In anticipation of the upcoming 2018-2019 Application Thread ( I will wait for a moderator to make it.. I don't know what kind of mood GutOnc is in today... probably cheery as usual..), I write this post of "Why You Should Apply to Nephrology." For the uninitiated, I am a graduating nephrology fellow who has extreme dislike of the subspecialty of nephrology and only finished the fellowship because of "reasons." I have no intention of practicing nephrology. Hence, you know when I am listing to you the reasons why you should do it, then you know I am not sugarcoating anything. Of note, this is not satire, I promise.
- It is somewhat easier to enter academics via nephrology than in another more competitive subspecialty such as cardiology, GI, PCCM - with a dearth of candidates and even less so research oriented candidates from top residency spots, it actually becomes somewhat easy for an applicant who is not the TOP GUN medical student/resident (Step 1 260+, all honors as a student, Top research med school, saved two villages before residency, top residency pedigree, AMG etc) to "climb the ropes" and go from a "meh" residency to a "top reputation" nephrology program. From there, you will have enough connections and reputation to enter an academic faculty position at another fellowship program. Trust me I have seen it happen with fairly good frequency.
- You get to keep your Internal medicine skills up to date. Now this does not necessarily mean you will retain or practice all of your outpatient GIM, though you could if you wanted to since HD patients see the nephrologist most of the time. While you may not be a "master internist" that some of the older nephrologists (i.e. the ones who do not participate in MOE) seem to fashion themselves as, you will not be so pigeonholed into a very peculiar niche that you can still provide a good breadth of general medical knowledge. In some ways, you can have the esteem and confidence of practicing the parts of general medicine but without any of the "case management" aspects of it. While some may say HD is purely a case management situation, I was merely referring to management of non-HD nephrology issues.
- You really get to know the patients from CKD to HD who really really rely on you to help them get things done. Their PMD is hit or miss and often takes a backseat to all of the specialists. For the patients who are communicated to well ahead of time and know what to expect (and all patients from all spectrum of the socioeconomic rings of life can and do become good CKD/HD patients as long as they have a good attentive doctor from the beginning). You can feel great satisfaction knowing you really helped save a patient from
- The ASN governing society knows nephrology is "in trouble." No need for me to further belabor this point here. But needless to say, they have made great strides in improving access to educational materials, GME, and highlighting new research breakthroughs. As a fellow you can get two-three years of free membership and subscription and free delivery of the two major journals JASN and CJASN. The annual meetings are also very fellow friendly.
- Job security is definitely there. With a dearth of applicants, there are always jobs there. However, the quality of jobs may leave much to be desired (see other posts, no need to belabor this point here). As long as you flexible to move anywhere and possibly even do locums tenens, you will get a job in nephrology. But perhaps the most useful customization is to combine GIM with nephrology. Although in academics you would need a special set up for this, as a private community physician, this is perhaps to your benefit. Most insurances will only allow so many subspecialty visits in one year. But if you see your patients as GIM, then you may be afforded more time for preventative services (and then just double up on their renal care). As a matter of fact, virtually most parts of nephrology (sans glomerular disease, HD, and transplant) can easily be absorbed into GIM. But there are also plenty of medical director supplemental jobs out there. It's all about being flexible about where you are willing to live. The big cities are saturated so good luck there. But as long as you can move rural, you will have some business.
- The old guard nephrologists are retiring now and will continue to retire over the next 10 years. Their spots will finally be open for the younger generation.
- You will be needed by your hospital colleagues. The glass half full argument is HD, CRRT, SCUF, TPE are valuable extracorporeal therapies and the expertise of the nephrologist willl always be there for these cases. The glass half empty argument is... in the other threads.
- You will be respected. Well you will be respected by the MS1 up to the PGY3 level at least. That's something.
- You have some customization options - the nephrology subspecialties are rather limited but at least offer a very unique branching point. Renal transplant is available and not terribly hard to obtain. Going this route limits you to academics (no private practice transplant nephrologists out there) but it also gets you into academics for certain. CCM is a possible pathway but it's not a natural fit like PCCM is. N-CCM at a big academic institution does ensure you will become a CRRT guru at a big academic center. But in private practice, there is really no established N-CCM shift work type of set up unless you create it yourself. Interventional Nephrology is also a niche in certain parts of the country.
- You will become adept at volume status ... the bronze level way of going by volume status anyway. But that's something.
I might think of more later. Yes some of these have some backhanded compliments in there. But for a new nephrology graduate who hates every thing about it, I think I am quite sincere in my opinion about these aforementioned items.
Good luck everyone. You will definitely match!
