I Love Nephrology, but Should I Be a Nephrologist?

“Just follow your heart, do what makes you happy” is the unsolicited career guidance that medical trainees will receive by almost everyone they come across. Happiness is the ultimate goal when it comes to making career decisions, right? I am a postdoctoral researcher interested in kidney disease, with the majority of my research focusing on outcomes of AKI. If I decide to pursue nephrology down the road, do I really know what I’ll be getting myself into? You may have experienced the same rush of emotions when choosing your fellowship, or maybe you’ve engaged in similar discussions with your young mentees. Can I build my career in nephrology as well as feel satisfied in life? Data from periodic surveys have shown a high rate of satisfaction among nephrologists; however, my personal interactions with cotrainees suggest otherwise. Many of the residents I have spoken to, who have yet to choose a fellowship, have voiced views of this field as one that is demanding and offers little reward. Mark Rosenberg, in his powerful presidential address, started Kidney Week 2019 by highlighting one of the greatest challenges in the kidney world: its progression toward becoming an “aging field.” United States medical graduates pursuing careers in nephrology have declined precipitously (1) over the past few years. Among the top reasons for this declining interest are misperceptions that care of patients with ESKD is too complicated (1,2), lack of a particular procedure, earning potential, job opportunities, financial debt, family considerations, and geographical constraints, among others (2–34). These perceptions and declining interests usually start as early as medical school, where the foundational concepts underlying the pathophysiology of the kidney are often not adequately laid. This could spiral into the undesirable consequences that follow, including disheartening inpatient elective experiences (2) and scanty opportunities to explore the various dimensions of nephrology, a rotation that is not deemed compulsory in some medical schools in the United States. Of all the worrisome elements, one of the main reasons underlying the fundamental basis of the recent decline in choosing nephrology is the lack of a role model early in the trajectory of one’s medical career (5). The American Society of Nephrology (ASN) recognizes the need of having a good role model in a field such as medicine, where multiple specialties exist and it can be overwhelming to make career-related decisions. ASN has initiated a series of programs aimed at renewing interest among students and residents in nephrology careers and research, with an aim to ensure there will be enough well trained nephrologists caring for the growing kidney disease population (1). One such mentor-focused initiative introduced by the ASN in 2017 was the Kidney STARS (Students and Residents) program, of which I had the pleasure of being part of in Kidney Week 2019. The main objective of the Kidney STARS program is to stimulate and nurture the interest of undergraduate, medical, and graduate students, and residents in nephrology. In 2019, Kidney Week hosted an impressive total of 283 recipients of the STARS award, representing numerous countries including the United States, Canada, Mexico, Germany, United Kingdom, Brazil, China, Italy, Netherlands, Lebanon, Japan, and the Philippines. The STARS program selects a diverse group of trainees with one thing in common: a preexisting interest, or a keenness to develop an interest, in nephrology. The program is designed in a way that it clusters students (groups of eight to ten) and pairs them with a faculty mentor (clinician or physician scientist) and a fellow mentor (part of ASN’s Karen L. Campbell, PhD, Travel Support Program for Fellows). Each group is encouraged to attend a few events throughout Kidney Week together, led by the mentors. In 2019, I attended Kidney Week for the first time as an ASN STARS recipient. With an impressive turnout of 14,000 attendees, the experience of such large-scale conferences can be overwhelming and, to an extent, frightening. Interactions and communications initiated by mentors and other trainees before Kidney Week were extremely beneficial at reducing the anxiety that accompanies a young trainee stepping into a 2,300,000 square foot convention center. Email threads with preliminary introductions and a welcoming breakfast to put a face to names provided a sense of comfort, with time to bond and structure group activities for an enriching week. I thoroughly enjoyed the discussion-based activities, including attending select sessions with new mentors. Having immediate access to, and the availability of, an expert in the field to answer queries is an effective way to improve understanding and spark further interest in kidney diseases. Likewise, having mentors navigate you through the poster exhibition (which showcases thousands of posters) not only helps expedite the process of covering the majority of these posters, but also facilitates conversation by exposing students to the most current research, spearheading nephrology. As our group passed through the exhibition aisles, I spent most of my time appreciating the posters on prediction of AKI outcomes, my area of interest. The efficiency with which we can predict outcomes after AKI and tailor management has been studied by various groups, using elements such as α1 antitrypsin protein biomarker, predictive cox regression models and clinical parameters such as preoperative urine–specific gravity. This is the beauty of science: different groups, different countries, different approaches to the same disease outcome, all trying to put together pieces of a larger jigsaw puzzle. In addition to these activities, each group is encouraged to attend a focused career guidance panel. These panels are led by experts in nephrology, opening the floor to all questions regarding research, clinical, and academic career pathways. In my opinion, receiving advice from the accomplished nephrologists with similar career trajectories, alongside hearing past and future plans of like-minded trainees, wasthe most beneficial component of the program. Whether it was the relief that I am not alone in the struggle, that not everyone has it all figured out, or the encouragement of the panelists, I gained valuable perspective into my career-planning decisions and left the session feeling refreshingly determined. The closing lunch of the program offered another interactive session with representatives from the American Association of Kidney Patients present to answer queries raised by students about patient health and personal experiences. This session was another prime example of informing trainees of the many dimensions of nephrology, including patient care. The insight I gained during this session was invaluable, as a substantial amount of my current projects involve patient care and follow-up. One of the patient representatives emphasized the importance of transparency in health care, alongside facilitating patient understanding. From a researcher viewpoint, his concerns and suggestions for increasing physician–patient communication in every aspect of health care, including research and academia, greatly resonated with me. Often in the research world, especially when working on protocols that do not involve patient interaction more than the extent of a verbal consent to collect their urine, we may overlook the fact that a patient is entitled to answers and explanations. In a project that I was recently a part of, I had drilled into my daily consenting routine to end the interaction with “Don’t worry, you won’t be seeing us again” to reinforce to the patient that we are just here for collection and not changing their plan of care. Now that I look back, that approach was wrong. The patient may want follow-up from their research team, and us dismissing this possibility can do substantial harm for future physician–patient and/or hospital encounters the patient has. Thus, I brought the patient’s suggestions back with me, and every time I collect a blood or urine sample from a patient for research purposes, I now make sure to spend some time with the patient going over what we will do with the specimens and how it will benefit us, as well as the patient. As a medical trainee at the rim of starting clinical training after some time doing research in kidney disease, the mentor-driven and education-focused STARS program has significantly contributed to my career decisions. Personally, I believe that guidance through excellent mentorship and having an integrative, encouraging environment is crucial to a successful career. My mentorship at Yale University is outstanding, and STARS highlights that mentorship and promoting education are the fundamental basis of the kidney world. I feel more confident knowing now that, no matter where I end up, I will be supported by nephrology mentors and continue to receive excellent training. The introduction of programs such as STARS, allowing early and consistent exposure to the field of nephrology, expanding faculty participation in mentoring, and inviting students from all realms of training to attend Kidney Week, are solid initiatives led by ASN. They have attempted to counteract declining student interest in nephrology by promoting this initiative among the budding generation of future health care professionals. These efforts, among many others, are crucial in recent times and abide by ASN’s mission statement to promote education and awareness in nephrology. The “time is now,” as our previous ASN president emphasized at last year’s Kidney Week, to bring about this change and enhance student interest and satisfaction in nephrology. Disclosures The author has nothing to disclose. Funding None.

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