May 01, 2018
7 min read

An appeal to industry leaders: Take charge of the future of nephrology

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Each year, the American Society of Nephrology provides updates on developments and trends for incoming nephrologists and the adult nephrology workforce. As a result, we know the demographics and nuances of our specialty better than most. ASN’s 2017 Nephrology Fellows Survey results have revealed insightful data points about the upcoming generation of nephrologists, such as the difficulty matching fellows, higher percentages of women and international medical graduates and the shifting job expectations of new nephrologists for better work-life balance.1 All of these data must be taken into consideration as we integrate new generations of nephrologists into practice.

In addition to the ASN survey data, we also know private nephrology practices, particularly smaller practices, have difficulty attracting the new generation of incoming nephrologists. This is due in part to as many as 36% of graduating nephrology fellows decide to work for hospitals, but not as nephrologists.2 They become employed as hospitalists. In that role, fellows forgo specialty training and provide general medicine services within the “safer” confines of the hospital setting while enjoying higher initial salaried positions. The starting salary difference can be as high as $60,000, with an initial salary $240,000 for a hospitalist vs. approximately $180,000 for a private practice nephrologist.2 Even larger private practices that successfully sign new recruits have difficulty retaining them. Some 50% leave within the first 5 years.2 This is a huge resource drain on our specialty.

Pessimism vs a call to arms

Robert Provenzano

Understandably, many of my colleagues view these developments with pessimism. I prefer to see it as a call to arms. Our specialty is at a pivotal juncture and in need of decisive leadership to defend our future, protect the value and viability of our practices, and ensure patients have greater access to quality kidney care. We have an opportunity, if not a duty, to scrutinize the way we currently conduct our work and chart a new course.

If not, what will become of the patients we all entered this profession to serve? Now is the time to decide if the legacy we leave behind is one of a failure to adapt or one of a courageous reinvention of the way we practice — both in terms of how we serve patients and how we groom the next generation of nephrologists to do so.

An evolving field

The role of nephrologists is evolving. Operating costs have increased and, unfortunately, clinical reimbursements have not kept pace, particularly with the transition to value-driven reimbursement systems.3


Nephrologists are trained as physicians, not business people. As such, many are conditioned to work harder, but not necessarily smarter. They are taking on additional work outside of patient care to compensate for less-than-ideal reimbursements. In many cases, nephrologists entered into joint ventures with dialysis facilities and served as medical directors to pursue financial incentives from government programs and income from alternative sources such as rent, legal work, royalties and research.3 Although this may seem helpful at first, it is a short-term solution and one that ignores a core problem.

Growing administrative burdens, which have resulted from increased reporting requirements and complex reimbursement systems, have strained many practices. As such, practices have morphed into complex business enterprises to understand and address administrative needs such as coding, billing, collections, cost analysis, payer contracting, human resources, legal, compliance and accounting. The administrative workload is not only a drain on practicing nephrologists but also does not fit with the expectations of nephrology fellows entering the workforce.

Incoming fellows have a different perspective on work-life balance than those who came before them. The work-life balance perspective of new fellows may require practices to proactively address family planning needs,4 as some junior nephrologists may require leaves of absence as they start their families and balance the needs of their personal and professional lives.

As such, there are a growing number of nephrology fellows who are having a difficult time finding job satisfaction.4 Instead of joining senior nephrologists in private practice, they are more likely to seek an employed position, in many cases, with a hospital. The traditional partnership model that previously existed between junior and senior nephrologists is eroding, as the future of a practice as a viable business is questioned by younger nephrologists.

Graduating nephrologists also must meet strenuous financial burdens: Student debt for a U.S. medical graduate averages $220,000.5 This is another area in which hospitals are gaining traction over private practices, as they are often able to offer attractive up-front signing bonuses and/or debt repayment opportunities that many private practices do not offer.

These changing demographics and preferences come at a time when the specialty is experiencing its own evolution. The world of nephrology has changed drastically in the past decade due to regulatory and legislative changes, as well as market shifts and technological advances.3 Medicare, the largest purchaser of nephrology services, consistently makes most of the patient volume for nephrology practices.3 Thus, the field of nephrology is particularly vulnerable to changes in federal health care policy, adding to the need to be flexible and adapt to outside variables affecting our practice.


Methods to address the challenges

Each of these challenges brings with it an opportunity. Nephrology practices have become more complex, and the demands on nephrologists’ time are more onerous. We have an opportunity to respond with smarter business practices and partnerships that support the potential for improved patient care, increased earnings and minimized risks.

First, practice leadership must manage the practice as a business and operate it accordingly. Largely, practices have neither focused on business processes nor performed those processes professionally. To remain competitive and independent, it is time to get your house in order, so to speak, and look carefully at what practice services you may require to remain competitive, what these services cost and what value is delivered to your patients. For smaller practices, this may require the assistance of a professional management company.

Next, seek out partners who can enhance your presence in the market. Given the reality of the health care industry today and the continued regulatory march toward value-driven reimbursement, bigger may be better, or at least have some advantages you should consider. Thus, it may be prudent to consider scaling and merging.

Finally, educate yourself on how your business is performing and determine the need of the practice to evolve to both better manage the costs of care and achieve quality outcomes for your patients. Again, your practice is a business asset and requires responsible management in order to maintain and grow its value.

Your practice needs to deploy the right people in the right places, like any successful business. The traditional partnership model between junior and senior nephrologists is quickly becoming obsolete. Recognizing the needs and skills of young nephrologists entering the field is important in helping you to attract and retain the talent required to operate successfully.

Accumulated debt from medical school and fellowship might make novel compensation models, such as up-front signing bonuses, more attractive. In exchange, you could determine a tenure for the fellow to stay with the practice. Also, young nephrologists may have an interest in becoming financially vested with the practice, which can serve junior and senior physicians alike. In other words, have the discussion within your practice and recognize the opportunities that exist to create competitive advantages to attract young talent. Be transparent with potential new nephrologists, share your practice and business strategy, and discuss the financial performance and viability of your business. Let them see that there could be a future with your practice.


In addition, recognize the changing nephrology workforce demographics and take advantage of the skills emerging nephrologists can offer to your practice and patients. For example, international medical graduates may help connect with populations of patients you could be better serving in your community. Patients appreciate physicians who are relatable, who understand their culture and speak their language. For nephrologists trying to balance the needs of family and work, consider modifying your business model to include the option of a part-time schedule.

Younger nephrologists bring with them training in electronic medical records, applications and information technology that can help you modernize your IT infrastructure. They have shared their training with non-physician providers, such as physician assistants and nurse practitioners, which may help your practice as it reacts to declining reimbursement pressures and increasing reporting and administrative burdens.

To succeed in this new era, senior and junior nephrologists both must be willing to learn from the other. Often nephrologists become their own worst enemies, locked in a hierarchal relationship with junior physicians. That mindset needs to evolve rapidly. Taking into consideration the wisdom that your years of experience have brought you, find ways to share your wisdom with receptive young nephrologists. In turn, be receptive to the skill sets and knowledge base they can share with you and your practice. By attracting young nephrologists into your practice and treating them as long-term members of your team, you are helping groom them for the future needs of your practice and for future generations of patients.

Ultimately, all nephrologists bear the same burdens and have the same responsibilities to our patients and to our communities, and also to each other.

Lead the way

The changes within our industry have been monumental. It is understandable to feel off-balance in light of new regulations, business pressures and changes in the demographics of the nephrology workforce — not to mention competitive pressures from expanding hospital and health care systems.

We are evolving from an era in which presumed physician quality was based on physician popularity. With EMRs, we increasingly track and report our quality outcomes — the curtain has been pulled back. Let’s take advantage of this opportunity to drive visible improvements in care and better serve the needs of our patients and communities.

In some ways, as physicians we have been trained not to admit what we don’t know. Cast that burden aside. At the end of the day, we are still physicians with patients to serve. Identify areas where you or your practice need input, and reach out to people with that knowledge base or expertise. Embrace the information you can gain from others in similar situations and consider using social media as a sounding board for the challenges you are working through. Understand your practice as a business, with its weaknesses and strengths, and map out a strategy. Choose your top priorities and delegate to ensure progress can happen despite the multitude of demands on your time. Bring bright, young nephrologists on board and invest in them to build a strong foundation for the future of your business. Only you can drive the success of your practice and determine the legacy you will leave for those who follow.