The Pediatric Nephrology Workforce Crisis: A Call to Action

Abstract

Pediatric nephrology was established as a formal specialty by the American Board of Pediatrics (ABP) more than 40 years ago to provide physicians with dedicated expertise in diagnosing and treating conditions related to the kidneys and urinary tract, encompassing congenital, hereditary, and acquired conditions; electrolyte and acid-base disorders; hypertension; and kidney replacement therapy including kidney transplantation in both acute/inpatient and longitudinal outpatient care settings.1Salerno A.E. Weinstein A. Hanevold C. American Society of Pediatric Nephrology Position Paper: standard resources required for a pediatric nephrology practice.J Pediatr. 2016; 174: 254-259Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Remarkable growth and unique challenges are predicted in the field owing to the improved survival rates of children with chronic illnesses, growing recognition of acute kidney injury (particularly in the intensive care unit) with an acknowledgment that children who develop acute kidney injury merit outpatient nephrology follow-up, advances in organ transplantation and dialysis technologies, and improved fetal survival from antenatal surgical interventions.2Bertram J.F. Goldstein S.L. Pape L. Schaefer F. Shroff R.C. Warady B.A. Kidney disease in children: latest advances and remaining challenges.Nat Rev Nephrol. 2016; 12: 182-191Crossref PubMed Scopus (26) Google Scholar Unfortunately, this increased demand has been met with growing alarm within the pediatric nephrology community regarding a looming workforce shortage over the past several years, which may be insufficient to meet the medical needs of children with kidney disease. This includes both an aging physician cohort with imminent retirement or attrition out of the specialty, as well as a weakened pipeline owing to waning trainee interest in the field.3American Board of Pediatrics Physicians Workforce Data Book, Pediatric Workforce Trendsdistribution of US-based pediatric subspecialists ever certified by the ABP, age 70 and under.www.abp.org/content/us-map-subspecialists-stateDate: 2019Google Scholar From 2013 to 2019, the number of pediatric nephrologists increased from 530 to 644, a 21.5% increase that represents the smallest absolute increase over time of all pediatric subspecialties certified by the ABP. This meager growth is in stark contrast with pediatric critical care medicine (a 142% increase) and pediatric emergency medicine (a 122% increase).4Turner A. Ricketts T. Leslie L.K. Comparison of number and geographic distribution of pediatric subspecialists and patient proximity to specialized care in the US between 2003 and 2019.JAMA Pediatr. 2020; 174: 852-860Crossref PubMed Scopus (25) Google Scholar Additionally, a striking geographic disparity exists with regard to access to pediatric nephrologists with many Midwestern states containing few (if any) certified pediatric nephrologists or pediatric nephrology training programs (Figure 1; available at www.jpeds.com). These data provided by the ABP Workforce Report are likely an over-representation of pediatric nephrology coverage, because it only depicts the practice location of board-certified pediatric nephrologists and does not account for those individuals who choose to practice part time and/or in general pediatrics owing to the lack of an acceptable position within the desired geographic location. Recent workforce trends analysis from the American Academy of Pediatrics indicates that pediatric nephrologists work an average of 54.7 hours per week, with a little more than 55% of their time dedicated to direct patient care and nearly 40% of patients must wait 2 weeks or longer for an appointment.5Rimsza M.E. Ruch-Ross H.S. Clemens C.J. Moskowitz W.B. Mulvey H.J. Workforce trends and analysis of selected pediatric subspecialties in the United States.Acad Pediatr. 2018; 18: 805-812Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar In response to the imminent workforce shortage facing our profession, the American Society of Pediatric Nephrology (ASPN) convened a national Workforce Summit. This half-day conference occurred on November 6, 2019, in Washington, DC, and gathered a diverse group of pediatric nephrologists with interest and expertise in workforce development (Appendix 2; available at www.jpeds.com). Members were charged with the formation of a task force designed to create a comprehensive mitigation strategy to address the challenges faced by our profession. This resulted in 4 work groups: (1) Trainee Education and Exposure; (2) Reimbursement and Policy Issues; (3) Fellowship Training Duration; and (4) Retention, Burnout, and Professional Well-Being. The purpose of this white paper is to describe the detailed analysis of workforce trends undertaken during the summit and to highlight the proposed task force solutions. The results of this work may be of interest to other underserved pediatric subspecialists who are facing similar workforce concerns. Recruitment of future pediatric nephrologists occurs by developing early interest with learners in both undergraduate training and medical school, well before entering pediatric residency. For undergraduate and medical students, kidney physiology may not be presented with a pediatric clinical context that helps future pediatricians to contemplate the field. It is frequently considered a challenging subject by new learners, thereby requiring the enthusiasm of gifted educators and strong mentorship to avoid an early aversion to the field.6Sozio S.M. Pivert K.A. Shah H.H. Chakkera H.A. Asmar A.R. Varma M.R. et al.Increasing medical student interest in nephrology.Am J Nephrol. 2019; 50: 4-10Crossref PubMed Scopus (11) Google Scholar Although most pediatricians starting residency have not yet committed to their future practice or specialty, most enter residency with a preliminary list they are considering. Therefore, early exposure to specialties and mentorship with specialists in medical school is important to career choice.6Sozio S.M. Pivert K.A. Shah H.H. Chakkera H.A. Asmar A.R. Varma M.R. et al.Increasing medical student interest in nephrology.Am J Nephrol. 2019; 50: 4-10Crossref PubMed Scopus (11) Google Scholar,7Nakhoul G.N. Mehdi A. Taliercio J.J. Brateanu A. Diwakar A. Daou R. et al.Residents' perception of the nephrology specialty.Kidney Int Rep. 2020; 5: 94-99Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Pediatric nephrology is listed as one of the core subspecialties for maintenance of accreditation for pediatric residency programs through the Accreditation Council for Graduate Medical Education (ACGME).8Accreditation Council for Graduate Medical Education (ACGME)ACGME Program requirements for graduate medical education in pediatrics. Approved: 2012, Revised common program requirements effective July 1, 2015. p. 18.www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_07012015.pdfGoogle Scholar Increased visibility of nephrology involvement in the care of complex, critically ill patients may play an attractive role in residents' consideration of this specialty as future career. Yet, many pediatric residency programs across the US may not have a pediatric nephrologist on staff, which further limits trainees’ exposure to pediatric nephrology in action. Of the 210 ACGME-certified pediatric residencies, 171 (81%) report at least 1 pediatric nephrologist on staff providing direct patient care through their public websites, although only 47 pediatric residency programs (22%) have an associated pediatric nephrology fellowship training program at the same institution. To address these barriers, a multifaceted effort by pediatric nephrologists, pediatric department chairs, academic institutions, and professional nephrology societies is needed. Pediatric nephrologists must seek available vacancies and integrate themselves as mentors, lecturers, and course directors at all levels of undergraduate and graduate medical education. This dedicated teaching effort must be recognized by their department chairs with protected academic time, and as an integral metric toward successful promotion. Refinement of a clinician-educator pathway may enhance career development as well as allow for the development of novel teaching tools and advancements in educational research.9Roberts J.K. Burgner A.M. Yau T. The nephrology clinician educator: pathway and future.Adv Chronic Kidney Dis. 2020; 27: 312-319.e1Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Pediatric residency program directors should ensure that all residents gain exposure to nephrology no later than the end of their second residency training year, and ideally during their intern year to allow sufficient time to explore the specialty further for those who may be interested. Expanded opportunities for nephrology “electives,” a specialty-focused continuity clinic experience mentored by a staff nephrologist, and “away” rotations at centers with active pediatric nephrology programs should be offered. The National Institutes of Health (through the National Institute of Diabetes and Digestive and Kidney Diseases), the American Society of Nephrology (ASN) and the ASPN have developed programs targeted toward medical students and residents to attract them to nephrology and pediatric nephrology, respectively (Table I). Content for trainee recruitment includes video profiles describing a “day in the life” of a nephrologist.10American Society of Nephrology Career Video Profiles.www.asn-online.org/education/training/students/career-videos.aspxDate accessed: October 31, 2020Google Scholar,11American Society of Pediatric Nephrology Careers in Nephrology Video Profiles.www.aspneph.org/careers-in-nephrologyGoogle Scholar The ASN sponsors the Tutored Research and Education for Kidney Scholars (Kidney TREKS) program, a week-long research course retreat and long-term mentorship program for medical students with an interest in nephrology.12Maursetter L.J. Stern L.D. Sozio S.M. Patel A.B. Rao R. Shah H.H. et al.Enhancing nephrology career interest through the ASN kidney TREKS program.J Am Soc Nephrol. 2016; 27: 1604-1607Crossref PubMed Scopus (17) Google Scholar Another ASN initiative is the Kidney Mentoring and Awareness Program for Students, which engages medical and premedical students in community activities focused on screening for kidney disease under the mentorship of nephrologists.13Bayliss G.P. Cobb J. Decker B. Hellman R. Vasavada N. Mackelaite L. et al.Kidney mentoring and assessment program for students: a guide for engaging medical students in nephrology.Clin Kidney J. 2019; 12: 761-766Crossref PubMed Scopus (9) Google Scholar The ASPN has sponsored a dedicated student and resident program as part of the annual Pediatric Academic Societies national conference. The program pairs trainees with pediatric nephrology fellows and practicing pediatric nephrologists on facilitated poster walks, career development programming, and fosters sustained interest in pediatric nephrology. Of 210 trainees sponsored by ASPN to attend the annual ASPN meeting between 2005 and 2017, 117 (55.7%) are now practicing pediatric nephrologists or board-certified in pediatric nephrology. The ASPN Foundation was established in 2015 and has been instrumental in developing a sustainable funding model, of which a key strategic aim is to support the society's trainee engagement activities.Table INephrology trainee pipeline programsProgramsSponsorDescriptionKURE (Kidney Undergraduate Research Experience)NIDDKMatches 20 undergraduate students with MD and PhD researchers for an 8-week nephrology-focused summer research experiencePROmoTE (PRedOctoral PhD and MD research training in Teams)NIDDKMatches 12 medical and PhD students into mentored teams for summer renal research experienceKidney MAPS (Mentoring and Awareness Program for Students)ASNLocal chapters recruit, engage and mentor medical and paramedical students through participation in nephrology-focused community screening eventsKidney TREKS (Tutored Research and Education for Kidney Scholars)ASNA week-long research retreat and long- term mentorship program for medical students designed to foster interest in careers in nephrology and researchPAS (Pediatric Academic Societies) Student and Resident ProgramASPNTravel stipend and free registration to the annual PAS/ASPN scientific meeting with dedicated trainee focused programming, including round table discussions and mentored poster walksNIDDK, National Institute of Diabetes and Digestive and Kidney Diseases. Open table in a new tab NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases. The generational shift in how young trainees seek and consume medical information should be considered in our outreach efforts. The widespread use of social media in medicine offers new avenues to engage trainees and develop long-distance mentorship opportunities.14Colbert G.B. Topf J. Jhaveri K.D. Oates T. Rheault M.N. Shah S. et al.The social media revolution in nephrology education.Kidney Int Rep. 2018; 3: 519-529Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Nephrology training programs that establish and engage actively in social media (eg, #Nephtwitter) were more likely to fill their open fellowship positions.15Matchett C.L. Astor B.C. Maursetter L.J. Factors associated with nephrology fellowship program fill rates.Clin J Am Soc Nephrol. 2020; 15: 1340-1341Crossref PubMed Scopus (2) Google Scholar The free open access availability of medical education content online (eg, Twitter journal clubs, and tweetorials) may allow unique exposure to nephrology content beyond the traditional confines of the class room or clinic, and is particularly useful for trainees at institutions with limited nephrology resources. Given the significant health disparities that exist in nephrology care across the world, leading to a disproportionate impact of chronic kidney disease on minority populations,16Crews D.C. Bello A.K. Saadi G. Burden, access, and disparities in kidney disease.Kidney Int. 2019; 95: 242-248Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar all stake holders must also engage in concerted efforts to appeal to trainees from under-represented minorities to build a diverse future nephrology workforce. Purposeful mentorship pairings with diverse faculty, targeted electives, and funding opportunities for minority trainees, and, above all else, a commitment from professional nephrology societies toward a culture of inclusion, diversity, and antiracism is key to achieving this goal. Substantial changes to the current remuneration system for pediatric nephrology must occur to sustain a healthy workforce and to encourage the pipeline of trainees to consider a career in pediatric nephrology. Revenue-generating programs essential to a comprehensive and inclusive children's hospital, including critical care, neonatology, pediatric oncology and stem cell transplantation, cardiothoracic surgery, solid organ transplantation, urology, and general pediatric surgical programs all rely heavily on the expertise of a pediatric nephrology program and the availability of kidney replacement therapies. Pediatric nephrologists provide a unique array of specialized services, including the provision of acute and chronic dialysis, continuous kidney replacement therapies, kidney transplantation, percutaneous kidney biopsy, ambulatory blood pressure monitoring, and, in many programs, oversee apheresis services as well. The AAP Section of Critical Care Medicine Guidelines lists a pediatric nephrologist and the services of hemodialysis, peritoneal dialysis, and continuous kidney replacement therapy as “essential” for a Level 1 pediatric intensive care unit.17Rosenberg D.I. Moss M.M. Guidelines and levels of care for pediatric intensive care units.Pediatrics. 2004; 114: 1114-1125Crossref PubMed Scopus (64) Google Scholar The American College of Surgeons mandates that “in Level I and II trauma centers, medical specialists on staff must include nephrology and their respective support teams.”18Rotondo M.F.C.C. Smith R.S. Resources for optimal care of the injured patient. 6th edition ed. Internet: American College of Surgeons, Committee on Trauma. Collaborative clinical services.www.facs.org/-/media/files/quality-programs/trauma/vrc-resources/resources-for-optimal-care.ashxGoogle Scholar Yet, in the current fee-for-service system, essential care for children with kidney disease is neither sufficiently valued nor appropriately compensated. Data to understand the positive downstream revenue generated by the Pediatric Nephrology services are difficult to obtain, but it is clear that other revenue-generating programmatic initiatives are reliant on the presence of a pediatric nephrology service. Proposed solutions to provide further clarity could include a formal analysis of “The Value of Pediatric Nephrologist to a Health Organization” supervised by a health economist, which has long been a project felt to be of significant interest to the ASPN, although has thus far been stymied by funding issues. Smaller case study-type investigations of certain procedures (eg, kidney biopsy) using national administrative claims databases to demonstrate both the direct value attributed to a pediatric nephrologist, as well as the indirect value through facility charges, subsequent infusions and hospitalizations, and new referral practices, may be a more feasible short-term project that could be useful to demonstrate a more complete spectrum of the value a pediatric nephrologist brings to a healthcare organization. The most widely used metric for clinical productivity in the US—the relative value unit (RVU) system—can be broken down into several components which comprise the “work” RVU, which in theory accounts for work performed by a provider in delivering a specific healthcare service and varies based on time and effort. It is widely believed that current work RVUs are inequitable to primarily nonprocedural-based specialties, such as nephrology, and favors procedure-based specialties19Sinsky C.A. Dugdale D.C. Medicare payment for cognitive vs procedural care: minding the gap.JAMA Intern Med. 2013; 173: 1733-1737PubMed Google Scholar; consequently, the pay scale for pediatric nephrologists is markedly less than in other pediatric subspecialties or compared with adult nephrologists (Figure 2). However, unique to pediatric nephrology is the fact that most programs must provide 24-hour coverage (often dialysis services for critically ill patients), which can lead to relatively intense call burdens as compared with other similar specialties. The perceived and demonstrated poor compensation for this high workload has resulted in waning trainee interest in pursuing a career in pediatric nephrology. After 21 years of clinical practice, the total median compensation wage gap between a pediatric nephrologist and a pediatric cardiologist is estimated to be around $1.9 million (Figure 3). Defining what an appropriate work RVU (or better yet, moving to value-based payment methodology) for a pediatric nephrologist may help with hospital administration in terms of striking an appropriate workload balance, compensation expectations, and facilitate better career development. Our professional society must lead pioneering efforts to collect accurate, detailed data regarding the burden of call in comparison with other specialties, specifically with regard to frequency of pages, telephone calls, and frequency of returning to the hospital for overnight dialysis procedures. Leveraging the power of hospital electronic medical record use and data analytics reporting tools and the implementation of national surveys to collect this information could be of great value at the negotiating table on both an individual and workforce-level basis. Ongoing advocacy efforts by various societies including the Renal Physicians Association have yielded laudable improvements in the 2021 Medicare Fee Schedule proposed rule, which increased reimbursement for outpatient dialysis codes.20Renal Physicians Association “RPA News” September 2020 Newsletter.https://cdn.ymaws.com/www.renalmd.org/resource/resmgr/whats_new/september_2020_rpa_news.pdf?MvBriefArticleId=42795Google Scholar Notably, there was a smaller overall percentage increase in the pediatric codes as compared with the adult codes by nearly 50% and still markedly undervalues the care that is provided, given that the majority of the pediatric end-stage kidney disease population is home-based peritoneal dialysis in young, fragile, medically complex patients.21Medicare ProgramCY 2021 revisions to payment policies under the physician fee schedule and other changes to Part B payment policies.www.cms.gov/files/document/cms-1734-p-pdf.pdfGoogle Scholar Continued advocacy for payment parity with adult medicine is needed, with an insistence that at the very least Medicaid reimbursements must equal those of Medicare for equivalent services provided.Figure 3Unfilled pediatric subspecialties in National Resident Matching Program match 2017-2019 by average salary.Adapted from: 2018-2019 Association of American Medical Colleges (AAMC) summary statistics on medical school faculty total compensation for all schools MD or equivalent degree, clinical science departments and specialties; National Resident Matching Program (NRMP) Program Results 2017-2019. Annual salary data from AAMC summary statistics were used to generate the median expected 21-year total compensation, using the assumption of 7 years each at the assistant, associate, and professor faculty ranks.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Significant investments in loan repayment options are necessary to defray the substantial costs associated with undertaking an additional intensive 3-year fellowship training position. Enrollment in subspecialty training has been predicted to lead to an overall net loss in remuneration of more than $750,000 over a lifetime career as compared with pursuing a general pediatrics position.22Rochlin J.M. Simon H.K. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics?.Pediatrics. 2011; 127: 254-260Crossref PubMed Scopus (42) Google Scholar Recognizing the negative impact of educational debt on choosing a career in nephrology, ASN has committed $2,700,000 toward a 3-year loan mitigation pilot program for trainees considering a career in nephrology with a special focus on those from under-represented racial minorities.23Seeking excellence:building the nephrology pipeline.www.kidneynews.org/careers/leading-edge/seeking-excellence-building-the-nephrology-pipelineGoogle Scholar Current federal loan repayment options, including the National Institutes of Health loan repayment program will repay qualified educational debt of $50,000 per year in exchange for a 2-year research commitment, assuming the applicant can secure 50% protected research time in their faculty appointment. Many faculty positions may be eligible for Public Service Loan Forgiveness program. However, lackluster implementation and misinformation regarding requirements for the program have led to a high rejection rate of applications.24Berman J. “This government loan forgiveness program has rejected 99% of borrowers so far.” MarketWatch.www.marketwatch.com/story/this-government-loan-forgiveness-program-has-rejected-99-of-borrowers-so-far-2018-09-20Google Scholar As of the most recent November 2020 audit, only 2.4% of the Public Service Loan Forgiveness applications had been approved (n = 6493), with the most common causes for ineligibility owing to lack of proof of qualifying payment (59%), missing information (26%), or ineligible loan type (11%).25Public service loan forgiveness data.https://studentaid.gov/data-center/student/loan-forgiveness/pslf-dataGoogle Scholar A greater awareness of potential eligibility, program requirements, and bureaucratic hurdles for these programs should be disseminated in a transparent manner to trainees. After years of unwavering advocacy by the academic pediatric community, substantial progress was made when The Pediatric Subspecialty Loan Repayment Program was reauthorized into law by Congress during passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act in March 2020.26H.R. 748: the Coronavirus Aid, Relief, and Economic Security (CARES) Act.www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdfGoogle Scholar This program was previously authorized by Congress in 2010, although never funded during budget appropriations, and authorization eventually lapsed in 2014. Staunch advocacy efforts should continue to advocate for robust initial funding for this program to decrease the shortages of pediatric subspecialists. Pediatric nephrology has the highest percentage of International Medical Graduates on either exchange visitor (J-1) or temporary worker (H-1B) visas for any pediatric subspecialty at 40% according to the most recent workforce data from the ABP.27ABP pediatric physicians workforce data book.www.abp.org/content/pediatric-subspecialists-ever-certifiedDate: 2019Google Scholar Growing uncertainties with the current US political climate regarding immigration policies and/or stringent visa requirements may make the decision to pursue a pediatric nephrology training program even less attractive for exceptional International Medical Graduates and very well may contribute to even deeper workforce shortages in the future. Pediatric nephrology compares unfavorably with other pediatric subspecialties, with some of the lowest fill rates of any of the pediatric subspecialties (Figure 4; available at www.jpeds.com). A review of the ABP Interactive Workforce Data demonstrates that, of all the pediatric subspecialties, pediatric nephrology has the poorest 10-year performance, with a decrease of almost 7% in the number of pediatric fellows at all levels of training from 2009 (n = 123) to 2018 (n = 114).28ABP pediatric physicians workforce data book, 2018-2019.www.abp.org/sites/abp/files/workforcedata2018-2019.pdfGoogle Scholar The 2020 fellowship match cycle was admittedly better than years prior, although 19 of 41 programs (46%) went unfilled with only 38 of 64 positions (59%) filled by trainees.29NRMP results and data specialties matching services, 2020 appointment year.https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/02/Results-and-Data-SMS-2020.pdfGoogle Scholar The most recent 2021 fellowship match cycle results announced in December 2020 demonstrated a marked improvement relative to years prior with 73.9% of positions filled by trainees.302020 pediatric specialties match results statistics report.https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/12/PSM_MRS.pdfDate: 2020Google Scholar However, it remains to be seen whether this improvement represents a sustained change, or reflects uncertainties in the job market after residency training in the midst of the coronavirus disease 2019 pandemic. Currently, the ABP requires completion of 3 years of full-time fellowship training in an ACGME-accredited Pediatric Nephrology program with a minimum of 12 months of clinical experience and completion of a scholarly academic work product to become board eligible. Over the last few years, there has been increased discussion about petitioning the ABP to shorten the duration of training from 3 to 2 years as a measure to bolster pediatric nephrology fellowship recruitment. The ASPN Workforce and Program Director Committees have assessed the pros and cons of this proposal (Table II; available at www.jpeds.com). Data gleaned from surveys of current trainees and practicing nephrologists are equivocal in this regard. Among current trainees during the 2019-2020 academic year (n = 131), a survey by the ABP showed that 48% believe there should be no change in the length of training, 9% believe it should be shortened, 41% believe there should be 2 different tracks (3 years for academic research career and 2 years for others), and 2% believe it should be extended.31American Board of Pediatric survey of 2019-2020 Pediatric Nephrology Fellows.www.abp.org/sites/abp/files/pdf/nephcf.pdfGoogle Scholar Among the same cohort, 32% believe the duration of clinical training should be increased to more than 12 months, and 60% believe the current duration is sufficient. Regarding scholarly activities, 63% believe the amount of scholarly activities should not be the same for all fellows, and 73% believe research will be part of their career. A survey of mid-career pediatric nephrologists (n = 82) showed that 7% felt that the required training duration should be shortened, and 55% believed that it should remain unchanged. The option of 2 different tracks was supported by 38%.32American Board of Pediatric Survey of mid-career pediatric nephrologists.www.abp.org/sites/abp/files/pdf/nephmc.pdfDate accessed: October 14, 2020Google Scholar Whether a move to a 2-year training track would impact the number of applicants is not known, as there are other major factors affecting career choices of residents, including but not limited to life-work balance, and salary of pediatric nephrologists relative to other subspecialties.22Rochlin J.M. Simon H.K. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics?.Pediatrics. 2011; 127: 254-260Crossref PubMed Scopus (42) Google Scholar,33Primack W.A. Meyers K.E. Kirkwood S.J. Ruch-Ross H.S. Radabaugh C.L. Greenbaum L.A. The US pediatric nephrology workforce: a report commissioned by the American Academy of Pediatrics.Am J Kidney Dis. 2015; 66: 33-39Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar For comparison, the adult nephrology fellowship training model offers a 2-year clinically focused track with optional additional research or experience years in specific areas of nephrology, such as transplant and interventional nephrology. Despite that flexibility, adult nephrology fellowship match rates remain low and stagnant at 59%-62% for academic appointment years 2016-2020.34The NRMP match - results and data. Specialties Matching Service. 2020 appointment year. Page 59: Nephrology.https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/02/Results-and-Data-SMS-2020.pdfGoogle Scholar In addition, fellowship and training issues did not factor into the reasons for not recommending nephrology as a career choice in the most recent 2019 ASN fellows survey.35American Society of Nephrology 2019 Fellows Surveywww.asn-online.org/education/training/workforce/Nephrology_Fellow_Survey_Report_2019.pdfGoogle Scholar The awareness of burnout among physicians has increased over the past several years, with a large study by administered by Medscape demonstrating rates higher than among the general US working population over a 6-year period (40% vs 28%), although rates of burnout or depression were estimated at 51% for adult nephrologists.36Martin K.L. Medscape nephrologist lifestyle, happiness, and burnout survey.www.medscape.com/slideshow/2020-lifestyle-nephrologist-6012499 - 2FebGoogle Scholar,37Shanafelt T.D. West C.P. Sinsky C. Trockel M. Tutty M. Satele D.V. et al.Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.Mayo Clin Proc. 2019; 94: 1681-1694Abstract Full Text Full Text PDF PubMed Scopus (375) Google Scholar There was wide variability by specialty, however, with pediatric subspecialties as a group ranking at or near the bottom of 24 specialty groups for both burnout (24th) and dissatisfaction with work-life integration (17th) in 2017. An ongoing longitudinal study of US pediatric residents has shown consistently high levels of burnout (50%-60%) across all 3 training years.38Kemper K.J. Schwartz A. Wilson P.M. Mahan J.D. Schubert C.J. Staples B.B. et al.Burnout in pediatric residents: three years of national survey data.Pediatrics. 2020; 145: e20191030Crossref PubMed Scopus (24) Google Scholar More specific data for pediatric nephrology faculty and trainees, however, have been lacking. A pilot study performed by members of the ASPN Workforce Committee in 2020 through the Association of Pediatric Program Directors research network found much lower rates of burnout among both fellows and faculty (13% and 16%, respectively).39Halbach S.M. Pillutla K. Schwartz A. Seo-Mayer P. Weidemann D.K. Mahan J.D. The Sustainable Pediatric Nephrology Workforce Project (SUPERPOWER): a pilot study of burnout and resilience. American Society of Nephrology Annual Meeting.www.asn-online.org/education/kidneyweek/2020/program-abstract.aspx?controlId=3447645Google Scholar The study window for the pilot spanned the spring 2020 peak of the coronavirus disease 2019 pandemic. Although the effects of the pandemic on physician burnout remain to be determined, one hypothesis may be that a greater sense of purpose drawing physicians together for a common cause may be a key driver for the difference seen in rates for 2020. Personal accomplishment is 1 of the 3 domains assessed in the most common instrument to determine burnout, the others being emotional exhaustion and depersonalization. Through collaboration with other subspecialties, the pilot study conducted this year will expand in 2021 to include more programs and refined survey questions to better understand our current challenges and inform future interventions. Addressing and mitigating physician burnout is essential for not only a thriving workforce where individuals can function at the peak of their potential, but also in avoiding the consequences of burnout, such as high turnover, patient dissatisfaction, and a lower quality care. A 2015 survey to practicing pediatric nephrologists indicated that nearly one-third planned to decrease or stop clinical activities within the next 5 years owing to retirement (53%) or a desire to spend more time in nonclinical pursuits (37%).33Primack W.A. Meyers K.E. Kirkwood S.J. Ruch-Ross H.S. Radabaugh C.L. Greenbaum L.A. The US pediatric nephrology workforce: a report commissioned by the American Academy of Pediatrics.Am J Kidney Dis. 2015; 66: 33-39Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Although we do not have data to connect these findings specifically with burnout, the latter group's decision highlights the potential impact of a suboptimal working environment on attrition in pediatric nephrology. To be effective, the solutions to optimize physician well-being should be implemented at multiple levels: individual, programmatic, and institutional. Much attention has been directed at individual-level strategies, such as mindfulness and gratitude practices, and attending to mental and physical health. Although it is true that these habits and behaviors are under one's personal control and responsibility, and essential for well-being under any circumstances, they alone are not sufficient to achieve widespread change across the medical profession. Programs and institutions must also take responsibility for prioritizing physician wellness through actions that promote autonomy, culture change, and physician engagement. The adoption of creative coverage solutions such as per diem call coverage, part-time work schedules that foster an improvement in physician work-life balance, a better integration of advanced practice providers into daily practice workflows, and provision of the full spectrum of support services needed to run a successful pediatric nephrology practice irrespective of its size, are critical steps in addressing burnout and limiting attrition from the field.1Salerno A.E. Weinstein A. Hanevold C. American Society of Pediatric Nephrology Position Paper: standard resources required for a pediatric nephrology practice.J Pediatr. 2016; 174: 254-259Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The ASPN is well-positioned to be a leader in educating individuals and programs on best practices in promoting physician wellness through workshops, leadership training, and promotion of research findings. The role of the ASPN and social media in maintaining a thriving sense of community in a small specialty that has many practitioners in small programs through the US is vital in supporting our sense of purpose as pediatric nephrologists. Establishing a national peer mentoring program for practicing pediatric nephrologists, particularly those working in smaller divisions, establishing new pediatric nephrology training programs, or embarking on their careers as attendings is one important measure that would increase inclusivity for the specialty. The newly established Equity, Diversity, and Inclusion Committee is also a fundamental step in building inclusiveness and addressing bias which can have negative impacts on well-being. As we strive to improve the health and well-being of all children, we must strengthen the pipeline of pediatric nephrologists to nurture the next generation of compassionate clinicians, innovative physician-scientists, and inspirational leaders in our field. Fair and equitable reimbursement policies and governmental strategies to support a diverse, inclusive workforce are a crucial component of ensuring the sustainability of our profession. Creative solutions, although not simple, are potentially achievable through the concerted efforts of professional societies and organizations to address the key issues presented herein. We outline potential opportunities for our profession to achieve continued growth and development of the pediatric nephrology workforce to ultimately allow the delivery of optimal care to children with kidney disease.