What are red flags you look for in programs?
For those who are set on being a nephrologist (hopefully academic), you would want to look out for some quality of life (or lack thereof) red flags.
Because you want to get the best training out there (it is a buyer's market after all), you should make sure these programs have the full scope of nephrology practice.
Red flags would be
1) Absence of night float system - admittedly not every smaller program can have renal night float. So this is not a deal breaker. But I would be leery of a program with only 4 fellows in a large academic medical center.
2) Whether fellows have dropped out before. This is the ultimately red flag and signifies a low quality fellowship program. No nephrology fellow at a top notch institute and program would be swayed by the Nephrology is Dead thread. Therefore if people have dropped out before, that would mean more may do so in the future. Imagine q3 call lol. do you think attendings are going to pick up no fellow night call? nope lol. prove me wrong haha.
3) Lack of renal pathology in house or renal fellows doing percutaneous renal biopsies via ultrasound. While most nephrologists will not be doing his/her own biopsies in non-academic practice, doing biopsies in house tends to mean the renal pathology is in house. That is worth its weight
4) Lack of renal transplant - the top centers will all have renal transplant in house (whether or not they have the renal transplant fellowship)
5) Lack of peritoneal dialysis - this is becoming a lost art but will be crucial for nephrologists who will eventually pick up a few patients on PD in the future.
6) If they make the renal fellows doing the temporary HD catheters / vascaths. There should be no reason for renal fellows to do these procedures outside of personal interest of the fellow. ICU fellows can do procedures and lines to his/her heart's content because he/she does not have to write progress notes for patients on off-HD days, do on HD notes, do new consults, round on a full list of patients without a resident's help, go to renal clinic, go to the outpatient HD center....
The ICU fellow will do ICU consults of course but that's a far lower workload than what the renal fellow has to do.
7) If the attendings make fellows go in the middle of the night for EVERY consult. If someone has missed HD and is fluid overloaded, then its annoying but someone (the fellow) has to go in. If a deceased donor kidney is suddenly ready, then the fellow has to go in and call in patients on the list and then get them in and do a full H&P and make sure they havent developed any cancers like skin cancers since the last visit.
But if someone from calls for a Na of 127 and the ED did not decide it was worth it for ICU to see the patient (at which time ICU will not call renal overnight as ICU has the expertise and cajones to do 3% NaCl no problems) , then I do not see why the renal fellow needs to go in overnight for this. The fellow could simply ask the night residents to order whatever (i.e. add on uric acid, SOsm, TSH cortisol check U/A , lytes, UOsm etc... check labs q4 hours to monitor the effect of the NS given by ED ...) and then will see first thing in the morning.
8) Absence of conference time - whether NKF or ASN or the other kidney didactic conferences. This would mean you are just overworked as a scut monkey
9) Board pass rates - the renal boards are not terribly hard after you have done the ASN review course or a Brigham and learn the esoteric parts of nephrology. if there is a renal board pass rate issue, this would reflect either the fellows are worked too hard or the fellows there are not very bright. as we know from the Nephrology is Dead thread, lower tier programs take anyone with a pulse (but not a brain apparently)
10) Lack of CRRT / TPE - as the breadth of evidence for ATN and CRRT has shown lower clearance rates of 20-35mg/kg/hr are sufficient compared to higher ones, high clearance CVVHDF from those Prismaflex machines have fallen out of favor at many centers for the cheaper CVVHD machines that are usually used for home HD like the NxStage machines. Therefore absence of doing CVVH or CVVHDF versus just CVVHD is not really a red flag. but programs that also have the Prismaflex machines usually also do their own plasmapheresis for renal disease. Therefore, if a program does not do their own CRRT (or has a low volume) and outsources TPE to hematology, then consider against this program.
11) Older faculty - while this is not meant to be an ageist comment (more so mockery against older doctors beyond the age of 75 who remain in academics but who do not participate in MOC, no longer do original research, and are living on their glory days from the 80s) , I would caution against a program that has only older faculty members. You want a mix of older (for their experience and knowledge - especially if they are leaders on the ASN) and younger attendings (who understand the culture better and may have experience in point of care ultrasound and other newer skills like onconephrology) to teach you.
just a few things to look out for.
