Burnout in Nephrology
An article on burn out in nephrology. The leaders of the ASN (the governing body for nephrology) have taken note of a high attrition rate and burn out rates among the practicing nephrology community. The salient highlights are:
- Also, in a recent Medscape Lifestyle Report, 47% of nephrologists reported burnout symptoms, which ranked the fifth most severe compared to 24 other specialties (
4).
- Many factors contribute to physician burnout: work hours, night/weekend calls, excessive bureaucratic tasks, and moral distress (
4,
5). Burnout is independently associated with job dissatisfaction, faculty/staff turnover, and reduced productivity.
- Fellows who would not recommend nephrology to others cited the heavy workload, low compensation, and difficult schedule as important factors among others. When looking for jobs, they ranked as “important or very important” the frequency of weekend duties/overnight calls and length of each workday (
7)
- Although interest and strong mentors have a positive influence on the decision to go into nephrology (
6), it is clear that many have concerns about the workload of such a career. Unfortunately, many fellows end up regretting their career choice, and it seems that barriers to work-life integration may play an important role.
-Nephrology fellowship training is known for being arduous, even among the internal medicine subspecialties. Because we manage critically ill patients, there are many times when a nephrologist is needed urgently to help a patient.
- Training programs that are biased toward inpatient rotations should review rotation structure and consider increasing the balance between outpatient and inpatient experiences.
Burnout is rising in prevalence in all medical specialties. The initial thought of many older nephrologists is that the change in market forces, full capitation and bundled payments demanding fee for outcomes and not fee for service, would make nephrologists impervious due the extra demands because chronic HD has been this way for many years now.
However, HD patients do not fit an ACO model well. You can discharge early but how are you going to prevent readmissions? The primary issue is that patients who are non-adherent to fluid control (there are many good patients who can do it, but there are many who cannot do it) are the ones who end up in the hospital. Not to paint a picture of an incompetent HD unit to non-nephrologists, as nephrologists can ask the patient to do more ultrafiltration per session or even come in for extra sessions (CMS will pay for up to 17 sessions per month and with some patients with justification can be on a base 4x a week and provide reimbursements), but many times the patients cannot help it and end up with decompensated HF.
The squeeze between the "perfect world" that CMS demands and the dystopia that is ESRD care (not by anyone's fault, it's just the nature of the beast) are highly incompatible outcomes and place extra undue pressure on nephrologists which may contribute to stress in the workplace.
The mentorship and role model idea is a noble one. But short of becoming an academic nephrologists, maybe doing transplant, and doing research and getting grants and speakership honoraria (what do these all have in common? avoiding ESRD if possible), positive role models cannot do that much because at the end of the day, money talks. I am not saying everyone wants to sell out their patients and do unnecessary procedures on patients for a quick buck. Rather when you work as hard as cardiology (perhaps not as hard as EP or interventional cardiology, but general neprhology and general cardiology have a similar volume and complexity of patients, sans procedures in nephrology) and get paid a fraction and get no respect (e.g. nephrology vs CTICU ... often times nephrology becomes relegated to a dialysis technician who just places an order and CTICU dictates UF, duration, and potassium bath), it's hardly a wonder why community nephrologists are burning out.
