Don't apply to nephrology

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Aug 7, 2014
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Any of you thinking about nephrology, please do your research and apply before you blight your career.

Hate to see residents hoodwinked into this dying specialty.

Please review my posts in IM subspecialties for details of why I urge caution?


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Aug 7, 2014
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I did my fellowship with great interest in Nephrology - Acid base/electrolyte/Acute dialysis stuff. Joined a private practice - get around 170 K. my day starts at 6 and ends at 5. run around 4 hospitals and 3 dialysis units.

Real life of nephrology

- Oversupply - tremendous oversupply - so employers dont really have any need to offer a fair deal

universities need bodies to do the scutwork - there is no need for these bodies outside an academic setting

many nephrologists end up as hospitalists -" saw this in fellowship itself - but still liked nephro- s0 did not quit"
- Smooch primary care and hospitalists for consults - They dont absolutely have to refer,unless patient needs dialysis - No patient sues them for non dialysis requiring AKI

what do you treat ATN with anyway ???

- Dialysis patient compensation is awful and they expect you to sort out all their medical/social problems for which you dont get paid nor do u have the time.

- Dialysis rounding can easily replaced by a NP.

- Income in dialysis goes to davita/fresenius - they pretty much own everything across the country now

Nephrology is not what you see in residency - stay away from it. Dont waste 2 -3 years of your valuable life to become slave to either a dialysis company or a private group for the rest of your life with 1/2 - 2/3 income of a hospitalist

Do nephrology for right reason - It does not have income, does not have a lifestyle and does not have the charm that u see in residency

if you applied - you will get a spot - quit your interviews now and save yourself from a lifetime of misery

Nephrology changed a lot - here's the time line

Older Days

Few nephrology Positions
Growing ESRD population
Physicians owned their own dialysis units(facility charges are far greater than physician visit charges)
they could visit dialysis patients as many times as needed clinically(of course open to abuse)
Hospitalists were rare and Primary care physicians needed help more often + they understood the need to have a nephrology support structure - more referrals
consult codes were different and paid higher
Office made some money on Epo Injections

Davita/Fresenius bought dialysis units - Old nephrologists made a killing by selling their units
Older guys now stay on as directors/part share in the unit


False projections about increasing ESRD+ Totally false articles about a shortage of nephrologists (ASN has to say so to keep it's source of income)
No growth in ESRD population
Explosion in nephrology fellowship positions - even small community programs have fellowships
You can do no more than 4 visits per month
you only need one director for clinic and one person can be director at 2 places - most of them are occupied by nephrologists who see few patients but own big groups
Takes you ages to become a partner and top guy keeps hiring new slaves to keep the money flowing to him while he does little work.
Non compete clauses enforced by these guys who dont retire
No difference between consult codes and internal med codes - with no procedures or limited procedures to do - hardly any different billing than IM
Hospitalists took over - less likely to refer, as under pressure to get patients out to keep stay minimum+ Hospitalists have a tendency to resent specialists, some of whom can be jerks. With an oversupply of nephrologists now hospitalists have the say who they refer to - smooching matters not your patient skills. Makes one wonder if they refer because they believe that this physician provides good care or because they can go out to a fancy restaurant /have drinks funded by the consultant
Epo is restricted with indications

Primary care docs sold their practices to hospitals and are least bothered by what happens to their patients any more - they dont care where their patients end up.

Why Nephro is different from other specialties?

Cards- no one else can do angio, read echos
Gi - no one else can scope
Heme onc - no one else can order chemo- new drugs every year/ infusion charges
Rheumatology - biological only they can order
Pulmonary - bronch/ read PFTS / sleep study reading - singing for computer generated stuff and get paid !!

Let's talk about Nephro

Acute renal failure - u can ignore till dialysis- what therapy do u provide !!

Is there a single drug that changes meaningful and tangible outcome in nephrology.
Year after year we get studies disproving what we believe was beneficial. Epo is a classic example.

Even worse, very few dialysis are grateful for this life sustaining procedure of dialysis.

If cardiologists can exclusively read echos, why did nephrologists let go of renal us/ dopplers - why did we even let radiology take over interventional stuff - why couldn't we keep an exclusive access. Shouldn't interventional be part of every training ?
Renal US is done frequently enough , interventional nephrology needs huge patient numbers which are not there !!

Find a speciality where no one else other than you can do a procedure( a procedure that is needed a lot in numbers and paid per procedure)

If you don't put a needle or a scope in a patient ( dialysis doesn't count) ur pay is down.

Currently a Botox injection is valued more than ur complex acid base problem solving

Procedure is the king

Do nephrology if u like seeing ATN all day with no therapy in site, see dialysis patients who hate their own life saving procedure, ready to suck upto all PMD/ Hospitalist / generate revenue for ur senior partner till he dies.

I like GN/RTA/ CVVH/ acid base/ electrolyte and all the exciting parts but it constitutes a tiny fraction of real practice.

IF nephrology has to be competitive

Regain control of dialysis units
Regain control of renal imaging / procedures
Get better pay for our dialysis visits
Bring back consult codes

None of these r going to happen - for me I will accept it as I can't do anything other than Nephro - hubris of a specialist:)

IMGS - don't fall for the trap

Programs fill the spots with IMGs

Reason IMGs have a fascination with sub specialization and desire some subspecialty training , if they ever return to their home country.

Programs cash in on this to get bodies to do scutwork for fellowship, knowing very well that there are no jobs for their trainees.( can't think of another speciality that does on this scale )

It's high time IMG's get away from this warped thinking.

Try to get a specialty that is worth the time and effort.

If not stay on as internist or Hospitalist - at least a better pay and lifestyle

Don't delude yourself thinking you made it to a stellar program in nephrology because of your talent. You make it because no American grad wants it and you fool yourself thinking you made it!!

IMGs get IM easily because AMG's choose the better specialities.
Nephrology fellowship is not desired even by most IMG's and you chose it!!

Nephrology is like the scum
of the scum of all the specialities as of now
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5+ Year Member
Apr 4, 2011
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I am a general internist but my nephrology colleagues say about the same as what you report above.
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Oct 29, 2012
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I'd always thought specialists earned more until talking with a Nephrologist.
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Aug 7, 2014
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few others make less as well but at least they have a lifestyle

ID - Volume is there as inpatient, some get additional income from wound care, rarely anyone wakes them up at night
endocrine - Insulin pumps/new drugs increasing requirement. Number of diabetics esp young is massive. Office based mostly - no body wakes you up at night and weekends are off if pure office based!!

Nephrology - same pay / intense competition/sleep less with higher acuity patients/ Frustration taking care of extremely ill- attention needing dialysis patients with huge social issues/ weekends are far busier

at least if you subspecialize for the same income - choose a specialty that has a lifestyle like Endo or ID


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Dec 2, 2009
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saw the same thing during my prelim IM year. Nephrologist do nephrology less than 1/3 of the time and work as a hospitalist most of the time (most of my inpatient IM attendings at university teaching hospitals were nephrologists)