Nathaniel talks about the State of the Nephrology Fellowship

The State of the Nephrology Fellowship is Strong.

The paper by Rope et al comes at a crucial time for the field of nephrology. Interest in nephrology has waned among med students and residents. 40% of fellowship spots are going unfilled in the match. While the nephrology job market has shown incremental signs of improvement, there is evidence to support that it remains difficult in local markets and for international medical graduates. Diversity among current nephrology fellows lags behind internal medicine residencies. Results from online surveys from each of the past 2 years have indicated that nephrologists have both the least overall career satisfaction and that they feel the least well compensated among medical specialties. It has been 3 years now since Berns and colleagues wrote a call to action describing the “urgent need” to redefine the scope of the specialty.

Despite the prevailing sense of existential dread in nephrology dating back at least as far as bundled payments, there are signs of life. The survey by Rob Rope and colleagues indicates that the academic climate and training environment for responding nephrology fellows is strong. 81% of fellows said that their teaching was good or better. Fully 97% of nephrology fellows felt moderately-well prepared or better for independent practice after only 2 years of fellowship. Though differences make analysis difficult, compared to the last such assessment by Berns in 2010, aggregated competency appears at least the same, if not better.

More importantly, Rope sheds light on the engagement of current nephrology fellows in new media. It is evident that fellows are turning toward web-based, open-access resources for their education needs. 40% of the top 15 resources used by those fellows are available online only, including nephrology blogs and #NephJC. Fellows are consuming resources that enhance not only their fund of knowledge, but bring them in contact with a diverse array of opinions and expose them to mentorship they would not otherwise have. It is no surprise that blogger and educator, Joel Topf was recently announced as the American Society of Nephrology’s Robert G Narins Award recipient for 2017. This is part and parcel of the dawning of a new era in nephrology. A sort of nephrologic singularity crystallizing from a nidus of engaged individuals through the medium of social media: the Nephrology Social Media Collective.

I believe this is how fellows are answering Berns’ call to redefine the scope of nephrology. Through seamless collaboration and remote mentoring, fellows have unprecedented access to a unique self-directed educational experience which they are using to redefine the specialty and find their niche. Rope’s study confirms this. Fellows are asking for more training on emerging topics. Look at Table 4. Fellows want to know more about home modalities which are hot now as patient preference and value of care are increasingly considered. Fellows want to know more obstetric nephrology as preeclampsia has emerged as potentially the world’s most common glomerular disease. Fellows even went to the trouble of emphasizing in the free-text questions that they want more training in ultrasonography as point-of-care ultrasound emerges as a tool to enhance the physical exam.

This is not something to take lightly. It gives you an appreciation of the busy life of a nephrology fellow looking at the sheer amount of effort it took to get fellows to participate. Never mind that this 31% of fellows may be a fertile field for selection bias. By looking at the supplement you get a sense of the hard work and dedication it took to put this together. The team offered incentives, extended the deadline twice, contacted the program directors through multiple channels, sent reminders through social media and the ASN website, and sent a total of 8 email reminders. This, I can confirm having been a subject of the study and having only completed it on the last day before it was due after receiving all 8 emails as well as significant arm twisting from the program director.


I would be remiss if I didn’t say that this is the death knell for paternalism in nephrologic education. Nephrology fellows must be given the tools and protected time they require to find the next emerging need in nephrology. They need to be able to interact with individuals not just at the local level, but nationally and internationally to find the sort of career-defining projects that bring them satisfaction through lifelong learning. Online collaboration through social media and enhanced learning through open-access medical education resources is exactly the vehicle that is systematically reinvigorating nephrology as a specialty.

Nathaniel Reisinger
NSMC Intern
POCUS Champion




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