| Characteristic | Adult (N=359) | Pediatrics (N=42)* | Adult/ Pediatrics (N=3)* |
|---|---|---|---|
| Educational Status | |||
| USMG | 148 (41%) | 27 (64%) | 3 (100%) |
| IMG | 211 (59%) | 15 (36%) | NA |
| Years of Training Completed | |||
| 1 | 176 (49%) | 12 (29%) | 1 (33%) |
| 2 | 171 (48%) | 15 (36%) | 1 (33%) |
| 3 | 9 (3%) | 14 (33%) | 1 (33%) |
| 4 or more | 3 (1%) | 1 (2%) | NA |
| Gender Identity | |||
| Man | 217 (61%) | 11 (26%) | 2 (67%) |
| Woman | 138 (39%) | 30 (71%) | 1 (33%) |
| Prefer not to answer | 3 (1%) | 1 (2%) | NA |
| Citizenship Status | |||
| U.S. citizen | 205 (57%) | 29 (69%) | 3 (100%) |
| Permanent resident | 37 (10%) | 4 (10%) | NA |
| H-1, H-2, or H-3 visa (temporary worker) | 29 (8%) | NA | NA |
| J-1 or J-2 visa (exchange visitor) | 85 (24%) | 9 (21%) | NA |
| Prefer not to answer | 3 (1%) | NA | NA |
| Ethnicity | |||
| Hispanic/Latinx | 41 (12%) | 3 (7%) | NA |
| Prefer not to answer | 7 (2%) | 3 (7%) | NA |
| Race | |||
| Asian Total | 152 (42%) | 14 (32%) | 0 (0%) |
| –East Asian | 29 (8%) | 2 (5%) | 0 (0%) |
| –South Asian | 105 (29%) | 9 (20%) | 0 (0%) |
| –Southeast Asian | 18 (5%) | 3 (7%) | 0 (0%) |
| White | 154 (43%) | 25 (57%) | 2 (67%) |
| Black or African American | 23 (6%) | 2 (5%) | 0 (0%) |
| American Indian or Alaska Native | 1 (0%) | 0 (0%) | 0 (0%) |
| Pacific Islander | 1 (0%) | 0 (0%) | 0 (0%) |
| Prefer not to answer | 31 (9%) | 3 (7%) | 1 (33%) |
| Census Division | |||
| New England | 36 (10%) | 4 (10%) | NA |
| Middle Atlantic | 81 (24%) | 13 (32%) | NA |
| East North Central | 47 (14%) | 7 (17%) | 2 (67%) |
| West North Central | 33 (10%) | 1 (2%) | NA |
| South Atlantic | 59 (17%) | 1 (2%) | NA |
| East South Central | 16 (5%) | 2 (5%) | NA |
| West South Central | 23 (7%) | 6 (15%) | NA |
| Mountain | 10 (3%) | NA | NA |
| Pacific | 39 (11%) | 7 (17%) | 1 (33%) |
| *NA = not available. | |||
On Deck: Results from the 2022 ASN Nephrology Fellow Survey
workforce
fellow
survey
report
Fellows Perspectives on Procedures and the Nephrology Job Market
ASN Data Subcommittee
Kurtis A. Pivert, MS 
Anna M. Burgner, MD, MEHP
Lili Chan, MD, MS
Susan Halbach, MD, MPH
Koyal Jain, MD, MPH, FASN
Benjamin Ko, MD
Hitesh H. Shah, MD, FASN
Stephen M. Sozio, MD, MHS, MEHP, FASN
Joshua Waitzman, MD, PhD
Suzanne M. Boyle, MD, MSCE
Executive Summary
Forty-three percent of current nephrology fellows participated in the 2022 iteration of ASN’s annual Nephrology Fellow Survey, including 42% of adult fellows (359 of 842) and 51% of pediatric fellows (45 of 88). Now in its ninth year, the survey included questions capturing adult fellows’ perspectives on procedural competency requirements for board certification in addition to longitudinal assessments of fellow demographics and post-fellowship employment trends. Among the key findings are the following.
Nine of Ten Fellows Recommend Nephrology
A record-high 90% of all respondents, including 90% of participating international medical graduate (IMG) and 89% of U.S. medical graduate (USMG) fellows, would recommend nephrology to medical students and residents. Reasons to recommend the specialty were encapsulated well by one fellow who said “nephrology is a contemplative science—demanding care for a spectrum of patients varying from general to critical care.” As in previous years, respondents not endorsing nephrology cited the difficulty of fellowship, low compensation, poor work-life balance, and a challenging job market as demotivating factors.
Few Support Maintaining Procedural Competency Requirements in Non-Tunneled Dialysis Catheters and Kidney Biopsies for Board Certification …
Most participating adult fellows indicated that demonstrated competence in performing non-tunneled dialysis catheter placement (or lines) and kidney biopsies (both native and transplant) should no longer be required for nephrology board certification eligibility. Across all fellows (both 1st- and 2nd-year fellows combined), just 30% of respondents supported maintaining the competency requirement for lines and 31% supported the requirement for biopsies, with 20% and 21%, respectively, favoring removal of the procedural requirements altogether. Fellow perspectives did not differ between 1st- and 2nd-year fellows (p > 0.1 for all procedures, Chi-squared test of independence).
… and Only Slightly More Self-Assessed as Competent in Non-Tunneled Catheters and Kidney Biopsies
Fifty-five percent of adult fellow respondents (53% of 1st-years, Figure 1; 58% of 2nd-years, Figure 2) self-assessed themselves as prepared (upon graduation) for unsupervised practice in placing non-tunneled dialysis catheters, and just 42% self-assessed as prepared for unsupervised practice in performing kidney biopsies (1st-years, 41%; 2nd-years, 44%). Of note, 24% of graduating fellows indicated they are not competent to perform non-tunneled hemodialysis catheters, and 28% not competent to perform kidney biopsies.
Starting Base Compensation Kept Pace with Inflation
Median base starting salary for graduating adult fellows rose 9.8% to $219,500 in 2022, keeping pace with inflation (see VI. Focus on the Pediatric Workforce for data on pediatric nephrologists). Women respondents entering practice reported earning $1000 less on average starting compensation than their male colleagues (median $219,000 vs. $220,000, respectively).
Most Graduating Fellows Are Entering General Nephrology
Of the 117 respondents starting their first post-fellowship job, most (84%) were practicing general clinical nephrology. Just 5% were practicing both nephrology and another subspecialty (such as critical care or transplant nephrology). Half of the adult fellows were entering private practice (51%, 60 respondents), with most working in large cities (73%, 85). California (18), New York (8), and Georgia (7) were the most common markets for newly employed nephrologists.
There Are Disproportionately Fewer Underrepresented in Medicine and Women Nephrology Trainees Compared to the U.S. Population
Across adult, pediatric, and adult/pediatric trainees just 11% of respondents were of Hispanic ethnicity, 6% were Black, and 42% were women (Figure 3).
Local Job Market Perspectives Improve, But Diverge Between IMGs and USMGs
Perspectives on the job market have steadily improved since their nadir in 2020. However, it appears that IMGs continue to have worse impressions of the local job market (defined as within 50 miles of their training institution) than USMGs. Only 40% of IMGs perceived an appropriate number of positions locally vs. 55% for USMGs. IMGs frequently cite visa restrictions as reason that they are unable to secure a satisfactory position (accounting for 50% of the IMG respondents who experienced difficulties this year). This might be the primary driver of the discrepancy between USMG and IMG perspectives.
I. On Deck—The Nephrology Pipeline
The 2022 ASN Nephrology Fellow Survey attained a 43% response rate, near the upper range of rates observed since the survey’s initiation in 2014 (29%–55%). Demographic details on the 404 current adult, pediatric, and adult/pediatric nephrology fellows in training who responded are summarized in Table 1.
Demographics
US medical graduates (USMGs) were overrepresented in this year’s adult cohort comprising 41% of respondents, slightly more than the 34% reported by the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book Academic Year 2020–2021. Correspondingly, international medical graduates (IMGs) were underrepresented—59% of respondents vs. 66% of all adult fellows per ACGME. Although proportions of women adult fellow respondents were similar to the population of adult fellows (39% vs. 38% per ACGME), fewer pediatric women fellows participated (71% vs. 80%).
Median respondent age was 33 years for both adult and pediatric fellows, although age varied more among adult fellows—range 25–55 years vs. range 30–41 years for pediatrics.
A majority of respondents were U.S. citizens, with 23% training on a J-1 visa and 7% on an H-1B (Figure 4). Forty-one (10%) respondents were graduates of an osteopathic medical school. As would be expected in a representative sample of fellows in 2-year adult fellowships and 3-year pediatric fellowships, approximately one-half of adult (171 fellows) and one-third of pediatric (14) respondents were completing their final accredited year of training.
Table 1: Respondent Demographics1
Training Programs and Location
Nearly all respondents were in a fellowship affiliated with an academic medical center (378, 94%) with just 23 (6%) training at a community hospital. Among adult fellows, clinical nephrology was the most common fellowship being pursued (90%), with 6% focused on research and 3% in joint nephrology–critical care medicine fellowships (Figure 5).
Motivation and Recommending Nephrology
Overall, 22% of respondents were set on pursuing nephrology during or before medical school (IMGs, 20%; USMGs, 26%), with half of IMG and USMG respondents choosing the specialty during their 2nd or 3rd years of residency (Figure 7). Nearly a third of respondents had participated in one or more ASN programs to increase interest in the specialty, with the most participating in Kidney STARS (Students and Residents) which is focused on physicians in the early phases of training (Table 2).
USMGs were carrying a high educational debt burden—median $240,000 in debt vs $25,000 for IMGs (Figure 8). Pediatric fellows had the highest overall debt—median $191,000 vs. $128,000 for adult fellows. Men reported more debt than women (median $160,000 vs. $120,000, respectively).
Table 2: ASN Program Participation
| ASN Program | Description | N (%) |
|---|---|---|
| Kidney STARS | Free Kidney Week Registration & Networking Opportunities | 83 (21%) |
| Campbell Fellows | Travel Support Program for Fellows | 23 (6%) |
| Kidney TREKS | 1-week Research Course Retreat & Long-Term Mentorship Program | 7 (2%) |
| Lipps Research Fellowship | Research Fellowships Funding Fellows Conducting Original, Meritorious Research Projects | 6 (1%) |
Nine out of 10 fellows would recommend nephrology to medical students and residents (Figure 9), the highest since the survey’s initiation in 2014. For IMG respondents, this represents a 43% increase from the nadir observed in 2015, when just 63% of IMGs would recommend nephrology. Proportions of fellow respondents recommending nephrology were consistent across fellowship types (adult nephrology, 89%; pediatrics, 95%; adult/pediatrics, 100%; p = 0.28, Chi-squared test) and gender (women, 92%; men, 89%; p = 0.3, Chi-squared test).
Perspectives—Recommending Nephrology
Longitudinal patient relationships and the broad range of pathology and practice offered in nephrology have been commonly cited as important reasons to pursue the specialty and were echoed among this year’s respondents recommending nephrology.
It is a great field in which you can integrate knowledge from biology, physics, and chemistry to make sense of the physiology. The pathophysiology is interesting, and you get the opportunity to follow patients longitudinally, from the beginnings of CKD to post-transplant, which is really amazing to see.—1st-Year USMG
It is the most logical and objective field in medicine. The fundamental understanding of physiology you learn in Nephrology gives you the ability to understand the entirety of a patient’s management. If you like “every field of medicine” Nephrology is the ideal field, as you learn to manage many aspects of Cardiology, Hematology/Oncology, Infectious Disease, Endocrinology, Surgery, Critical care etc.—1st-Year USMG
The mystique of the kidney. Nephrology integrates with numerous other specialties so we are exposed to a broad range of pathology in other fields as well. Continuity of care in dialysis patients is unmatched in other specialties giving us the opportunity to connect with our patients.—1st-Year USMG
Perspectives—Not Recommending Nephrology
Respondents not recommending the specialty shared their concerns about how day-to-day practice failed to meet their expectations, noting a lack of autonomy and respect on the nephrology consult service.
While nephrology is interesting from a pathophysiology perspective, the day to day practice is demoralizing. On the inpatient side, primary teams are more focused on telling you what to do (start dialysis, start CRRT) rather than asking a consult question and on the outpatient side, the majority of the time is spent managing dialysis (a machine, not a patient) or completing non-interesting mild CKD consultations that likely could have been handled by a primary care doctor if there was more support and guidance for primary care. Overall, while nephrology is interesting in textbooks, the day to day practice of nephrology does not reflect the interesting cases we read about, is stressful, is full of demoralizing interactions with other healthcare providers, and is not rewarding.—2nd-Year USMG
Work-life balance and starting compensation have been commonly cited demotivating factors, especially among IMGs seeking visa waiver positions.
Tough fellowship however at the end of it I get poor work life balance as an attending nephrologist, lots of driving around hospital/dialysis clinics and extremely poor compensation aka less than a IM hospitalist who has less training than a nephrologist and works less hours. This is especially true for IMGs on J1/H1 as they end up getting jobs with poor salary.—2nd-Year IMG
Long hours, poor compensation, tedious work (lots of driving during work day), high patient volume so not enough time to give to individual patients. You can make more as a Hospitalist with 7 on/7 off models without night shifts and brutal weekend calls. Big city jobs and dialysis center ownership seems saturated. Nobody seems to be doing anything to improve the quality of life of nephrologists or to improve compensation.—2nd-Year IMG
A high educational debt burden—common among USMG fellows (Figure 8)—can discourage fellows from endorsing nephrology.
Good employment opportunities are tough to come by. The jobs just don’t pay well enough initially and also the work load is a lot to justify the low pay. It’s hard to feel enthusiastic about taking a job that pays $180,000, having you work over 60 hours per week while you graduate with loans of over $350,000.—3rd-Year USMG
II. Future Plans, Leading Job Market Indicators, and Important Job Factors
Note
This Section Reports ADULT Fellow Responses Only
After the current academic year, 50% of adult respondents were continuing their current fellowship and 31% were entering practice (private practice, 22%; academic practice, 10%; Figure 10). Ten percent of respondents were seeking additional subspecialty fellowship training in either transplant nephrology (17 fellows), nephrology–critical care (10), interventional nephrology (7), glomerular disease (2), or home dialysis (1 fellow). Of note, 15 graduating fellows who had not yet completed a U.S.-based residency required for board eligibility planned to enter internal medicine. Forty-four percent of respondents (regardless of fellowship year) planned on practicing in the same state of the fellowship program, and 32% in the same city.
This year, fewer fellows expressed concerns about the availability of positions within the local job market, defined within a 50-mile radius of their training program. Fifty-five percent of USMGs and 40% of IMGs perceived an appropriate number of local opportunities (Figure 11). Indeed, the portion of respondents indicating “Appropriate/Too Many/Far Too Many” local job opportunities were the highest since the survey’s inception in 2014 (see Historic Job Trends). Historically, assessments of the national job market have been more optimistic than for local opportunities. Yet this year USMGs were less enthusiastic about the availability of jobs across the U.S., with only 50% indicating there were an appropriate number of available positions compared with IMGs (55%) (Figure 12). Unlike the visa restrictions that impact many IMG nephrologists, it’s unclear what factor(s) could be driving the differing perceptions at the national level.
Historic Job Trends—Combined Responses for Appropriate/Too Many/Far Too Many Jobs*
Important Factors When Selecting a Job
Among the 357 adult fellows who responded to the question measuring the importance of certain aspects of potential job offers:
Frequency of weekend call (54%), frequency of overnight call (53%), and having a position in a desired location (50%) were rated “Extremely Important” by half of the respondents (Figure 13).
Both overnight call frequency (USMG: 76 respondents [tied 2nd]; IMG: 112 respondents [2nd]) and weekend call frequency (USMG: 76 [tied 2nd]; IMG: 115 [1st]) were among the top three factors rated “Extremely Important” for both USMG and IMG respondents when evaluating employment opportunities. For USMGs, a job in a desired location was the top-rated factor (84 respondents), while for IMGs a job meeting visa requirements rounded out the top three (100 respondents).
Top three factors rated “Extremely Important” by both women and men were the same—overnight call frequency (women, 1st; men, 3rd), weekend call frequency (women, 2nd; men, 1st), and job in a desired location (women, 3rd; men, 2nd).
III. On the Hunt—Fellow Job Search Experiences
Note
This Section Reports ADULT Fellow Responses Only
| Positions Sought | |
| Job Type | N |
|---|---|
| Clinical Nephrology | 113 |
| Dual Nephrology/Other Specialty | 14 |
| Nephrology—Research | 11 |
| Medical Education | 11 |
| Hospitalist | 6 |
| Other | 6 |
| Other Specialty | 5 |
| Primary care | 4 |
| Industry | 4 |
Seventy percent of graduating adult trainees (127 of 180 respondents) had initiated or completed their search for post-fellowship employment at the time of survey. The most common positions sought were in clinical nephrology (113 respondents) and clinical nephrology with another specialty (14). Most popular practice settings were hospital systems (103 respondents) and private practice (83).
Graduating adult fellow respondents had applied for an average of 4.2 jobs (USMG, mean 3.2; IMG, 4.9), and received an average of 3.6 offers of employment (USMG, mean 3.5; IMG, 3.7). Although the number of job applications did not differ between men and women (mean 4.1 for both), women received an average of 3.2 employment offers versus 3.9 for their male peers. Sixty-five percent of graduating adult respondents (117 fellows, see IV. Entering Practice) had accepted a position, 23% (41) had not been offered a job, and 12% (22 fellows) had received a job offer but were still searching for another job.
| Employment Settings Sought | |
| Practice Settings | N |
|---|---|
| Hospital System | 103 |
| Private Practice | 83 |
| Government | 17 |
| Other Setting | 4 |
| Pharmaceutical Company | 3 |
| Industry–Other | 2 |
One-third of respondents seeking employment experienced difficulty in finding a position they considered satisfactory—44% of IMGs (44 fellows) and 18% of USMGs (13 fellows). Finding jobs in a desired location and that offered adequate compensation topped the list of reasons for both IMG and USMG fellows (Table 3).
Table 3: Reasons Cited for Difficulty in Finding Satisfactory Nephrology Position*
| Unable to Find a Job: | IMG (N=33) | USMG (N=14) |
|---|---|---|
| In a desired location | 32 (73%) | 6 (46%) |
| Offering adequate salary/compensation | 23 (52%) | 9 (69%) |
| That met visa status requirements | 22 (50%) | 1 (8%) |
| In a desired practice setting (e.g., hospital, group practice) | 20 (45%) | 5 (38%) |
| Offering employment opportunities for spouse/partner | 7 (16%) | 1 (8%) |
| Other | 6 (14%) | 2 (15%) |
| *N=57 | ||
IV. Entering Practice
Note
This Section Reports ADULT Fellow Responses Only
| First Post-Fellowship Position–Responsibilities* | |
| Responsibilities | N (%) |
|---|---|
| Outpatient clinic—CKD | 97 (84%) |
| Outpatient In-Center Hemodialysis | 93 (81%) |
| PD | 88 (77%) |
| CRRT | 84 (73%) |
| Home HD | 64 (56%) |
| Education | 37 (32%) |
| Medical directorship with a dialysis provider | 30 (26%) |
| Apheresis | 21 (18%) |
| Joint venture with a dialysis provider | 20 (17%) |
| Clinical research | 20 (17%) |
| Outpatient clinic—Transplant | 18 (16%) |
| Kidney biopsy | 18 (16%) |
| Dialysis catheter placement | 15 (13%) |
| Interventional nephrology | 5 (4%) |
| Basic science research | 2 (2%) |
| *N=115 | |
Of the 117 adult respondents starting post-fellowship practice, five planned to enter positions outside the U.S. Among the 112 based within the U.S., California (18 fellows), New York (8), and Georgia (7) were the top practice destinations (Figure 14). Just 15% entering practice were located in a small city and 2% in a rural area, with many fellows’ jobs situated in large cities (73%) or suburban locations (11%). Most (98 respondents, 84%) were starting clinical nephrology positions (Figure 15), with 6 respondents each starting research (5%) and dual nephrology/other specialty positions (5%). Only one respondent was starting practice in hospital medicine. Half (60 fellows) were beginning in private practice and 44% (51) in a hospital system (Figure 16). Outpatient CKD clinic (84% of respondents), in-center hemodialysis (81%), peritoneal dialysis (77%), and continuous kidney replacement therapy (73%) were the most common responsibilities anticipated by fellows in their first post-gradation position.
Compensation and Incentives
Commensurate with an annualized inflation rate of 9.1%, median base salary rose 9.8% to $219,500 in 2022. Base salary varied by respondent gender (women, median $219,000; men, $220,000; Base Salary—Gender) and medical school location (IMGs, median $230,000; USMGs, $200,500; Medical School). Beyond base compensation, nearly all respondents (114) received at least one incentive (detailed in Table 4), with income guarantees (50%), support for MOC/CME (39%), and a sign-on bonus (38%) most commonly reported. Only 17% of those entering practice (19 fellows) received a J-1 visa waiver and 13% H-1 visa sponsorship (15). Half of incentive recipients (52%) indicated incentives were “Extremely/Very Important” in choosing to accept a job (Figure 17). Incentive pay also varied by gender (women, median $20,000; men, $18,500; Incentive Pay by Gender) and medical school (IMG, median $20,000’; USMG, $15,000; Incentive Pay by Medical School).
Base Salary—Gender
Base Salary—Medical School
Table 4: Incentives Received*
| Incentive | N (%) |
|---|---|
| Income guarantees | 57 (50%) |
| Support for maintenance of certification and continuing medical education | 45 (39%) |
| Sign-on bonus | 43 (38%) |
| Career development opportunities | 43 (38%) |
| Relocation allowances | 36 (32%) |
| J-1 visa waiver | 19 (17%) |
| H-1 visa sponsorship | 15 (13%) |
| Real estate venture | 10 (9%) |
| Protected time for research/research “start-up” package | 9 (8%) |
| Other | 9 (8%) |
| Spouse/partner job transition assistance | 6 (5%) |
| Educational loan repayment | 3 (3%) |
| On-call payments | 2 (2%) |
| *N=114 | |
Importance of Incentives
Incentive Pay—Gender
Incentive Pay—Medical School
V. Perspectives on Procedural Competencies
Note
This Section Reports ADULT Fellow Responses Only
This year’s Fellow Survey included questions on procedural requirements for nephrology board certification to inform the work of ASN’s Task Force on the Future of Nephrology and the American Board of Internal Medicine (ABIM) as they consider changes to the nephrology training, certification, and recertification process (see Kidney News). The survey asked fellows: the number of procedures they performed during fellowship training; their self-perceived competency to independently perform procedures after graduation; and their opinion on whether competency in procedures should by required for board certification eligibility.
The following procedures were considered:
Non-tunneled hemodialysis catheter (aka line) placement
Kidney biopsies (native and transplant)
POCUS examinations
Procedure Volume During Fellow Training
There was wide variation among the number of each procedure fellows performed overall and stratified by fellowship year, training program affiliation (academic medical center– vs. community–based), and geographic location.
Non-tunneled hemodialysis catheters During the course of their fellowship respondents had placed a median 8 (IQR 12) lines—median 5 lines for 1st- and 10 for 2nd-year fellows (lines performed by fellowship year).
Biopsies Overall, respondents had performed a median 10 (IQR 12) biopsies during their fellowship to date. As expected, 1st-year fellows performed fewer (median 6) than 2nd-years (median 10, see biopsies performed by fellowship year).
POCUS Fellows were asked how often they performed in a typical month. The median number of exams performed per month was 4 (IQR 8), with similar rates among 1st-years (median 4) and 2nd-years (median 5, see POCUS exams by fellowship year).
The potential of training program type to influence the number of procedures performed was examined by comparing responses from respondents who self-identified as training at an academic- (334) vs. a community-located (22) program across fellowship year (using zero-inflated poisson regression). Given the large imbalance between cohorts, results should be interpreted with caution. Those in training at community programs performed more non-tunneled hemodialysis catheter placements (median 11 vs. 8 for academic programs; p = 0.17) and POCUS exams (median 6.5 vs. 4; p < 0.01), but fewer biopsies (3.5 vs. 10; p < 0.01).
Comparisons of procedures were also performed based on respondents’ Census Regions found a trend among fellows training in the Northeast Region to perform more biopsies (median 10) than respondents training in the rest of the U.S. (range 7–8; p = 0.02, Kruskal-Wallis test; p > 0.05 Dunn test adjusted p values). No differences were found between regions for lines and POCUS exams.
Finally, men consistently performed more procedures than their women peers (see Figure 18, Figure 19, and Figure 20), but differences were not statistically significant (p ≥ 0.12 for all, Kruskal-Wallis test).
Self-Assessed Competence
Only 58% of 2nd-year fellows agreed they were prepared to independently perform non-tunneled hemodialysis catheter placement; 44%, kidney biopsies; and 33%, POCUS exams. These percentages suggest that most fellows fall short of the current competency standard for kidney biopsy and POCUS and only a small majority self-assess as competent in line placement.
It’s important to note that:
This survey was administered less than 60 days before most 2nd-year fellows were expected to graduate
24% of graduating fellows freely admit that they are not competent to perform these procedures, yet under current board certification requirements their program director must attest to their competence to perform the procedure in order for them to be eligible to sit for the ABIM nephrology board certification exam
Of graduating fellows entering practice, only 16% (18 respondents) indicated they would be responsible for performing kidney biopsies and 13% (15) would be responsible for placing non-tunneled dialysis catheters
To determine if there was an association between fellows’ perceived competency and the number of procedures performed (which may be associated with fellows’ access to opportunities to perform procedures) we analyzed respondents’ self-rating for each procedure with the number they performed and their fellowship year using ordinal logistic regression. Respondents were asked to self-assess their preparedness for independent practice using a Likert scale (ranging from “Strongly Disagree,” “Disagree,” “Neither Agree nor Disagree,” “Agree,” to “Strongly Agree”) to answer the statement Upon graduation I will be able to competently perform [PROCEDURE] in unsupervised practice.
For each procedure there was statistically significant association with an increase in the number performed with likelihood of an increase from one category to another at any level in the corresponding self-assessed competency Likert scale (see Self-Assessed Competency by Number of Procedures Performed). There was also a statistically significant relationship with fellowship year and number performed for biopsies and POCUS (reference level 2nd-year fellows for both comparisons), but not for line placement, suggesting that fellows place most of their non-tunneled catheters during their first fellowship year which is often front-loaded with clinical experiences.
Requirement for Board Eligibility
Fellow perspectives on procedural requirements for board eligibility were assessed by asking respondents whether the training standard for each procedure should be:
Competency: Fellows can successfully perform the procedure independently
Opportunity to Train: Fellows know indications/contraindications and risks/benefits but are not required to perform the procedure to sit for the board exam. Every program must provide every fellow who would like to become competent in the procedure the opportunity to train to competence.
Neither
A majority of respondents agreed each of three procedures should be switched to an opportunity to train standard (non-tunneled hemodialysis catheters, 48%; kidney biopsies, 52%; and POCUS, 60%) (see respondent opinions by fellowship year on non-tunneled hemodialysis catheters, kidney biopsies, and POCUS). There were no differences between 1st- and 2nd-year fellows in recommendations for retaining procedural competencies for lines and biopsies or adding POCUS (p ≥ 0.11 for all; Chi-square test for independence).
Differences in respondents’ recommendation for retaining non-tunneled hemodialysis catheters and biopsies or including POCUS as required procedural competencies by training program location (academic medical center vs. community) did not differ significantly (p = 0.44, p = 0.1, and p = 0.14, respectively; Chi-square test for independence). There were no geographic differences among respondents’ recommendation for ABIM required procedural competencies for non-tunneled hemodialysis catheters, POCUS, nor for kidney biopsy (after post-hoc Bonferroni adjustment).
Non-Tunneled Hemodialysis Catheters
Performed During Fellowship
Self-Assessed Competence
ABIM Standard
Kidney Biopsies (Native and Transplant)
Performed During Fellowship
Self-Assessed Competence
ABIM Standard
Point-of-Care Ultrasound (POCUS)
Performed in Typical Month
Self-Assessed Competence
ABIM Standard
Self-Assessed Competency by Number of Procedures Performed
Non-Tunneled Hemodialysis Catheters
Kidney Biopsies
POCUS
VI. Focus on the Pediatric Workforce
Important
This Section Reports PEDIATRIC Fellow Responses Only
Demographics
The 42 pediatric and 3 adult/pediatric nephrology fellows responding were underrepresented by USMG (64% vs 73% USMG pediatric fellows per ACGME data) and women (71% vs. 80%), although somewhat representative of some aspects of race and ethnicity (54% White [vs. 57%], 5% Black [5%], 7% Hispanic [7%], and 32% Asian [25%]). Most respondents were U.S. citizens or permanent residents, with 20% training on a J-1 visa. Demographics for the 42 pediatric and 3 adult/pediatric nephrology fellow respondents are summarized in Table 5. Pediatric respondents carried a median $191,000 in educational debt, with USMGs burdened by higher debt levels (median $206,000 vs. $100,000 for IMGs) (Figure 24).
Table 5: Pediatric and Adult/Pediatric Respondent Demographics2
| Characteristic | Pediatrics (N=42)* | Adult/ Pediatrics (N=3)* |
|---|---|---|
| Educational Status | ||
| USMG | 27 (64%) | 3 (100%) |
| IMG | 15 (36%) | NA |
| Years of Training Completed | ||
| 1 | 12 (29%) | 1 (33%) |
| 2 | 15 (36%) | 1 (33%) |
| 3 | 14 (33%) | 1 (33%) |
| 4 or more | 1 (2%) | NA |
| Gender Identity | ||
| Man | 11 (26%) | 2 (67%) |
| Woman | 30 (71%) | 1 (33%) |
| Prefer not to answer | 1 (2%) | NA |
| Citizenship Status | ||
| U.S. citizen | 29 (69%) | 3 (100%) |
| Permanent resident | 4 (10%) | NA |
| H-1, H-2, or H-3 visa (temporary worker) | NA | NA |
| J-1 or J-2 visa (exchange visitor) | 9 (21%) | NA |
| Prefer not to answer | NA | NA |
| Ethnicity | ||
| Hispanic/Latinx | 3 (7%) | NA |
| Prefer not to answer | 3 (7%) | NA |
| Race | ||
| Asian Total | 14 (32%) | 0 (0%) |
| –East Asian | 2 (5%) | 0 (0%) |
| –South Asian | 9 (20%) | 0 (0%) |
| –Southeast Asian | 3 (7%) | 0 (0%) |
| White | 25 (57%) | 2 (67%) |
| Black or African American | 2 (5%) | 0 (0%) |
| American Indian or Alaska Native | 0 (0%) | 0 (0%) |
| Pacific Islander | 0 (0%) | 0 (0%) |
| Prefer not to answer | 3 (7%) | 1 (33%) |
| Census Division | ||
| New England | 4 (10%) | NA |
| Middle Atlantic | 13 (32%) | NA |
| East North Central | 7 (17%) | 2 (67%) |
| West North Central | 1 (2%) | NA |
| South Atlantic | 1 (2%) | NA |
| East South Central | 2 (5%) | NA |
| West South Central | 6 (15%) | NA |
| Mountain | NA | NA |
| Pacific | 7 (17%) | 1 (33%) |
| *NA = not available. | ||
Future Plans
Most respondents were continuing their fellowship (64%), with 9 graduating fellows entering academic practice positions (20%, Figure 25). One-quarter of all responding pediatric fellows anticipated starting their first post-fellowship position in the same state as their training program, and 19% in the same city.
Pediatric Nephrology Job Market—Leading Indicators
Pediatric respondents perceived a challenging local job market with less than one-third perceiving an appropriate number of opportunities within close proximity to their training program (Figure 26). Yet respondents were slightly more optimistic about national conditions—overall 44% said there an appropriate number of jobs across the U.S.—with USMGs viewing the market more positively than their IMG peers (Figure 27).
Pediatric Job Search Experiences
Thirteen of the 16 respondents completing their final accredited year of training had initiated a job search, applying for a median 3 positions and receiving a median 2 job offers. Clinical and research positions at hospital systems were the most commonly sought jobs and employment settings (see Tables 6A and 6B). Five pediatric respondents indicated having difficulty finding a position they considered satisfactory, with USMGs having difficulty finding jobs in desired locations (2 respondents) and IMGs finding positions with adequate compensation.
Tables 6A and 6B: Pediatric Post-Fellowship Positions
| Table 6A: Positions Sought | |
| Job Type | N |
|---|---|
| Nephrology—Clinical | 35 |
| Nephrology—Research | 9 |
| Nephrology (Clinical) combined with Other Clinical Specialty (e.g., critical care) | 4 |
| Medical Education | 4 |
| Other | 4 |
| Hospitalist | 2 |
| Non-nephrology—Pediatrics | 1 |
| Industry | 1 |
| Table 6B: Settings Sought | |
| Practice Settings | N |
|---|---|
| Hospital System (including academic or university-based) | 38 |
| Private Practice | 9 |
| Other Setting | 2 |
| Government | 1 |
| Pharmaceutical Company | 1 |
Entering Pediatric Practice
Every respondent was starting in either a clinical or research position at a hospital system (11 respondents, Figure 28). Most pediatric fellows entering practice indicated their clinical responsibilities focused on outpatient CKD clinic (100%), along with dialysis modalities, kidney transplant, and kidney biopsy (all 75%, Table 7). Of the 8 respondents starting practice, all were women whose first job were in either a large city (7 respondents) or the suburbs (1), with a fairly consistent set of job responsibilities (see below). Median base compensation was $169,000 (Figure 29).
All respondents entering practice (8) received at least one incentive (detailed in Table 8), with career development opportunities (6 respondents), a sign-on bonus (5), and relocation allowances (4) most commonly reported. Only 1 fellow entering practice received a J-1 visa waiver and 2 respondents a H-1 visa sponsorship. Median incentive pay was $21,000. Most incentive recipients (6 respondents) indicated incentives were “Extremely/Very Important” in choosing to accept a job.
Table 7: First Post-Fellowship Position—Responsibilities*
| Responsibilities | N (%) |
|---|---|
| Outpatient clinic—CKD | 8 (100%) |
| Outpatient In-Center Hemodialysis | 6 (75%) |
| PD | 6 (75%) |
| CRRT | 6 (75%) |
| Outpatient clinic—Transplant | 6 (75%) |
| Kidney biopsy | 6 (75%) |
| Clinical research | 6 (75%) |
| Education | 5 (62%) |
| Apheresis | 3 (38%) |
| Dialysis catheter placement | 1 (12%) |
| *N=8 | |
Table 8: Pediatric Fellows—Incentives Received*
| Incentive | N (%) |
|---|---|
| Career development opportunities | 6 (75%) |
| Sign-on bonus | 5 (62%) |
| Relocation allowances | 4 (50%) |
| Spouse/partner job transition assistance | 3 (38%) |
| Support for maintenance of certification and continuing medical education | 3 (38%) |
| Protected time for research/research “start-up” package | 3 (38%) |
| H-1 visa sponsorship | 2 (25%) |
| Income guarantees | 2 (25%) |
| J-1 visa waiver | 1 (12%) |
| Educational loan repayment | 1 (12%) |
| *N=8 | |
Methods
Who were surveyed?
The 2022 Nephrology Fellow Survey was distributed to a survey frame of 930 adult, pediatric, and adult/pediatric nephrology fellows drawn from the ASN and American Society for Pediatric Nephrology member databases. The survey received a 43% response rate, with participation from 359 adult, 45 pediatric, and 3 adult/pediatric fellows in training.
How was the survey constructed?
The survey instrument comprised:
- Longitudinal questions drawn from the original 2014 survey focusing on job search experiences, perceptions of the specialty, practice patterns, and demographics
- Questions developed by the ASN Data Subcommittee to assess adult nephrology fellows’ experiences and preferences about current required procedural competencies for board certification, including number performed and self-assessed competence.
The final instrument was piloted by ASN Data Subcommittee members and distributed via Qualtrics.
When was the survey conducted?
Invitation emails were sent to adult fellows on May 3 and the survey closed on May 20, 2022. Pediatric fellows received a survey invitation on May 9, and their survey portion closed May 27. Participating fellows were eligible to win one of 10 complimentary one-year ASN memberships or one of two complimentary BRCU registrations.
How were responses analyzed?
The ASN Nephrology Fellow Survey was reviewed and approved by the Johns Hopkins University School of Medicine Institutional Research Board (Study # 00205206). Data obtained from 2021 responses were analyzed using R (R Core Team [2021]. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria.).
Why does ASN survey nephrology fellows in training?
Since 2014, ASN has conducted an annual fellow survey to understand:
- The composition of the incoming workforce, including race, ethnicity, and gender
- Motivating factors for choosing the specialty to tailor approaches to sustain interest in nephrology
- Potential gaps in nephrology education
- Demand for nephrologists in the U.S.
Footnotes
U.S. Census Divisions
New England: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont.
Middle Atlantic: New Jersey, New York, Pennsylvania.
East North Central: Illinois, Indiana, Michigan, Ohio, Wisconsin.
West North Central: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota.
South Atlantic: Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, D.C., West Virginia.
East South Central: Alabama, Kentucky, Mississippi, Tennessee.
West South Central: Arkansas, Louisiana, Oklahoma, Texas.
Mountain: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming.
Pacific: Alaska, California, Hawaii, Oregon, Washington.↩︎
U.S. Census Divisions
New England: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont.
Middle Atlantic: New Jersey, New York, Pennsylvania.
East North Central: Illinois, Indiana, Michigan, Ohio, Wisconsin.
West North Central: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota.
South Atlantic: Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, D.C., West Virginia.
East South Central: Alabama, Kentucky, Mississippi, Tennessee.
West South Central: Arkansas, Louisiana, Oklahoma, Texas.
Mountain: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming.
Pacific: Alaska, California, Hawaii, Oregon, Washington.↩︎
Citation
BibTeX citation:
@online{a._pivert2022,
author = {A. Pivert, Kurtis and M. Burgner, Anna and Chan, Lili and
Halbach, Susan and Jain, Koyal and Ko, Benjamin and H. Shah, Hitesh
and M. Sozio, Stephen and Waitzman, Joshua and M. Boyle, Suzanne},
title = {On {Deck:} {Results} from the 2022 {ASN} {Nephrology}
{Fellow} {Survey}},
date = {2022-10-21},
url = {https://data.asn-online.org/posts/2022_fellow_survey/},
langid = {en}
}
For attribution, please cite this work as:
A. Pivert, Kurtis, Anna M. Burgner, Lili Chan, Susan Halbach, Koyal
Jain, Benjamin Ko, Hitesh H. Shah, Stephen M. Sozio, Joshua Waitzman,
and Suzanne M. Boyle. 2022. “On Deck: Results from the 2022 ASN
Nephrology Fellow Survey.” October 21, 2022. https://data.asn-online.org/posts/2022_fellow_survey/.