World Kidney Day reminds us of the 850 million people globally affected by kidney diseases. It draws attention to the 1 in 7 American adults managing Chronic Kidney Disease (CKD) and the 660,000 Americans with end-stage renal disease (ESRD). It also reminds us that kidney disease is the 9th leading cause of death in the United States.
But perhaps one of the most important statistics on World Kidney Day is that half of those with advanced kidney disease in the U.S. do not even know they have it. Too many people find out about their kidney disease when their kidneys fail and they are in the emergency room for dialysis.
It’s clear we can do better. We can, and must, pursue new approaches to kidney care that improve early diagnosis, emphasize prevention, and help keep patients off of dialysis. However, we cannot achieve better kidney care without also doing better for those who provide it.
Today, we’re in the midst of a nephrology crisis, and interest levels in nephrology careers is incredibly low. In 2018, out of 474 slots for nephrology training in the U.S., only 91 U.S. MDs matched into a nephrology fellowship program, and 40 percent of the training slots went unfilled. While the entire medical community is facing the challenges of provider burnout, lack of job satisfaction, and physician shortages, nephrology is in a particularly bad state.
And, this couldn’t be occurring at a worse time, as a recent study predicted the occurrence of ESRD in the U.S. will grow by 11 to 18 percent from 2015-2030. This will only serve to to place further strain on the nephrology community with higher workloads and even less time to provide the kind of quality care they strive to deliver.
It’s critical that we think about how we can solve nephrologists’ problems so that they can better tackle those of their patients with kidney disease. Where can we start? Consider a recent survey of internal medicine fellows who elected not to pursue nephrology. They were largely dissuaded by: a complicated patient population, a specialty that does not offer enough procedures, difficult-to-understand subject matter, and a perceived lack of role models.
That actually goes a long way to pinpointing the driving forces behind the nephrology crisis. While burnout and job dissatisfaction are incredibly personal person to person, there are some common themes.
One of them is the difficulty of becoming a nephrologist. It’s well-known that nephrology fellowships are incredibly challenging, and as a result fellows can end up uncertain about or regretting their choice.
The second is the difficulty of the practice itself. The patient population tends to be complex and high-risk. As a result, nephrologists are often put in emergency or urgent care situations, sometimes being called in to address patients’ needs at all hours and at a variety of facilities from hospitals to dialysis centers, many of which provide little infrastructure for holistic care.
Third is that the kidney care system is totally broken, and nephrologists and potential nephrologists recognize that. Most doctors aren’t drawn to the specialty to focus only on dialysis, and they certainly don’t want to be the last line of care before kidney failure.
But, the reality is that nephrology can be an incredibly rewarding specialty, it can allow one to develop deeply meaningful relationship with patients and their families, and it certainly can and should be more than just channeling patients to in-center dialysis. But in order to tackle the nephrology crisis head-on, we need to redefine nephrology for the providers of today and tomorrow.
To do this, we need to begin championing, promoting, and giving visibility to all the different kinds of great nephrologists. In addition to recognizing those conducting important nephrology research, we must encourage a culture that supports those delivering high-quality care in various clinical settings, innovating care with new practices or building new technology, and otherwise improving our specialty for providers and patients. As a profession, we have to have an open mind about what it means to be a successful nephrologist and to recognize and celebrate that there are many paths to success.
We also need to attract the best nurses, social workers, pharmacists, dietitians, technicians, and other providers, because high-quality kidney care is a team-based approach. This was recently demonstrated through a randomized trial that showed multidisciplinary care led to better outcomes than physician care alone. It’s important that we support all kinds of providers, as they not only improve care for patients, but free up time for, relieve burden on, and supplement the care of nephrologists.
But a team-based approach has to start with a solid relationship between nephrologist and primary care providers, who are on the front lines of patient care. According to the CDC, approximately 1 in 3 American adults with diabetes and 1 in 5 with high blood pressure may have CKD (in fact these conditions are the leading cause of new CKD cases). These conditions, as well as other CKD risk factors such as obesity and family history are known to primary care providers through their intimate patient relationships.
If we can educate and engage primary care providers, then we can identify those at risk of or with early stage CKD and refer them to a nephrologists’ care to slow progression and improve outcomes.
These aren’t the only solutions to addressing the looming nephrology crisis. As a specialty, we need to raise awareness and engage other providers to address growing concerns. Ultimately, we need to empower nephrologists to focus on what they entered practice to do: deliver quality kidney care for patients. The nephrology community must share the rewards of our practice, the amazing patients we care for, and the opportunities we have to interact with many colleagues from all specialties who enrich our professional lives.
Carmen A. Peralta is a nephrologist and professor of medicine, University of California, San Francisco, and chief medical officer, Cricket Health.
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