Are We Missing the Mark? Program Leadership Perceptions of Nephrology Career Choice.

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.