Renal medicine, otherwise known as nephrology, is the study of the kidney, an organ that has many functions and roles that intertwine with multiple different body systems. Work as a renal doctor therefore requires a varied knowledge and offers rewarding career opportunities.
The Role Of a Renal Doctor:
Nephrology encompasses many aspects of general medicine. A complex and vulnerable organ, the kidney can be affected by multiple pathologies, including hypertension, liver failure, sepsis, diabetes plus many more.
This makes work as a renal doctor a challenging environment and attracts those with a passion for physiology and an aptitude for problem solving(1).
The career offers a fine balance between the acute care of severely ill inpatients with acute kidney injury (AKI) and developing relationships with those who suffer from more chronic kidney conditions in outpatient clinics.
Continuity of care remains an attractive prospect in renal medicine when caring for those requiring dialysis for end stage renal failure and transplant recipients. Due to the range of conditions, doctors will work in a large multidisciplinary team, communicating effectively with doctors from different departments, transplant surgeons, nurses, dieticians, and social workers2.
Though a medical specialty, nephrologists should be competent at imaging techniques such as ultrasound, and interventional procedures such as central vein catheterisation, renal biopsy and insertion of dialysis catheters.
The increasing numbers of patients suffering from chronic kidney disease (CKD)3 requiring dialysis and/or renal transplantation means the numbers of renal doctors will need to follow suit.
A constantly evolving specialty, many aspects of renal medicine are still to be elucidated, with much still to be discovered in terms of understanding the relationship cardiovascular risk and CKD, as well as research into the optimisation of renal replacement therapy (RRT).
A Typical Week:
The working life of a renal doctor is highly variable depending on the specialist area of interest. Consultants can expect to run several outpatient clinics a week which can be general nephrological issues or focused on specialist issues such as transplant clinics, vasculitis, or polycystic kidney disease (PKD). Those specialising in RRT and haemodialysis will routinely visit dialysis units, whether in the hospital or satellite.
Irrespective of subspecialty, time will be spent in the renal units looking after acutely ill patients as part of the inpatient ward team. It is also not uncommon to be asked to see patients in different hospital wards with suspected renal issues requiring expert advice. On-call rotas are organised to look over the care of inpatients out of hours.
Usually consultants can be expected to be on-call for a certain period of time ie. 1 week in 10; with the rota divided amongst the number of renal consultants at the unit. Accordingly, the percentage of on call work depends on the size of the unit and the number of other consultants. Specific time will also be set aside for multidisciplinary team meetings regarding patients as well as supporting professional activities like teaching and admin4.
The Route To Becoming A Renal Medicine Consultant:
After the completion of medical school and two years of foundation training, the first step to becoming a consultant nephrologist is to apply for core training. There are two possible pathways for core training; internal medical training (IMT) and acute care common stem (ACCS) in acute medicine which are both 3 years in duration.
IMT replaced core medical training (CMT) from August 2019. In 2019, there were 2,229 applications for 1,563 positions across the UK for core training5. The completion of either pathway, as well as passing the MRCP (UK), renders you eligible for further specialty training in nephrology.
IMT vs ACCS
The newly revised IMT curriculum aims to produce doctors with the generic professional and specialty specific capabilities needed to manage patients presenting with a wide range of general medical symptoms and conditions. It will include mandatory training in geriatric medicine, critical care and outpatients.
Doctors with a strong interest in the ‘acute’ end of the general medicine spectrum and management of the sick patient should consider ACCS. The first two years of ACCS are spent rotating through Emergency Medicine (EM), Acute Internal Medicine, Anaesthetics and Intensive Care Medicine (ICM), followed by a third year spent in general medical specialities(6).
After completing core training, it is time to apply for the UK wide national recruitment process into specialty training (ST3). Compared to core training, applications are more competitive with 150 applicants for 66 posts in 2019.
Specialty training in nephrology will last a minimum of 3 years during which you must pass the European Specialty Examination in Nephrology (ESENeph) exam as a summative assessment of knowledge. Under the new IMT curriculum this will lead to a dual certificate of completion of training (CCT) in both renal medicine and internal medicine.
There are many subspecialties in which renal medicine consultants can develop a special interest in. The growing field of RRT offers subspecialties such as haemodialysis, peritoneal dialysis and transplantation.
On the more acute end of the spectrum, acute kidney injury (AKI) is an area which is still to be discovered as it is still associated with a high mortality rate, particularly in intensive care unit (ICU) patients7.
Those with a special interest in acute kidney injury, have the opportunity to combine renal medicine and intensive care medicine during training to get a dual CCT. A career in renal medicine is often accompanied by a strong academic tradition, a small number of trainees enter the clinical academic training pathway combining their clinical work with research and teaching with the objective of obtaining an MD or PhD.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849. Salaries can be further enhanced with NHS excellence awards.
Renal consultants can also enhance their earnings by partaking in private practice alongside NHS work. A study in 2008 showed, on average, that working privately could supplement a consultant’s salary by about 25% of their NHS salary - a modest amount compared to other specialities such as plastic surgery and cardiology(8).
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
Top tips to get into specialty training:
Show interest early on - As a student try to maximise time in renal medicine by opting to do student selected components in this area. Consider becoming a student member of The Renal Association
Relevant rotation in foundation years - Apply for rotation in a relevant field to grow experience. If not renal medicine, then another relevant medical field
Develop a relevant academic portfolio - Keep your e-portfolio updated and try to get involved with clinical audits and research projects related to renal medicine. It is also worth trying to gain teaching and management experience.
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Maxwell A. So you want to be a Nephrologist. Ulster Medical Journal. 2010;154(3):79.
Renal medicine [Internet]. Health Careers. 2020 [cited 14 September 2020]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/renal-medicine
Coresh J. Update on the Burden of CKD. Journal of the American Society of Nephrology. 2017;28(4):1020-1022
Working life (renal medicine) [Internet]. Health Careers. 2020 [cited 14 September 2020]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/renal-medicine/working-life
Straining competition ratios 2019 - https://specialtytraining.hee.nhs.uk/Competition-Ratios
About ACCS [Internet]. Imtrecruitment.org.uk. 2020 [cited 14 September 2020]. Available from: https://www.imtrecruitment.org.uk/about-imt/about-accs
Truche A, Ragey S, Souweine B, Bailly S, Zafrani L, Bouadma L et al. ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients. Annals of Intensive Care. 2018;8(1).
Morris S, Elliott B, Ma A, McConnachie A, Rice N, Skåtun D et al. Analysis of consultants' NHS and private incomes in England in 2003/4. Journal of the Royal Society of Medicine. 2008;101(7):372-380.