Abstract
Rationale & Objective
Interest in nephrology fellowship training remains lower than in many other internal medicine subspecialties. Although prior studies have identified resident-defined factors influencing career choice, it is unclear whether nephrology program leadership accurately recognizes these influences. We evaluated leadership perceptions of factors shaping residents’ interest in nephrology and assessed concordance with previously reported resident priorities.
Study Design
National cross-sectional survey.
Setting & Participants
Program directors and associate program directors at Accreditation Council for Graduate Medical Education-accredited programs in the United States (July-December 2025).
Exposures
Leadership perceptions of factors influencing residents’ specialty choice, including financial compensation, work–life balance, prestige, stress, clinical exposure, and timing of subspecialty decision making.
Outcomes
Perceived deterrents and facilitators to pursuing nephrology and alignment with previously published resident-reported priorities.
Analytical Approach
Descriptive statistics summarizing categorical and Likert-scale survey responses.
Results
Sixty-two program directors and associate program directors responded, representing 50 programs across 25 states. Most perceived nephrology as intellectually stimulating (97%) but challenging (100%), with a medically complex patient population (79%). Leadership identified low financial compensation (75%) and work–life balance (63%) as leading deterrents, consistent with resident-reported barriers. Discordance emerged in 2 domains: only 22% of respondents believed subspecialty decisions are made during medical school, despite prior resident data suggesting earlier interest formation; and leadership did not view nephrology’s broad scope as a recruitment barrier, whereas residents may favor subspecialties with clearer role differentiation.
Limitations
The modest response rate of 32% raises the possibility of nonresponse bias. Findings reflect self-reported perceptions and were not contemporaneously linked to resident responses. The survey instrument was not formally validated.
Conclusions
Program leadership recognizes key economic and lifestyle deterrents. However, misalignment regarding timing of career decisions and specialty identity suggests missed recruitment opportunities. Earlier medical school engagement and clearer delineation of nephrology career pathways represent actionable strategies.
Index Words: Career decision-making, medical education, nephrology program, nephrology recruitment, nephrology training, workforce
Plain-Language Summary
Interest in nephrology careers has been declining, but most research has focused on what residents think. In this study, we explored how nephrology program leaders perceive the factors that influence residents’ career decisions. We surveyed program directors and associate program directors across the United States and compared their responses with findings from prior resident surveys. We found that although leaders correctly identified some key concerns, such as compensation and job stress, they also misjudged other factors, including the timing of career decisions and the appeal of certain aspects of the specialty. These differences suggest that recruitment efforts could be improved by better aligning with resident perspectives. Strengthening early exposure and clearly communicating the strengths of nephrology may help attract more trainees to the field.
The burden of kidney disease is growing and outpacing the workforce in the United States as the nephrology specialty continues to face recruitment challenges. This was reflected in the fact that only 66% of the 501 nephrology fellowship positions offered were filled, and 52% of training programs remained unfilled for the 2026 appointment year.1 Notably, these rates are significantly lower than those for other internal medicine subspecialties.
These persistent recruitment challenges raise broader concerns about the future of the nephrology workforce. Analyses by the American Society of Nephrology continue to document a sustained decline in the proportion of US medical graduates entering nephrology. This alarming trend underscores uncertainty about nephrology’s capacity to meet future clinical demand despite expansion of fellowship positions.2 These anticipated workforce shortages are likely to compromise access to specialized kidney care, a problem further accentuated by the growing burden of chronic kidney disease.3
Prior studies have identified key factors influencing trainee interest in nephrology, including financial compensation, work–life balance, and patient complexity. Building on this work, we previously conducted a national mixed-methods study of internal medicine residents across 26 training programs in 16 US States, with 415 respondents.4 Our study confirmed these above factors and identified several additional resident-defined factors, such as job stress and exposure to nephrology during training. It also highlighted potential mismatches between the specialty’s perceived strengths and residents’ career priorities. Collectively, these findings raised an important follow-up question: whether educational leaders accurately recognize the factors that residents identify as most influential in their career decision making.
In the present study, we surveyed nephrology program leadership (program directors [PDs] and associate program directors [APDs]) to assess their perceptions of the factors they believe influence residents’ interest in nephrology. We also aimed to determine whether these perceptions align with resident-reported priorities. By evaluating the concordance of perspectives between program leadership and residents, we aim to identify potential targets to enhance recruitment into nephrology.
Methods
Study Design
This cross-sectional survey study was informed by our previously published qualitative and mixed-methods investigations examining internal medicine residents’ perceptions of nephrology as a career choice4,5 and is reported in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines for web-based surveys. In the original work,4 qualitative findings were used to identify key domains influencing resident interest, which subsequently informed the development of a structured resident-facing survey instrument. The prior resident survey included 60 questions spanning demographics, career plans, exposure to nephrology, and perceptions of the specialty and served as the conceptual foundation for the present instrument. For the present study, this survey was readapted for nephrology PDs, preserving the original conceptual domains while modifying item wording to reflect PDs’ perspectives on the factors they believe influence residents’ interest in nephrology. The adapted survey consisted of 40 questions, the majority of which were structured as closed-ended items using predefined response options, including Likert-scale, single-choice, and multiple-choice formats. A limited number of questions allowed free-text or numeric responses, primarily for ‘other’ specifications and percentage estimates. The adapted survey instrument underwent an iterative piloting process before distribution. Initial pilot testing was conducted by a review panel that included nephrology faculty members, nephrology and postdoctoral fellows, and a biostatistician. Pilot participants independently completed the survey and provided structured feedback regarding clarity, relevance, and interpretability of survey items. Revisions were made based on aggregated feedback. The revised instrument was redistributed to the same group for additional review. After a second round of refinement, the survey was further evaluated in a group discussion format with faculty participants, and final modifications were made by consensus.
The final survey instrument consisted of multiple-choice and Likert-scale items designed to assess program leadership perceptions of factors influencing residents’ specialty selection and interest in nephrology. Survey content included domains related to educational exposure to nephrology, perceptions of the specialty’s intellectual and clinical characteristics, anticipated career opportunities, and factors believed to promote or deter resident interest. Respondents were permitted to skip individual questions, and all responses were collected anonymously using the secure REDCap web-based platform. The study was reviewed by the Cleveland Clinic Institutional Review Board and determined to be exempt. All study procedures were conducted in accordance with relevant institutional and ethical guidelines.
Participants and Survey Distribution
The survey was conducted between July and December 2025. Using publicly available information from the Accreditation Council for Graduate Medical Education (ACGME), we identified all ACGME-accredited nephrology fellowship programs in the United States. PD and APD email addresses were obtained from publicly accessible program websites when available. Programs for which no contact information could be identified were excluded. Eligible PDs and APDs were invited to participate via email which included a link to the electronic survey. Nonrespondents received up to 3 reminder emails, each sent at 1-week intervals. The survey was distributed to 196 PDs and APDs representing 145 of the 178 nephrology fellowship programs.
Statistical Analyses
Survey responses were summarized using descriptive statistics. Categorical variables were reported as percentages, and Likert-scale responses were analyzed descriptively. Descriptive analyses were generated using REDCap’s built-in reporting and summary statistics functions. No inferential hypothesis testing was conducted given the exploratory nature of the study.
Results
Respondent and Program Characteristics
A total of 62 program leadership respondents participated in the survey (individual response rate 32%), representing 50 training programs (program response rate 35%) across 25 states, including Alabama, Arizona, California, Georgia, Illinois, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, Missouri, Mississippi, North Carolina, Nebraska, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Washington, Wisconsin, and West Virginia. Among respondents who reported their role, 70% were PDs and 28% were APDs, with the remaining respondents reporting other roles (2%). Among respondents who reported the type of program affiliation, 87% were affiliated with university-based nephrology fellowship programs, while the remaining 13% were affiliated with community-based programs. Most programs were affiliated with large teaching hospitals (>500 beds; 82%). Program size varied, with 32% of respondents representing programs with >8 fellows, 37% representing programs with 5-8 fellows, and 31% representing programs with ≤4 fellows.
Program Leadership Perceptions
On Resident Perception of Nephrology
Most respondents perceived that residents find nephrology interesting (79%) and intellectually stimulating (97%). At the same time, respondents felt that residents associate nephrology with substantial clinical and cognitive demands, with all of them (100%) viewing it as a challenging specialty. Nearly all respondents felt that nephrology is associated with a high level of disease acuity (98%) and is perceived as stressful (93%). Additionally, a majority felt that residents perceive nephrology as involving a wide spectrum of pathologies (82%) and that the patient population can be difficult to work with (79%).
Regarding professional fulfillment, 87% of respondents felt that residents view nephrology as a field in which nephrologists can make a difference in patients’ lives, and 90% reported that residents perceive nephrology as offering opportunities to practice in an academic setting. Only 12% felt that residents view nephrology as offering a good work–life balance, and 12% felt that residents perceive financial compensation in nephrology to be good. Similarly, 16% perceived that residents view nephrology as a prestigious specialty, and 12% perceived that residents view nephrology as offering opportunities to perform procedures (Fig 1).
Figure 1.
Program leadership understanding of residents’ perception of nephrology. APD, associate program director; PD, program director.
On Drivers of Specialty Choice
When asked to identify factors they believe most influence residents’ specialty choice overall, respondents most frequently selected financial compensation (85%) and work–life balance (70%). Prestige or professional influence was selected by 27%, and stress of the job was selected by 22% of respondents.
On Deterrents to Choosing Nephrology
When asked specifically about deterrents to pursuing nephrology, respondents most frequently identified low financial compensation (75%). Additional commonly cited deterrents included work–life balance (63%), lack of prestige or professional influence (33%), high job stress (32%), and the difficulty of the nephrology patient population (25%) (Fig 2).
Figure 2.
Program leadership understanding of top resident deterrents to pursuing nephrology. APD, associate program director; PD, program director.
On Nephrology Education and Clinical Exposure
Respondents generally rated the quality of nephrology education favorably, with 88% reporting that the quality of formal nephrology education is good and 85% reporting meaningful interactions between residents and nephrologists. In contrast, perceptions regarding adequacy of exposure were less favorable, with only 48% reporting that nephrology clinical rotations during residency are adequate (Fig 3).
Figure 3.
Program leadership perception of the adequacy of exposure to nephrology.
On Timing of Specialty Decision Making
Respondents varied in their perceptions of when residents decide on subspecialty careers. Only 22% believed that residents make career decisions during medical school, whereas 73% identified residency as the primary period during which subspecialty decisions are formed. The remaining respondents (5%) reported uncertainty regarding the timing of residents’ specialty decision making (Fig 4).
Figure 4.
Program leadership understanding of timing of subspecialty decision making by residents. APD, associate program director; MS, medical student; PD, program director; PGY, postgraduate year.
On Mentorship and Career Choices
Most respondents (76%) reported being actively involved in mentoring residents regarding career decisions. When asked about who might discourage residents from pursuing nephrology, 66% of respondents felt that nonnephrologists do, with 31% reporting that nephrologists themselves can also discourage residents. Of the respondents, 93% indicated that they would choose nephrology again if given the opportunity.
Discussion
In this study, we compared nephrology program leadership perceptions with findings from our prior national survey of internal medicine residents, allowing direct assessment of concordance and discordance between these perspectives. Program leadership in this study demonstrated substantial awareness of several factors that residents have previously identified as shaping perceptions of nephrology and influencing specialty choice. Program leadership largely recognized nephrology as an intellectually challenging field and acknowledged that residents perceive the specialty as demanding, with high levels of job stress and a medically complex patient population. They also recognized that residents view nephrology as a field in which physicians can make a meaningful difference in patients’ lives, while simultaneously acknowledging concerns regarding the perceived low financial compensation. Collectively, these findings suggest that program leadership appreciates the dual nature of nephrology as both intellectually rewarding and clinically demanding, consistent with prior studies examining trainee perceptions of the specialty.2, 3, 4, 5, 6
Program leadership also correctly identified resident-reported deterrents hindering specialty recruitment. Compared with previously cited factors in our resident perceptions study, financial compensation, work–life balance, job related stress, and difficult patient population emerged as prominent considerations influencing specialty choice (Fig 1). This concordance suggests that program leaders have their ‘finger on the pulse’ with respect to many of the core challenges shaping residents’ decisions regarding pursuing nephrology fellowship training.
However, although nephrology’s wide spectrum of pathology was recognized by program leadership, it was not identified as a deterrent. Prior studies of internal medicine residents suggest that career interest is increasingly driven by subspecialties offering clearer role delineation and more distinct professional identities relative to general internal medicine. Roles perceived as broad, longitudinal, and overlapping with generalist practice are less attractive.6, 7, 8 This discordance may represent an underappreciated mismatch between program leadership perceptions and resident priorities that contributes to declining interest in nephrology. Additionally, program leadership appeared to overestimate the contribution of prestige as a deterrent. Although lack of prestige or professional influence was frequently cited by the leadership, prior studies suggest that prestige plays a comparatively smaller role in residents’ decision making than economic and lifestyle considerations.8,9 More broadly, this finding reflects a pattern in which program leadership may miscalibrate resident perceptions, overestimating certain negative aspects of the specialty while underestimating more favorable attributes. Similarly, although prior literature has emphasized inpatient-heavy exposure as a limitation in nephrology training, our findings suggest that program leadership may overestimate the extent to which residents perceive nephrology as predominantly inpatient. Together, these discrepancies highlight potential opportunities to better align recruitment messaging with resident perceptions.
Program leadership perceptions of nephrology education closely aligned with resident-reported views regarding the quality of education and clinical exposure. In the present study, program leadership generally perceived the quality of nephrology education to be high, strongly endorsing formal teaching and resident–nephrologist interactions. This finding aligns with prior work demonstrating that trainees value the intellectual content and educational rigor of nephrology.2,10 In contrast, program leadership expressed less favorable views regarding the adequacy of nephrology clinical exposure. They frequently perceived nephrology rotations and overall exposure during training to be insufficient, corroborating resident-reported concerns that limited or late exposure may negatively influence interest in the specialty.4, 5, 6,11 These findings suggest that although educational quality and specialty interactions are viewed positively, gaps in the quantity and timing of exposure remain a shared concern and represent a potentially modifiable factor in recruitment efforts.
One area of discordance between program leadership and residents relates to perceptions of the timing of subspecialty decision making. Although most residents ultimately make their subspecialty decisions during residency, our findings suggest that a substantial proportion report forming their preferences earlier in medical school, a period that may be underrecognized by program leadership. In the present study, fewer than 22% of program directors believed that residents decide on fellowship choice during medical school, with most identifying residency as the primary period of decision making. In contrast, in our prior national resident survey, approximately 45% of residents reported forming their subspecialty interests during medical school. This mismatch suggests that program leadership may underestimate the importance of early exposure to nephrology in shaping career interest. Prior work across multiple specialties has demonstrated that career intentions often crystallize during medical school, underscoring the importance of early and meaningful subspecialty exposure.12, 13, 14 Misalignment regarding the timing of career decisions has important implications for recruitment strategies, as efforts focused predominantly on residency-level interventions may miss a critical window during which many trainees have already excluded nephrology as a career option.
Limitations
The following limitations should be considered when interpreting these findings. First, this study captures program leaders’ perceptions of resident views rather than residents’ perspectives directly. As such, responses may be influenced by personal bias and may not fully reflect residents’ actual experiences or decision-making processes. Additionally, program leadership and resident data were not collected contemporaneously or linked at the program level. Second, and though typical of survey studies, the response rate was modest, raising the possibility of nonresponse bias and limiting generalizability. Third, although the survey instrument was informed by prior qualitative and mixed-methods work and underwent iterative piloting, it has not been formally validated, which may affect measurement precision. Finally, the cross-sectional design limits causal inference and precludes assessment of how perceptions may evolve over time, particularly in the context of ongoing changes in nephrology training, workforce dynamics, and health care delivery.
In conclusion, this study provides insight into how nephrology program leadership perceives the factors influencing residents’ interest in the specialty and highlights areas of alignment and misalignment with previously reported resident perspectives. Although leadership accurately identified several key deterrents, including financial compensation, job stress, and patient complexity, important discrepancies were observed. Program leadership appeared to overestimate certain deterrents, such as lack of prestige, while underestimating others, such as the broad scope of the specialty. In addition, leadership appeared to underrecognize the extent to which residents begin forming subspecialty preferences during medical school. These findings suggest that recruitment strategies may benefit from better alignment with resident priorities, including greater emphasis on early exposure to nephrology, as well as consideration of increasing subspecialization within the field or more clearly delineating areas of focused practice to better align with trainee preferences. Efforts to address these gaps may help optimize recruitment and strengthen the future nephrology workforce.
Article Information
Authors’ Full Names and Academic Degrees
Georges N. Nakhoul, MD, MEd, Amy S. Nowacki, PhD, Elias Bassil, MD, Joseph Hajj, MD, Corey Cavanaugh, MD, Remy Daou, MD, Crystal Gadegbeku, MD, Ali Mehdi, MD, MEd, and Jonathan J. Taliercio, DO.
Authors’ Contributions
GN conceived and designed the study, distributed the survey invitations, managed data collection, and drafted the manuscript. AN performed the statistical analyses. All authors contributed to survey development and interpretation of the results, critically revised the manuscript, and approved the final version for submission. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
None.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Data Sharing
Deidentified survey data are available from the corresponding author upon reasonable request.
Peer Review
Received February 20, 2026. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and the Editor-in-Chief. Accepted in revised form May 27, 2026.
Footnotes
Complete article and author information provided before references.
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