Comparing two models that reduce the number of nephrology fellowship positions in the United States

There has been a steady decline in the number of applications to nephrology training programs. One solution is to decrease the number of available fellowship positions. Proponents believe that training programs have grown too big but the method for reduction has not been established. This investigation analyzes two models that decrease the number of available training positions and compares them head-to-head to identify the least burdensome method by which this reduction should occur. In the survival of the fittest model (SotFM) fellowship positions are eliminated if they were unfilled in the National Residency Match Program's (NRMP) 2013 Specialty Match. In the equal proportions model (EPM) a formula is used to calculate a priority score using ESRD prevalence data from the 2013 USRDS Report and the geometric mean between a given jurisdiction's current apportionment (n) and its next position (n + 1). The least burdensome model is that which results in the (1) least number of jurisdictions losing fellow positions and (2) lowest percent reduction for any single jurisdiction. There were 416 nephrology positions offered and 47 unfilled in 2013. In the SotFM, 23 jurisdictions would sacrifice these 47 positions. In the EPM, 369 positions were apportioned (=416-47); only 9 jurisdictions would experience a reduction. The largest single-jurisdiction reduction in fellow positions was 67% (SotFM) and 50% (EPM). The EPM results in a less burdensome reduction of fellow positions nationwide. The EPM is a time-tested model that injects fairness into the painful process of reducing the total number of fellow positions across America.