Why Nephrology Grads Cannot Expect To Earn The Same As Their Partners !

[Renal_Prometheus]

Years ago, I had a colleague who accepted a neph job out of fellowship and he was excited with the prospects. Although starting salaries were low(180K/year), within 3 years he will make partner, and according to what the partners told him, they average around 500K/year. Sounds great right? Fast forward to today and this friend has left that job and is working as a hospitalist. So what happened? From my conversations with him, his partners actually didn’t lie to him, they just didn’t tell him he would make the same as them.


Let me give you 2 other examples of real life people. Names are erased for anonymity. I’ve been privy to their situation because we still communicate with each other to this day.


Friend A: This friend took a job in a large city with one of the dominant groups(20+ nephrologists in the group). Starting around 170k/year with partners making over 400k/year. Partners share in the JV(dialysis unit and access center) and dialysis billing, sounds very equitable on paper right? This group had no history of exploiting new grads and not making them partner. Sounds very fair, on paper. In the first year, he noticed something very wrong with distribution of hospital coverage. While the senior partners were stationed in large hospitals with large patient census, the new guy was given the task of “conquering new territory”. So basically he was driving to 6-7 hospitals/LTAC per day seeing 3-4 patients per place. He could never get a foothold in one place with large patient census. Very quickly, he realized that even if he made partner, his billing would never be at the same level as his partners. And since nephrology reimbursement is based on volume, it was just not worthwhile to keep doing this, so he quit. Since my friend left this group, they have hired couple of new grads and those have quit within 1-2 years as well. But when they recruit new fellows, they can say people quit on their own for “personal/family reasons.” It’s not because the group didn’t make them partner.



Friend B: This friend took a job in a medium sized city with the largest nephrology group in town(12 nephrologists). During recruitment, the senior partner told him that starting salary was 200k/year for 3 years, but that “he” personally took home over 500k/year as partner. Sounds great right? Wrong; my friend assumed that he would make the same once he made partnership and that was completely incorrect. Within couple of years, friend B realized that he was working significantly more and making less than a hospitalist on a per hr basis. What was the issue? About half of the income generated comes from joint venture investments in dialysis units. And while the senior partners kept the profitable units to themselves, they gave him the less profitable dialysis units to invest. So not only did this guy had to take out a huge loan to invest, his return on cash was “so so” at best. He was so sick of it at the end that he quit to take a hospitalist job. He’s currently making over 400k/year, working 22 days out of the month, and is much happier. The devil is in the details and new graduating fellows simply are not equipped to negotiate the complexities of nephrology practice revenue distribution.



I’m saying all this not to dissuade any applicant from applying to nephrology if they are truly interested. The problem I see today is that nobody is telling the applicant the downsides, which can cause severe career damage for those investing this many years to potentially be worse off than a hospitalist. Do you think that fellowship programs, so eager to get bodies for scut work, will tell you this? Or do think recruiting nephrology groups will tell you that joining their group is a “trap”. What’s unfortunate is that an applicant will look at the average nephrology salary online, and think it’s pretty good, and will go into the specialty based on that. What they don’t realize is that it’s average the of the “winners”, while the losers who have left the specialty are not included. There is a survivorship bias in the stats. I think most graduating fellows will give it a go at a nephrology job just based on sunken cost fallacy alone. But just because they joined a nephrology group, doesn’t mean they will remain a nephrologist long term. If you ask me, based on what I see and my personal experience, I would venture to guess that 30-50% of neph grads will leave this specialty within 5 years of graduation. Don’t be fooled when fellowship programs tell you 100% of their grads were successful in getting a neph job; they just won’t tell you what percent are still practicing nephrology. Best of luck to all future nephrologists!

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[Tenesmus83]

Years ago, I had a colleague who accepted a neph job out of fellowship and he was excited with the prospects. Although starting salaries were low(180K/year), within 3 years he will make partner, and according to what the partners told him, they average around 500K/year. Sounds great right? Fast forward to today and this friend has left that job and is working as a hospitalist. So what happened? From my conversations with him, his partners actually didn’t lie to him, they just didn’t tell him he would make the same as them.


Let me give you 2 other examples of real life people. Names are erased for anonymity. I’ve been privy to their situation because we still communicate with each other to this day.


Friend A: This friend took a job in a large city with one of the dominant groups(20+ nephrologists in the group). Starting around 170k/year with partners making over 400k/year. Partners share in the JV(dialysis unit and access center) and dialysis billing, sounds very equitable on paper right? This group had no history of exploiting new grads and not making them partner. Sounds very fair, on paper. In the first year, he noticed something very wrong with distribution of hospital coverage. While the senior partners were stationed in large hospitals with large patient census, the new guy was given the task of “conquering new territory”. So basically he was driving to 6-7 hospitals/LTAC per day seeing 3-4 patients per place. He could never get a foothold in one place with large patient census. Very quickly, he realized that even if he made partner, his billing would never be at the same level as his partners. And since nephrology reimbursement is based on volume, it was just not worthwhile to keep doing this, so he quit. Since my friend left this group, they have hired couple of new grads and those have quit within 1-2 years as well. But when they recruit new fellows, they can say people quit on their own for “personal/family reasons.” It’s not because the group didn’t make them partner.



Friend B: This friend took a job in a medium sized city with the largest nephrology group in town(12 nephrologists). During recruitment, the senior partner told him that starting salary was 200k/year for 3 years, but that “he” personally took home over 500k/year as partner. Sounds great right? Wrong; my friend assumed that he would make the same once he made partnership and that was completely incorrect. Within couple of years, friend B realized that he was working significantly more and making less than a hospitalist on a per hr basis. What was the issue? About half of the income generated comes from joint venture investments in dialysis units. And while the senior partners kept the profitable units to themselves, they gave him the less profitable dialysis units to invest. So not only did this guy had to take out a huge loan to invest, his return on cash was “so so” at best. He was so sick of it at the end that he quit to take a hospitalist job. He’s currently making over 400k/year, working 22 days out of the month, and is much happier. The devil is in the details and new graduating fellows simply are not equipped to negotiate the complexities of nephrology practice revenue distribution.



I’m saying all this not to dissuade any applicant from applying to nephrology if they are truly interested. The problem I see today is that nobody is telling the applicant the downsides, which can cause severe career damage for those investing this many years to potentially be worse off than a hospitalist. Do you think that fellowship programs, so eager to get bodies for scut work, will tell you this? Or do think recruiting nephrology groups will tell you that joining their group is a “trap”. What’s unfortunate is that an applicant will look at the average nephrology salary online, and think it’s pretty good, and will go into the specialty based on that. What they don’t realize is that it’s average the of the “winners”, while the losers who have left the specialty are not included. There is a survivorship bias in the stats. I think most graduating fellows will give it a go at a nephrology job just based on sunken cost fallacy alone. But just because they joined a nephrology group, doesn’t mean they will remain a nephrologist long term. If you ask me, based on what I see and my personal experience, I would venture to guess that 30-50% of neph grads will leave this specialty within 5 years of graduation. Don’t be fooled when fellowship programs tell you 100% of their grads were successful in getting a neph job; they just won’t tell you what percent are still practicing nephrology. Best of luck to all future nephrologists!

Thank you for providing incredible insight to the SDN community. What you say mirrors the neph situation in my area.

 

[Prehealth1011]

@Renal_Prometheus Every salary survey shows Nephrology grads outearning general IM pretty easily. Is this because it takes into account the salaries of older Nephrology docs who are already partners?

 

[Renal_Prometheus]

@Renal_Prometheus Every salary survey shows Nephrology grads outearning general IM pretty easily. Is this because it takes into account the salaries of older Nephrology docs who are already partners?

like I said in my post. This is a survey of the winners. The losers, new grads without investments in dialysis unit JV and medical directorships, who have left the specialty, are not included in the survey.

 

[Costco]

like I said in my post. This is a survey of the winners. The losers, new grads without investments in dialysis unit JV and medical directorships, who have left the specialty, are not included in the survey.

This was an interesting paradox that I could not resolve until now. Thanks.

 

[Renal_Prometheus]

This was an interesting paradox that I could not resolve until now. Thanks.

You are welcome. I hate to see any more young people suckered into this specialty only to figure out years later it was all an illusion. Too much damage has been already done to those who believed that there was hope in this specialty. I wish no more harm to be done to anyone, anymore.

 

[tacowithgreensauce]

i am thankful for these types of post and think they are under-appreciated.

 

[Renal_Prometheus]

Let me drop another nugget of wisdom on nephrology practice revenue generation. This is from my own experience as well as verification with friends from other groups. Generally speaking, if you have no medical directorship money or dialysis unit joint ventures(JVs), your take home pay is roughly 250k-300k/year for a full time nephrologist. That's right, In the range of a hospitalist salary, without the 6 months off. If you add your collections(hospital+clinic+dialysis rounds) minus overhead expenses, 250-300k/yr is what you can expect. Groups supplement their income with medical directorship money, but what if your partners doesn't share that with you. There are plenty of groups like that. You start to see how new graduates will go back to hospitalist once they figure out it's not worth their time? Oh you want to joint venture in a new dialysis unit? There aren't any opening up, and the existing JVs your older partners are not gonna share in that revenue because they bought in years ago. Oh wait, there is a new dialysis unit opening up?, congratulations, why don't you go take out a loan and maybe you will make back your principal investment in 7 years. You guys see where I'm going with this? And this is all assuming(big assumption), that after getting payed starting salary of 200k/year for several years, your group doesn't take advantage of you and tell you to go take a hike. It's very common to see in a group, both equal partners, that the older partner make 500K/yr(multiple JVs/medical directorships) and the younger partner with nothing makes 250-300k/yr. The younger partner will usually leave and go back to hospitalist at some point. Meanwhile fellowship program will continue to market how much nephrologists make a lot of money(referencing older nephrologists with multiple sources of revenue from JVs and real estate). The younger grad simply cannot to expect to make the same because there are no new dialysis units opening up, or very limited growth potential. You guys don't be fooled by the MGMA nephrology salaries, it's a survey of the winners; the losers have left the game. One more thing, If you are doing neph for the money, you have been misled by forces acting in their best interest and not yours. Fellowship programs need bodies for scut work. Why do you think the specialty is so noncompetitive? Don't torture yourself just to find out that you were be used by the fellowship program, and then by your partners only to work harder and make less than a hospitalist. Passion and interest will not feed your family or pay your mortgage. The competitiveness of a specialty is always a reflection of financial realities on the ground. Don't end up hurting yourself just to be a sub-specialist!

 

[cardsperson]

I like these posts because, while I'm not a nephrologist, I think it's important to be aware of market forces as a whole. The only question I have as an outsider, one who was a hospitalist prior to going into cardiology, is why fellowship-trained young nephrons would go to hospitalist, when the pay is about the same and the work is probably more challenging (not intellectually, but the fact that you're primary and have to juggle a lot of balls for each patient instead of being able to focus on one specific problem)?

 

[NewYorkDoctors]

Nephrology fellowship call is really brutal . Depending on number of fellows , it’s usually q4 call . No night float system except the larger programs . Each call is brutal . The renal attending expect you to see every single consult overnight. Increase those RVU s. Not just the urgent HDs (which must be seen stat and arranged for stat ) but also any akivor hyponatremia that’s not on the medicine service because of fear of mismanagement and blame .

you can’t imagine how many times I trekked in at night for BS fluid overload on bipap. And by law a fellow or attending must be present for the beginning of the dialysis to bill. Then no early dismissal .
Most in hospital consults are so boring . No thinking involved . A PA is all you need for hd , crrt , cardiorenal ayndrome consults .

the CTicu is also the worst . They pretty much want crrt for all of their ckd or esrd patients post cabg because of the fluid and electrolyte abnormalities postoperative . I get it . It’s an elective procedure and all steps should be taken. But while the ct intensivist wants full control of crrt (and I often ceded the point ) , the renal attending mad EMR schlep in all odd hours of the night to “start crrt “ which was merely write and order and a note. Then the intensivist takes over and I get a lecture in the morning about how a nephrologist needs to take over crrt and gain respect . Seriously ?
One night on call awhen I was rather ill I missed a call from cticu . Hence attending was called directly . Guess what happens? Order written from home without attending nephrologist going in . Wonderful .

the outpatient HD unit rotation is a big farce . A PA could follow the algorithm there . Plus it’s free primary care . Patients sit there for 3-4 hrs each and when you do HD rounds decide to bring up their back pain and other primary care nuisances for which you cannot bill for on HD . So many Zpaks written by the “leave me alone” dialysis doctor .

night call for transplant is also a bear ...

While Ccu and micu overnight can also be tough , at least it’s an in house fellow in a night rotation

for all applicants to renal fellowship , make sure you go full academic and Cush otherwise stay away from this trap .

 

[Renal_Prometheus]

I like these posts because, while I'm not a nephrologist, I think it's important to be aware of market forces as a whole. The only question I have as an outsider, one who was a hospitalist prior to going into cardiology, is why fellowship-trained young nephrons would go to hospitalist, when the pay is about the same and the work is probably more challenging (not intellectually, but the fact that you're primary and have to juggle a lot of balls for each patient instead of being able to focus on one specific problem)?

Because you would make more as a hospitalist. The number of hrs you are working as a nephrologist, If you work the same number of hrs as a hospitalist you would make more. Plus you don’t have to run between multiple hospitals per day and take night calls.

 

[Renal_Prometheus]

This is to prove that I'm not making this up. Exploitation by older partners is a common theme in nephrology. And it's more prevalent today because practice revenue is declining overall and many groups rely on trapping a non-suspecting new grad and offer nothing but empty promises. So if you don't have the stomach to do 2 yrs of fellowship, plus 2-3 yrs of indentured servitude for 200k/yr, and come out with nothing, please don't do this fellowship.


The Choices We Make Dictate The Life We Lead

excerpt from the article:

"They have heard horror stories from their more experienced peers not being offered partnership, or not getting the Medical Directorships promised or not being allowed to participate in joint venture opportunities. As one nephrologist three years out of training put it, “There is greed in nephrology; many of the older physicians do not want to share and ultimately, they do not. There is a lack of stability for fellows going into practices and no guarantees that after all your efforts that you will get a fair shake.”

He believes this concern is another factor as to why residents are not going into the specialty or nephrologists coming out of training choose an employed Hospitalist position. These thoughts or similar have been shared by numerous nephrology fellows interviewed (all of which request anonymity for obvious reasons). There are nephrology practices out there that have a reputation for hiring, working people unfairly and then firing them without offering anything. In other cases, there are limited opportunities to joint venture and many practices in popular locations have the bulk of their units already opened with limited growth available. These are issues the residents and fellows are wrestling with that make the decision to go into nephrology a difficult one. "

 

[NewYorkDoctors]

This is to prove that I'm not making this up. Exploitation by older partners is a common theme in nephrology. And it's more prevalent today because practice revenue is declining overall and many groups rely on trapping a non-suspecting new grad and offer nothing but empty promises. So if you don't have the stomach to do 2 yrs of fellowship, plus 2-3 yrs of indentured servitude for 200k/yr, and come out with nothing, please don't do this fellowship.


The Choices We Make Dictate The Life We Lead

excerpt from the article:

"They have heard horror stories from their more experienced peers not being offered partnership, or not getting the Medical Directorships promised or not being allowed to participate in joint venture opportunities. As one nephrologist three years out of training put it, “There is greed in nephrology; many of the older physicians do not want to share and ultimately, they do not. There is a lack of stability for fellows going into practices and no guarantees that after all your efforts that you will get a fair shake.”

He believes this concern is another factor as to why residents are not going into the specialty or nephrologists coming out of training choose an employed Hospitalist position. These thoughts or similar have been shared by numerous nephrology fellows interviewed (all of which request anonymity for obvious reasons). There are nephrology practices out there that have a reputation for hiring, working people unfairly and then firing them without offering anything. In other cases, there are limited opportunities to joint venture and many practices in popular locations have the bulk of their units already opened with limited growth available. These are issues the residents and fellows are wrestling with that make the decision to go into nephrology a difficult one. "

And there is NOTHING the ASN can do about this. The ASN cannot change the behavior of PRIVATE nephrologists. But ultimately this is not an issue with the DISCIPLINE of Nephrology itself. Nephrology sold out chronic HD to corporate interest years ago. So this is just the end product of hyper-capitalism. Always drive a profit for those at the top and cut corners everywhere. Soon all of medicine will be like this... the only reason why the Cardiologists still do their own procedures is because the AHA have GREAT LOBBYISTS in Washington D.C. Otherwise interventional radiology would be doing cardiac caths. The nephrologists gave all their rights and HD centers up years when they sold out to Davita and Fresenius. Why? Greed.. why else? That and poor planning for future generations. Sounds like a capitalist to me. Note I am not a full blown socialist. But I do believe that the natural end product of capitalism is corporatism. The dialysis-industrial complex is a "subspecialty" of the medical industrial complex.

 

[Renal_Prometheus]

As you can read from this article, nephrology graduates returning to hospitalist work is all too common. But I'm sure these
people were promised amazing career opportunities when they went for their fellowship interviews. My point is, don't believe
what people say; believe what people do.

COVID-19 takes a toll on recruiting renal fellows

Nephrology News and Issues | With the most recent delta variant – and the potential for others to follow – the coronavirus has made hospitalization rates and high death tolls a way of life. There is nothing in the foreseeable future that makes one believe things will get back to normal anytime...

www.healio.com

 

[Schroed]

My nephrology fellowship was awesome. Had one of the best times in five years of training (3 yr IM and 2yr nephrology). Post-fellowship was difficult because I joined a small screwy practice with partners who I didn't want to grow up to be like. So, I left, became a hospitalist for a few months and joined a bigger nephrology group. My personal experience was that nephrology paid better than nocturnist/hospitalist per hour. So, not sure where the complaint about nephrology is coming from... I paid off my $280k student loan in less than two years post-nephrology fellowship. I still plan on doing part-time nephrology after I finish the critical care fellowship. Nephrology is awesome.

 

[NewYorkDoctors]

Hello fellow renal intensivist . Glad you found the same escape from the grind of the chronic HD machine . Consider yourself lucky (as I do myself ) .

Regarding the pay is lower issue for nephrology , see renal Prometheus other posts . He outlines the issues quite well . He has real world experience regarding private practice nephrology . Doesn’t sound like you’ve been through that grind house (not that you need to)
Take an analogy . I am of Caucasian descent . if I said something like “I don’t see why those (insert ethnicity / race / sexual orientation ) people are complaining. I don’t have that problem “ you can see how that kind of comment is not very enlightened to others situations .


But your happy situation also sends a similar message that I have been sending . Renal is great as a medical discipline . But do CCM as an escape. It still goes back to the original issue of private practice nephrology is not a viable career for many graduates due to real world business factors. Read the posts .

 

[Chemist0157]

My nephrology fellowship was awesome. Had one of the best times in five years of training (3 yr IM and 2yr nephrology). Post-fellowship was difficult because I joined a small screwy practice with partners who I didn't want to grow up to be like. So, I left, became a hospitalist for a few months and joined a bigger nephrology group. My personal experience was that nephrology paid better than nocturnist/hospitalist per hour. So, not sure where the complaint about nephrology is coming from... I paid off my $280k student loan in less than two years post-nephrology fellowship. I still plan on doing part-time nephrology after I finish the critical care fellowship. Nephrology is awesome.

I did not have much issue with going PP. I can appreciate here that some people did. I'm not sure the disconnect. I have been suspicious of geography. Nice on the loans. Hopefully, I will join you in the next few months.

 

[Renal_Prometheus]

I graduated from neph fellowship in 2016. I would say the majority, 60% of my cofellows and friends who graduated around the same time have left this specialty. The ones who are still practicing nephrology are miserable, and I constantly get texts about how they feel trapped because they are not making that much money, but don’t want to admit failure by going back to hospitalist. Can people do well in nephrology? I’m sure there are some who can, but I personally do not think it’s the norm. I think the majority of post-partner nephrologists, when adjusted for income per hr, get payed about the same to a little bit less than a hospitalist. If PP was this great, why are there so many who try to escape to critical care? The specialty has financial risks that is unparalleled vs higher paying specialties. Let’s say you joined a exploitative group, and after 3 yrs of hard work, they tell that you that you didn’t make partner. So are you going to try another nephrology group, give them 3 more years of your life getting payed 200k/yr and hope you make partner? The financial harm is tremendous! It’s happened to several of my friends(see my original post). It has happened with enough frequency that someone has written an article about it(see above). So don’t tell me nephrology is all peaches and cream. These are things fellowship programs didn’t tell me and I suspect majority of my neph friends would not have gone into it if they knew the risks they were taking. Too much risks and not enough upside, that’s the reason people are dropping out like flies.

 

[Renal_Prometheus]

I did not have much issue with going PP. I can appreciate here that some people did. I'm not sure the disconnect. I have been suspicious of geography. Nice on the loans. Hopefully, I will join you in the next few months.

At least you are acknowledging now that some people don’t do well in nephrology. You remember me and you got into a heated argument years ago about the same issue and you refused to even acknowledge it back then. Remember, how you kept denying the fact that some neph programs fill spots with IMGs without a residency? Who was right in the end? Your perception of truth will change over time as more people step forward to share their experiences.

 

[Chemist0157]

At least you are acknowledging now that some people don’t do well in nephrology. You remember me and you got into a heated argument years ago about the same issue and you refused to even acknowledge it back then. Remember, how you kept denying the fact that some neph programs fill spots with IMGs without a residency? Who was right in the end? Your perception of truth will change over time as more people step forward to share their experiences.

I also remember you not listening to my perspective and being quite dismissive. Have you also grown since then? I'd prefer to make myself available to residents and fellowships with questions and concerns and focus less on the back and forth.

 

[Renal_Prometheus]

I also remember you not listening to my perspective and being quite dismissive. Have you also grown since then? I'd prefer to make myself available to residents and fellowships with questions and concerns and focus less on the back and forth.

I don't think there's argument that nephrology is a non-desirable, non-competitive specialty. I don't think there's any argument there. We are arguing over to what degree it is failing. I have presented my experience and I respect your experience. So my question to you is, if you convince a resident to go into nephrology with your positive personal experience. And that person years down the road, end up badly like some of the articles talk about, and ends up going back to being a hospitalist. Are you going to take responsibility for his/her career outcome? Or do you make recommendation, but take no responsibility for other people's outcomes?

 

[NewYorkDoctors]

I don't think there's argument that nephrology is a non-desirable, non-competitive specialty. I don't think there's any argument there. We are arguing over to what degree it is failing. I have presented my experience and I respect your experience. So my question to you is, if you convince a resident to go into nephrology with your positive personal experience. And that person years down the road, end up badly like some of the articles talk about, and ends up going back to being a hospitalist. Are you going to take responsibility for his/her career outcome? Or do you make recommendation, but take no responsibility for other people's outcomes?

Probably the latter . Does a doctor ever apologize to a patient for ordering a test (like 25 Vitamin D) that commercial insurance will not reimburse and then the patient gets a big bill for ? The patient brings the bill to show the doctor as if that Will make any difference ?

This is not a personal attack on medisaint . I am just saying that’s what anyone in a position of power would be do .

 

[Chemist0157]

I don't think there's argument that nephrology is a non-desirable, non-competitive specialty. I don't think there's any argument there. We are arguing over to what degree it is failing. I have presented my experience and I respect your experience. So my question to you is, if you convince a resident to go into nephrology with your positive personal experience. And that person years down the road, end up badly like some of the articles talk about, and ends up going back to being a hospitalist. Are you going to take responsibility for his/her career outcome? Or do you make recommendation, but take no responsibility for other people's outcomes?

Oh, I’ve found all of this to be more nuanced than that. That’s been our difference.

That last bit is a little bizarre. I would take as much responsibility as an anonymous person can for the inquiry of another anonymous person on SDN. If it makes you feel better, I would be more optimistic for someone who is from a good program that is supportive, and I’d probably tell a resident who is already desperate to probably go find something else to do…

 

[NewYorkDoctors]

Oh, I’ve found all of this to be more nuanced than that. That’s been our difference.

That last bit is a little bizarre. I would take as much responsibility as an anonymous person can for the inquiry of another anonymous person on SDN. If it makes you feel better, I would be more optimistic for someone who is from a good program that is supportive, and I’d probably tell a resident who is already desperate to probably go find something else to do…

If you were a nephrology program director , would you then ask your coordinator to send out cold calls and emails to unmatched cardiology and PCCm applicants or international trained nephrologists who have not yet done US internal medicine residency during then scramble if your program went unfilled ?

 

[Chemist0157]

If you were a nephrology program director , would you then ask your coordinator to send out cold calls and emails to unmatched cardiology and PCCm applicants or international trained nephrologists who have not yet done US internal medicine residency during then scramble if your program went unfilled ?

Since we are continuing to wade into hypotheticals and making this more personal towards me, I am going to add some points. Let’s say I am a nephrology program director. Program generally does well. Fellows come and go, and they do well. Over the years, a spot has occasionally gone unfilled, but we have been able to fill it with a reasonable candidate.

Now, given the unpopularity of nephrology, this is happening more frequently. This year, we actually have two unfilled spots. If I feel confident we can fill those spots, there is no problem. But what if I don’t? What if we are not going to fill unless I take poor candidates?

I would probably take the approach my program did one year. Adapt or die. Either faculty step up or hire PA/NP to offset the workload. At the end of the day, programs should not be so heavily reliant on fellows to make sure the patient care is done. It worked out well. It helped the program avoid entering a death spiral where applicants know they went unfilled one year, and it worsens from there.

I don’t think it’s wrong to reach out to those who did not match into other specialties if they have interest in nephrology and are good candidates. IMGs are already the majority of fellows. Taking someone with no residency is a joke and off limits.

 

[NewYorkDoctors]

don’t take things so personally . We are anonymous and on a message forum . No one knows who you really are and by your posts I surmise you are a hard working physician and does his her best . Your stance is reasonable and fair . Too bad not all PD follow your example .

 

[Chemist0157]

don’t take things so personally . We are anonymous and on a message forum . No one knows who you really are and by your posts I surmise you are a hard working physician and does his her best . Your stance is reasonable and fair . Too bad not all PD follow your example .

Fair.

 

[Renal_Prometheus]

Nephrology programs need to do some self reflection on why the specialty is so undesirable and focus their attention on tackling that. Instead of every year scraping bottom of the barrel for applicants and engaging in salesmanship that would put a car salesman to shame with the empty promises.

 

[Renal_Prometheus]

You expect fellowship programs to tell you the truth? The same ones who can't get fellows and have to "sell" nephrology. The only one telling you the truth is the market, where it's the least matched specialty. You can relive the horrors from applicants in the past. Nothing has changed in nephrology, only worse.

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Sample1:
The problem in nephrology is not single domain like job offer or visa candidates etc . the problem in nephrology it is collected all the disadvantage in one speciality . lake of jobs in general . rare jobs in big cities . the amount of driving and multiple places you need to go every day so it is not like working in one hospital and one clinic rather you will be covering 2-3 hospitals 20-30 miles a apart and 3-4 dialysis centers . also the very low starting salary like 170-180 and the very notorious partnership pathway in nephrology as most of the group will abuse the new nephrologist who join the group for 3 years just on hope of giving partnership at the end of the road if any . add to that all the newly graduated nephrologist who will join private groups will be worked like a dog regardless if you are a visa candidates or not , so it is a second visa waiver if you did one before . so I personally think visa is not a big issue here .passion wise . I don't think speciality like nephrology is being loved at the medical student level . that why very few local graduates go for nephrology . add to that the ESRD who keep missing HD and keep coming just to be redialysed again and again it is extremely frustrating and disappointing .most of the peoples went to nephrology are IMG from india , Pakistan Africa and middle east . most of those people debris of other fellowship failed to catch something better . all of them they think that nephrology after graduation like their original country where nephrologist work mainly in one hospital and one clinic . they don't know that they will work in 3-4 dialysis centers , 3-4 hospitals and 2-3 clinics .
The peoples who go for hospitalist represents 35-40% of nephrologist and many of them practiced nephrology for some years and they discovered that they can make 1.6 what they make in nephrology with working only 0.6 of what they used to work in nephrology . moving to hospitalist is not relevant to visa at all .and in general internal medicine you still see less frustrating patient than ESRD in nephrology . that is why hospitalist overcoming nephrology it is not jut the visa or money .
By the end of the day of you love nephrology and you want to compromise with all of your other life for it helped with the hope it may improve some a day no body know when (if any) .just go for it it is waiting for you .

Sample2:
I think the best idea with what happening in nephrology ( the doomed fellowship ) is to shut down the fellowship applications completely for 5 years during that the ASN need to restructure the whole nephrology profession in this country including restructuring the training programs to be academically oriented rather a slavery oriented.
Other ideas is to cancel nephrology as an independent fellowship and create a new pathways like one year fellowship for HOSPITALIST if they want to do some nephrology work beside HOSPITALIST and one year of nephrology for intensivist who want to do some nephrology work beside ICU . In this case nephrology work will be an add on and people will be still making their main income from something more satisfying than just doomed nephrology alone .

Sample3:
nephrology is dead - no question whatsoever about it.
as a hospitalist atleast your work is cut out for you. Nephrology, you have to go around with a begging bowl for your consults/referrals.. This is not going to change, as the old timers hire you, just a recruit for begging. they have no reason to retire as these guys will stay on directors for life for the dialysis unit - all they care is for you to provide bodies to dialyze.
this specialty has been dead for a while.
Program directors need you to be a glorified nurse practitioner(Fellow)- it is cheaper to hire a fellow than an NP . what awaits you on the other end is

A) being a slave to davita/fresenius
B) earn less than a hospitalist
c) begging all the primary care doctors/hospitalists for your consults

this is a dead speciality - DONT SEE IT AS AN ESCAPE from your hospitalist job. There is nothing more demeaning, than begging for consults. You will be slave to some guy who owns a dialysis unit and you work as a body supplier for dialysis.
Being a beggar is what this specialty has cut out for you. don't waste your life - no matter how much you love nephron or physiology - it is hard to beg every day.
Unless you want to be a beggar - don't waste your time
Don't care about what you guys do in the end. Only reason I post , is for you guys to know what it is out in real world.
Program directors know nothing or don't care - as they are not in real world.
Most of the nephrology fellows end up as hospitalists - why waste your time slaving for these programs ?
quit before you make the mistake of applying!!

Sample4:
Academic nephrologists begging candidates at scramble to fill fellowship positions : priceless

Sample5:
Going to nephrology fellowship nowadays remind me with butterflies attraction to fire phenomenon (phototaxis ) . do not worry guys I am sure all the applicants will join top name programs because those programs they do not have anybody to fill their positions . you guys after joining the fellowship be ready to work very very hard day and night for 2 years . after graduation at the end of the road you guys will be a great hospitalists .

Sample6:
Nobody here recruit for hospitalist all of us went to nephrology at some point because we did not like hospitalist and we thought hospitalist is not life long career but later we discovered that we ran away from fire( hospitalist) to volcano (nephrology) . I totally agrees that hospitalist is disappointing but believe it or not nephrology is 100 fold more disappointing than hospitalist and the worst of it when you hate hospitalist and want get ride of it then you go to nephrology full of dreams to become specialist then after 2 years you find your self working as a hospitalist again at that time you will feel how bitter it is .

If you think people here are just recruiting for hospitalist , so why you think we are just recruiting in this forum only ? did you ask your self if we go to other fellowships forums and say the same words do you think it will work or make any sense ? I am sure if you think about it well you will discover where is the problem .

Theoretically speaking if we are in a different world logism should say that being a specialist in nephrology is a lot better than being general internist ,however on ground in this area of the world general internist is more wanted, more earning, less working, less stressed and more happy than nephrologist .unfortunately now nephrology now is on the bottom of all medical specialities including hospitalist, primary care and geriatrics .

If you think hospitalist who works 2 weeks a month does not have time to see the mountain and lake in the advertisement . I am pleased to tell you that as a nephrologist you may not have a chance to see your self in the mirror .

Sample7:
This is probably the most important thing one can say to those who went unmatched in other fields.
Renal has become a joke. Fellowship positions need to be slashed if this speciality is to be saved.

Sample8:
I am currently in my second year of nephrology Fellowship and bit disappointed after my job interviews. Yes, Job situation is better than 2012-2013, but the amount of work to be done with a salary between 180-200 max is ginormous. Most places want 2 weekends to be covered (obviously after a 5 day work M-F). Job description with some employers i interviewed looks like i will have to see 15-20 inpatients and 7-18 outpatients Plus dialysis rounds (dialysis units) in certain days (unsure how many Pts) every day. When i interviewed as hospitalist it felt like a red carpet welcome, but some Neph employers made me feel like they are doing a favor by giving me a job. Most of them will not give a partnership until after year 2 or 3 or even 4. You will be employed for 2-3 years and after that there is no guarantee for partnership. They say if both parties mutually agree they will give partnership, which means that they can say goodbye to you after making you slog for 2-3 years and then again with another job you have to start from scratch. Hospital employed nephrology positions pay better with upto 300K salary but the amount of work is worse than what i have listed above including placing lines in night. Some fellowship programs are starting to train candidates who have no residency in US ( due to shortage of fellows) and some have plans to start fellowship where a week of hospitalist rounding is done so candidates don't suffer financially. With this said, there are going to be more nephrologists (Less demand and more supply is already an big issue). I felt like there are more jobs advertised, but when i call most of them are solo practitioners listing their job and they can't find anybody for years as people have joined and left to become hospitalists. When i went to ASN to interview with some large private employers, i was startled to see 20-30 graduates been interviewed for 2 positions. Joining with a solo practitioner is usually a disaster unless its your own family, so most candidates go for large private groups who have 30-100 physicians in 1-2 states. I don't want to sound kind of pessimistic here but there are certain advantages to do this fellowship. My knowledge of acid/base/ckd and even internal medicine has increased by many folds and am very happy how much i learned. But when it comes to the realities of finding a job am little disappointed. I feel doing academic nephrology is not a bad deal as you are on consult service only 3-6 months of year depending on the location and rest of year is research/CKD clinic which helps with a good lifestyle if you are ok with a paycut ( awesome option for e.g. Physician couples). Do not compare yourself with Hospitalist salaries who work for 6 months of year and base pay is around 250-280K (increased in last 3 years) with most employers+RVU=300-350K and more income if you take extra shifts on week off time. I will keep here everybody updated and i am kind of leaning back to becoming a hospitalist unless i find a reasonable job which i haven't so far. Well there a tons of nephrologists working as hospitalist anyways and i will be one of them. Inspite of all this, i don't regret doing fellowship as am a better physician now. Thanks for reading my post.

Sample9:

In a remote hospital - 4 nephrologists working as hospitalists and all private groups fighting with each other for consults/not have their patients seen by nephrohospitalists. Hospitalist groups dont want to employ anymore nephro trained people, to avoid the politics.

What a situation to be in !!! pathetic and we see absolutely no action from ASN or the programs. do a fellowship and diminish your chances even for a hospitalist job!!!

Sample10:
Nephrology has a terrible attrition rate . In my group of 3 fellows I know 2 are no longer practicing nephrology. Unfortunately because of the drop in quality applicants nephrology programs are resorting to picking up burnt out hospitalists or applicants who couldn't make it into competitive specialities and who then accepted a position without having any interest in nephrology . But then academic attending nephrologists don't want to see patients or get phone calls at night and therefore they keep taking substandard applicants.

I think if there were to drop the number of positions to about half i.e 150/200 the quality of applicants would automatically rise and then with the reduced supply job market prospects would improve , salaries would rise . But that will lead to pain for the training programs in the short run but with long term gain for the speciality. But it's not human nature to usually take short term pain for long term gain.

 

[Kaustikos]

You expect fellowship programs to tell you the truth? The same ones who can't get fellows and have to "sell" nephrology. The only one telling you the truth is the market, where it's the least matched specialty. You can relive the horrors from applicants in the past. Nothing has changed in nephrology, only worse.

Official 2016-2017 Nephrology Fellowship Application Cycle​

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I think if there were to drop the number of positions to about half i.e 150/200 the quality of applicants would automatically rise and then with the reduced supply job market prospects would improve , salaries would rise . But that will lead to pain for the training programs in the short run but with long term gain for the speciality. But it's not human nature to usually take short term pain for long term gain.

Curious about those going into Nephrology to try to get into Critical Care. Seems like it'd be easy for a Crit Fellow to do a 1 year Nephro fellowship but that at this point why would an ICU fellowship take a Nephrologist? Easier to train an intensivist to do the other than a Nephrologist to train in critical care.
Also, seems like Nephrology isn't the most in demand fellowship for Critical Care but it's actually Infectious Disease.
But, going back to my question, what's the overall success rate of Nephrologists trying this approach?

 

[Renal_Prometheus]

Curious about those going into Nephrology to try to get into Critical Care. Seems like it'd be easy for a Crit Fellow to do a 1 year Nephro fellowship but that at this point why would an ICU fellowship take a Nephrologist? Easier to train an intensivist to do the other than a Nephrologist to train in critical care.
Also, seems like Nephrology isn't the most in demand fellowship for Critical Care but it's actually Infectious Disease.
But, going back to my question, what's the overall success rate of Nephrologists trying this approach?

Low, because there are limited number of one year cc spots. And by the time you graduate, all of your neph colleagues have figured out neph was a trap and all of them will be applying to cc to save their careers. So stop wasting your time.

 

[Kaustikos]

Low, because there are limited number of one year cc spots. And by the time you graduate, all of your neph colleagues have figured out neph was a trap and all of them will be applying to cc to save their careers. So stop wasting your time.

What I figured. I've had several colleagues not matching into critical care trying this approach but it didn't make sense. I talked to them about ID and the increasing demand for ID trained folks in ICU but they wanted to take this approach. Spoiler alert; not working out.

 

[Renal_Prometheus]

What I figured. I've had several colleagues not matching into critical care trying this approach but it didn't make sense. I talked to them about ID and the increasing demand for ID trained folks in ICU but they wanted to take this approach. Spoiler alert; not working out.

Desperate applicants gets screwed the hardest. The specialty can only get this type of people now a days.

 

[NewYorkDoctors]

There’s no significant need for a nephrologist in ICU outside of RRT needs .

I mean if you had a full time neph intensivist , what would change ? Renal dosing of meds ? Pharmacy does that (or rather double checks that ) . Monitoring urine output carefully and deciding on fluids vs diuretics ? Any modern trained intensivist will follow this , monitor vent mechanics , hemodynamics (such as the A line waveforms in a paralyzed patient in NSR getting 10mg/kg IBW TV) , pocus , and make the right choices . There would be earlier urine electrolytes but those have not been validated for volume responsiveness in the icu . Ever .

Moreover the evidence suggests no early RRT for ATN anyway .

Maybe a neph intensivist would start vasopressin earlier in certain septic shock patients based n VAST and VANISH . But again any modern intensivist who pays attention at the bedside will pick these things up better than the nephrologist.

Maybe a neph intensivist would have a lower threshold to try lasix drip (just because - no need to poopoo lasix drip due to no mortality benefit in ADHF - it’s a tool . Use it if you will monitor the outputs and labs frequently to achieve the goals of net negativity )


But i would definitely say ID ICU is worth more than neph ICU since antibotic stewardship and use in complex cases is more common (like a fungal infection in sicu from an open abdomen etc )

 

[Kaustikos]

There’s no significant need for a nephrologist in ICU outside of RRT needs .

I mean if you had a full time neph intensivist , what would change ? Renal dosing of meds ? Pharmacy does that (or rather double checks that ) . Monitoring urine output carefully and deciding on fluids vs diuretics ? Any modern trained intensivist will follow this , monitor vent mechanics , hemodynamics (such as the A line waveforms in a paralyzed patient in NSR getting 10mg/kg IBW TV) , pocus , and make the right choices . There would be earlier urine electrolytes but those have not been validated for volume responsiveness in the icu . Ever .

Moreover the evidence suggests no early RRT for ATN anyway .

Maybe a neph intensivist would start vasopressin earlier in certain septic shock patients based n VAST and VANISH . But again any modern intensivist who pays attention at the bedside will pick these things up better than the nephrologist.

Maybe a neph intensivist would have a lower threshold to try lasix drip (just because - no need to poopoo lasix drip due to no mortality benefit in ADHF - it’s a tool . Use it if you will monitor the outputs and labs frequently to achieve the goals of net negativity )


But i would definitely say ID ICU is worth more than neph ICU since antibotic stewardship and use in complex cases is more common (like a fungal infection in sicu from an open abdomen etc )

Thank you. That was definitely helpful and makes sense.

 

[NewYorkDoctors]

Thank you. That was definitely helpful and makes sense.

Back to your initial question , there are a few (very few ) dedicated guaranteed three year neph CC track. UPitt and Stonybrook university come to mind .

But it’s otherwise who the program director knows . Neph CC is really meant to be An academic intensivist who plans to do research in CRRT

 

[Renal_Prometheus]

A specialty with no barrier to entry, is not a specialty worth pursuing. The market doesn't lie, but people will(like programs who are desperate to get fellows for scut work). Don't be one of those suckers who waste years of your life being exploited by everyone else(fellowship + senior partners) and then finally realize at the end that you are still underpaid and that nephrology really is a bad specialty. There are plenty of examples above of people who have fell into this trap, so that you don't have to. Be smart. Don't be desperate.

 

[NewYorkDoctors]

ID is also as uncompetitive as Nephrology. But why is ID not looked at this unfavorably?

ID never promised the Mercedes 80s money making ability.
ID has a good lifestyle and no night call
ID has no real emergencies (having the ER or surgery call you at night for antibiotics is not that bad compared to getting the renal fellow to walk in to have the patient sign a piece of paper for consent for the HD - i mention renal fellow because a real life renal attending is NOT coming in the middle of the night. it would be some combination of albuterol/lasix/kayexelate/veltassa/sodium bicarbonate/IV fluids/BiPAP/intubation/MICU to turf the HD to first thing in the morning)

ID actually really does hit all the organ systems. Nephrology just pretends to because of some overlap with the adrenals/parathyroid and heart/lungs.

just a few things off the top of my head. what else?

 

[Prehealth1011]

I don't know much about ID, but exactly 0 people from my intern class want to do it. I'm not sure what their typical hours are. At least in our hospital, they're working HARD during their shift

A couple of them wants to do nephro and both are IMGs with no loans

 

[NewYorkDoctors]

I don't know much about ID, but exactly 0 people from my intern class want to do it. I'm not sure what their typical hours are. At least in our hospital, they're working HARD during their shift

A couple of them wants to do nephro and both are IMGs with no loans

yeah I know a few residents like that also in the past and presently. I can only hope they have a clear plan with their careers such as try to elevate into academia via nephrology or they have a family owned renal practice or something to take over.

 

[Renal_Prometheus]

I don't know much about ID, but exactly 0 people from my intern class want to do it. I'm not sure what their typical hours are. At least in our hospital, they're working HARD during their shift

A couple of them wants to do nephro and both are IMGs with no loans

the problem in academics is people have no idea what's going on in the real world. If these IMG residents would have worked couple of years as hospitalists, seen the number of neph graduates bailing on their own specialty, they would have second thoughts about joining this specialty. As with many things in life, by the time you figure out it was a mistake, it's already too late.

 

[NewYorkDoctors]

Outside of those primary match applicants who WANT to do (academic) nephrology (they should be celebrated and applauded for their dedication) , there should be ZERO SOAP/scramble applicants into nephrology. There is absolutely NO reason (and no shame by the programs do who this) for any cardiology or PCCM applicant who did not match to accept a cold call from a nephrology program to join them. This does nothing to help you get into the fellowship program / specialty you want and it's just them taking advantage of you. They will tell you anything to get you to be their warm body.

For those who did not match into their primary subspecialty, ignore the cold calls and emails to join the renal program. Do hospitalist and/or research for a year and re-apply. You will get into the specialty of your choice. If you relent and end up taking this scramble program, you will most likely be at a lower tier program and will not have much of a resume to join academic renal. Therefore, you will most likely end up in a dead end private practice job like RP and I keep warning about on here. Some poor souls might try to rationalize that doing nephrology makes you more competitive for CCM. Nope just nope. see prior posts. Georgestone had a really good one in the Nephrology is Dead thread explaining this.

if you initially dreamed of Cardiology (and its subspecialties perhaps) or PCCM (and maybe sleep), then just do hospitalist fora bit while tuning up your resume. You will be happier for it at the end of your life.

You should only do nephrology if you really like it. This implies you should only apply to nephrology during the primary match. There should be ZERO SOAP applicants to fill up a program.

I can see one potential SOAP candidate that MIGHT be okay. This would be someone who has done hospitalist for a number of years and has savings and wants to launch a private practice but wants to get a "useful subspecialty." In this case, the hospitalist may not want to go on the interview trail and wants to go somewhere "easy." (no non-float q4 call system is easy). I can see this hospitalist SOAPing to somewhere local and then grabbing the renal degree and then opening up dual PMD/nephrology private practice.

 

[aurevoir0711]

This thread was eye-opening. I knew nephrologists were not adequately compensated, but not to this extent. Looks like a dead horse to me.

 

[Top Gun]

I’m a nephrologist with a medical directorship at two outpatient dialysis units. I get paid an embarrassingly low salary, even by nephrology standards. But I still do it even after being 5 years out from fellowship. And I would much rather do that than hospitalist work. Here’s why. Because even though I don’t get paid as much as a hospitalist, I also don’t have to deal with all the bull$@it that hospitalists encounter, like nonsensical admissions from the ER, case managers breathing down my neck to discharge a patient, drug-seeking patients, disposition issues, etc…In nephrology, I can just concentrate on the medicine, more specifically the renal issues. And nephrology is often fascinating. I enjoy diagnosing and managing stuff like glomerulonephritis and various electrolyte and acid-base disorders, and renal physiology and pathophysiology is interesting. And you get continuity of care, because you follow CKD patients over a long period of time, so you get to know them very well. Though I admit consults for ESRD patients on dialysis aren’t exactly a challenge, but it pays the bills. I knew going into the field that I wasn’t going to be making boatloads of cash. Though I hope that will change once I obtain JV into the two dialysis units I have medical directorship at. My point is, don’t go into this field expecting to make a crap ton of money. Go into it only if you have genuine interest in it.

 

[NewYorkDoctors]

I’m a nephrologist with a medical directorship at two outpatient dialysis units. I get paid an embarrassingly low salary, even by nephrology standards. But I still do it even after being 5 years out from fellowship. And I would much rather do that than hospitalist work. Here’s why. Because even though I don’t get paid as much as a hospitalist, I also don’t have to deal with all the bull$@it that hospitalists encounter, like nonsensical admissions from the ER, case managers breathing down my neck to discharge a patient, drug-seeking patients, disposition issues, etc…In nephrology, I can just concentrate on the medicine, more specifically the renal issues. And nephrology is often fascinating. I enjoy diagnosing and managing stuff like glomerulonephritis and various electrolyte and acid-base disorders, and renal physiology and pathophysiology is interesting. And you get continuity of care, because you follow CKD patients over a long period of time, so you get to know them very well. Though I admit consults for ESRD patients on dialysis aren’t exactly a challenge, but it pays the bills. I knew going into the field that I wasn’t going to be making boatloads of cash. Though I hope that will change once I obtain JV into the two dialysis units I have medical directorship at. My point is, don’t go into this field expecting to make a crap ton of money. Go into it only if you have genuine interest in it.

Yep that is the thesis of this entire thread.

 

[Renal_Prometheus]

I’m a nephrologist with a medical directorship at two outpatient dialysis units. I get paid an embarrassingly low salary, even by nephrology standards. But I still do it even after being 5 years out from fellowship. And I would much rather do that than hospitalist work. Here’s why. Because even though I don’t get paid as much as a hospitalist, I also don’t have to deal with all the bull$@it that hospitalists encounter, like nonsensical admissions from the ER, case managers breathing down my neck to discharge a patient, drug-seeking patients, disposition issues, etc…In nephrology, I can just concentrate on the medicine, more specifically the renal issues. And nephrology is often fascinating. I enjoy diagnosing and managing stuff like glomerulonephritis and various electrolyte and acid-base disorders, and renal physiology and pathophysiology is interesting. And you get continuity of care, because you follow CKD patients over a long period of time, so you get to know them very well. Though I admit consults for ESRD patients on dialysis aren’t exactly a challenge, but it pays the bills. I knew going into the field that I wasn’t going to be making boatloads of cash. Though I hope that will change once I obtain JV into the two dialysis units I have medical directorship at. My point is, don’t go into this field expecting to make a crap ton of money. Go into it only if you have genuine interest in it.

JV into an exiting HD unit that's already been established for some time? Be careful man. In my experience, those are usually situations where the HD unit is losing money or half filled, and they are hoping by tying you up financially, you will be able fill those HD units with patients. I would be careful about to do a JV into a situation like that.

 

[Top Gun]

JV into an exiting HD unit that's already been established for some time? Be careful man. In my experience, those are usually situations where the HD unit is losing money or half filled, and they are hoping by tying you up financially, you will be able fill those HD units with patients. I would be careful about to do a JV into a situation like that.

Hmmm, I never realised that. Perhaps I’d better look into it more before going forward. Thanks for the advice.

 

[Renal_Prometheus]

Hmmm, I never realised that. Perhaps I’d better look into it more before going forward. Thanks for the advice.

yeah bro. If the dialysis unit is running and profitable, why would they share the revenue with you? This is why you only JV on new
HD units, to share profit and risk. There's something seriously wrong if an established HD unit asks you to JV. Just use your common sense man.

 

[Renal_Prometheus]

This is a topic I’ve touched upon in the past. The reason why nephrology was lucrative 20 yrs ago, is because new grads could easily build up an ESRD population and engage in multiple JVs very quickly. This is because back then, dialysis units were in expansion phase and there was need for new units. Fast forward today, dialysis units have hit saturation point and the profit margins in these units have been declining annually. So new grads simply cannot hope to make the same amount as older nephrologist with multiple established JVs. Part of the problem with nephrology is reimbursement for clinical care is low and you are completely reliant on investment income to make up the difference. For an established older nephrologist, investment income will make up 30-40% of their gross take home pay. So Imagine now new grads coming out and realizing that all the hard work is for nothing, the opportunities to JV is not there or very limited, and they are working harder and making less than a hospitalist even 5 years out of fellowship! That’s the reality we live in. Meanwhile fellowship programs continue to sell the BS that nephrologist will make a lot of money because they will get additional income from JVs and medical directorship fees, pointing to how well older nephrologists have done, while completely not acknowledging how market fundamentals have changed. Some naiive fellows will still fall for the trap, but they will learn the lessons the hard way in private practice. This is the same trap that most nephrology groups use to catch their unsuspecting new recruit. They will tell you that partners make a lot of money, implying that you will as well. Most neph groups allow partners to JV in any new unit that opens up; but they will not tell you HD units are not opening up any more because it’s already saturated and local population is not expanding! Young fellas falls into these meat grinder jobs, get worked couple of years for nothing, realize there’s no hope, and begrudgingly pick up and jump back to hospitalist jobs. Welcome to nephrology! Why do you think the fellowship programs are unfilled to begin with? It’s not what academics claim, that there’s a great unseen opportunity that the rest of the market has not caught on. In fact, the market knows more than most academics. 20 yrs ago, nephrology was competitive to get because it was lucrative. Now, nephrology is a very non-competitive specialty to get, and it doesn’t take genius to guess what has happened in private practice.

 

[NewYorkDoctors]

it makes me so happy when I see a handful of my renal CKD patients from stage 3 onward and I absolutely go HAM to engage in renoprotection to prevent progression to ESRD.
Besides monthly visits (though not necessarily monthly labwork, q3 unless unstable with some issue), I have bioimpedance spectroscopy (this pays for "CHF" which I can always say that hypertensive heart disease associated with CKD has caused CHF), POCUS (this pays), ISTAT labs to make quick decisions on Na, K, CO2 , pH issues, labwork that returns in 1 day at the local lab, remote BP monitoring to get the most accurate home BP measurements to titrate accordingly, and easy access to IR for renal biopsies (in the right situation) and the hospital IV infusion center a few blocks away, I take pleasure in working overtime to prevent renal progression to the 1) benefit of the patient 2) detriment of the dialysis-industrial complex , and 3) to rake in more revenue for office visits and procedures while sitting in my own office than any traveling HD shmuck ever could lol.

SGLT2 inhibitors (even in non diabetics, provided eGFR is appropriate) has helped with the BP and reducing weight
GLp1 agonists (off label in nondiabetics even) has helped suppress their appetite to lose weight (off label) and improve their CKD metrics.

ADdendum: some might say geez you are really overbilling it. well i dont see a Cr 1.4 80 year old every month. that's q3 months. i meant if there are BP, volume, electrolyte abnormalities, then i will see them q1 month. can't wait 3 months and let that diuretic cause hyponatremia after all. the point was that since I do not need to be a dialysis "ambulance chaser," I can exert more effort into the (sometimes tedious, but very important) task of following up these issues very carefully. Other nephrologists tend to just say "lose weight, control DM, take these meds. see you in 3 months. bye" while thinking "oh gosh i have to travel to that center in this traffic later today??"

If I ever get a partner who is a full time neph, I'll consider branching out into PD. Home HD is tied to an HD center usually so i don't want to deal with those politics and turf wars.