Transforming Nephrology

Abstract

Much has been written about the troubles facing nephrologists and the specialty of nephrology. These include declining interest in nephrology as a career, lower salaries compared with many other subspecialties, difficulty attracting outstanding residents who are passionate about nephrology into fellowship programs, and high rates of burnout and career dissatisfaction among practicing nephrologists (1,2). There is no doubt that the work of a nephrologist can be hard. Many of us, whether in academia or private practice, work long hours caring for challenging patients. Some work within health systems where our efforts are perhaps not as appreciated as we would like. Similar to other areas in the practice of medicine, nephrologists spend substantial time during their workdays, evenings, and weekend on tasks that have little meaning, such as completing forms, ticking boxes in the electronic medical record (EMR), and other tasks that do not effectively use our clinical training. For instance, a study focusing on four specialties (nephrology was not included) determined that clinicians spend only 27% of their total time on direct clinical care and 49.2% of their time on EMR and clerical work, with much of this time occurring after hours during personal time (3). This issue may be worse for nephrologists, who typically have to use several different EMRs at multiple clinical practice sites, including chronic dialysis facilities. Furthermore, many nephrologists spend hours traveling between multiple dialysis units, seeing patients in facilities owned by large for-profit dialysis companies where our contributions to patient care may not be highly valued. Compounding this are reforms on payment models that emphasize data reporting and increase the burden of documentation rather than encouraging patient-centered care. There is no wonder that many of us feel discouraged and burned out. A consequence of these feelings is that nephrologists have developed a cynicism regarding our profession and a feeling that things are only going to get worse. This cynicism leads to a destructive self-fulfilling prophesy that engenders a sense of helplessness. Our professional dissatisfaction is transparent to medical students and residents who are deciding on career choices and likely acts as a deterrent to choosing careers in nephrology. It is against these feelings that we believe it is critical for us to take a step back, ask why we chose nephrology as our specialty, and consider how we can recapture joy and excitement in our practice of nephrology. Perhaps most importantly, we need to take the necessary actions that will be required to accomplish this. This article focuses on these critical issues and offers a starting point to engage further discussion on the future of nephrology.Many of us chose nephrology out of fascination with the complex physiology underlying our specialty and an enthusiasm for improving the lives of patients with serious medical problems (4,5). In recent years, this enthusiasm has been tempered by factors that have...

Role of the Nephro-Hospitalist

“…A well described factor that increases burnout rates in nephrology is "windshield time," which is spent driving between multiple dialysis units and hospitals (8). Compounding this is the use of multiple electronic health record systems between multiple corporate dialysis organizations and privately owned facilities (9). Private practices may be turning to a nephrology hospitalist model to mitigate these issues, boost productivity, and improve job satisfaction.…”

A practical guide for the care of patients with end‐stage renal disease near the end of life

“…There are certainly systemic barriers affecting the nephrology workforce's ability to deliver high‐quality EOL care that includes a lack of communication training to have EOL conversations, clinical demands, cultural barriers, and financial incentives to continue dialysis . These realities challenge nephrology providers’ ability to deliver patient‐centered care and may lead to provider burnout . Despite these challenges, we believe nephrology providers can succeed in providing EOL care in the dialysis setting.…”

“…8 These realities challenge nephrology providers' ability to deliver patient-centered care and may lead to provider burnout. 9 Despite these challenges, we believe nephrology providers can succeed in providing EOL care in the dialysis setting. Our longitudinal relationships with dialysis patients make us uniquely situated to not only understand their physiology, but also use our frequent encounters to guide decisionmaking for EOL care.…”

A future for nephrology?

“…Their views were often less than optimistic about the future of Nephrology, but they agreed that change is needed to address the current sense of stagnation and angst facing the specialty. 4 …”