A recent study appeared as an Article in Press on May 2, 2014 in the American Journal of Kidney Diseases (AJKD) entitled “Prospective Analysis of After-Hour Pages to Nephrology Fellows.” This was an audit of the after hour pages received by 6 nephrology fellows at the University of Rochester, lasting for 61 days and recording 615 after hour pages. This study was prompted by the underwhelming interest in nephrology fellowship, as demonstrated by 44% of nephrology programs that participated in the National Resident Matching Program being unmatched in 2014.
The results demonstrated that fellows had to return to the hospital on 64% of overnight calls, most after hour pages did not require any modification of the current patient care plan, and 50% of the after hour pages occurred after 10pm. Only approximately one third of the nights allowed for the ACGME-recommended 5 hour minimum of uninterrupted sleep.
This study implies that after hour pages are a major deterrent to those that are considering the field of nephrology. Concern over declining nephrology fellowship applicants has been an area of active interest that has been addressed in several studies as well as an American Society of Nephrology task force. Shah et.al surveyed 204 US adult nephrology fellows and found that the three top reasons why fellows were somewhat, slightly, or not at all satisfied with their career choice included poor income potential after graduation, poor job opportunities after graduation, and long work hours . Jhaveri et.al performed a survey of 714 internal medicine subspecialty fellows and when asked about what they did not like in nephrology, 35% felt that dialysis and transplant patients were too complicated, and another approximately 30% felt they did not have any role models in the field. The burden of after hour pages did not seem to be a factor in either of these studies.
Most other internal medicine high acuity subspecialties likely receive a similar number of after hour pages. The overnight consults likely involve the cardiology and gastroenterology services as well, since these fields also have urgent procedures and interventions that may need to be performed emergently overnight. A survey of these fellows may yield the same results with frustration in after hour pages, although in our institution the cardiology fellowship program utilizes an in-house call model, so the frustration with after hour pages is likely to be different. That being said, only 4.6% of gastroenterology programs and 1.6% of cardiovascular fellowship programs went unfilled, compared with the 44% of nephrology programs cited above. Further studies should be performed in order to determine this disparity.
Dwindling interest in nephrology needs to continue to be investigated. As the population continues to age and comorbid diseases such as diabetes mellitus and hypertension become more and more prevalent, there will be a rapidly expanding need for nephrologists. Clearly, the lack of fellowship applicants is a multifaceted problem with far reaching effects. Although the burden of after hour pages may play a part in frustration, there are likely to be a number of other factors that play a role in the increasing dissatisfaction within the field.
Anonymous Fellow in a US based Nephrology Fellowship