American Academy of Physician Assistants. 2013 AAPA annual survey report. https://www.aapa.org/WorkArea/Download Asset.aspx?id52902. Accessed February 25, 2015. 15. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2011;127(2):254-260. 16. Mayer ML, Skinner AC. Influence of changes in supply on the distribution of pediatric subspecialty care. Arch Pediatr Adolesc Med. 2009;163(12):1087-1091. 17. Stockman JA 3rd, Freed GL. Adequacy of the supply of pediatric subspecialists: so near, yet so far. Arch Pediatr Adolesc Med. 2009;163(12):1160-1161. 18. Ku E, Johansen KL, Portale AA, Grimes B, Hsu CY. State level variations in nephrology workforce and timing and incidence of dialysis in the United States among children and adults: a retrospective cohort study. BMC Nephrol. 2015;16(1):2.
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