Nephrology fellowship after 17 years of hospitalist work ?

[Top Gun]

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right. on paper renal pathology, renal physiology, and managing renal diseases is as cool as it comes.

if one did not have to manage the social issues all of the ESRD patients, then renal might be more palatable at the lower pay

but having to be the de facto primary care physician for the ESRD patients (trust me their own PCPs are very very hands off for the most part except for the immunizations and screenings) makes it no better than dealing with the nonsensical issues of hospitalist patients.

That part is true. Whenever my chronic dialysis patients start talking about their sinus congestion or their dysuria or their constipation or abdominal pain, I wonder what their PCPs are even doing.

 

[NewYorkDoctors]

That part is true. Whenever my chronic dialysis patients start talking about their sinus congestion or their dysuria or their constipation or abdominal pain, I wonder what their PCPs are even doing.

well im sure it is a confluence of factors

the HD patients during their HD 3x a week (or more) are a captive audience. they dont care that the nephrologist is doing HD rounds. they see a Doctor and will ask all their medical questions. they got no where else to be anyway during those hours. only issue is you cannot be reimbursed for a clinic visit during this time so it's all free care if you choose to prescribe something or give advice

these patients are already going to the HD center 3x a week. so tey only have 2 or 3 weekdays available per work week to see the PCP (unless PCP has weekend horus). sometimes thye have to see cardiology, vascular surgery, radiology etc.... anyway

Maybe PCP did give the patient flonase or azelastine or something. but it did not work. the patients want a second opinion and know that nephrologists are trained as Internists.

maybe PCP referred to ENT but due to ENT's limited office hours and scheduling and the HD schedule, the patients cannot find a proper time to align everyhting.


bottom line you cannot "just be a renal specialist only" for your chronic HD patients. i mean you could try to be firm about it but if the patient cannot access PCP easily, you end up feeling guilty about it and give free care at the end of the day.

other subspecialists do not have to round on HD and talk to patient so often (4 times a month ... sometimes you see them more when you are rounding on other patients perhaps and are forced to say hello)

edit: for the PCPs in NYC who have a good IPA and see a lot of medi/medis or just managed medicaids (zero copay no deductible), these primary care patients can come four times a month to your OFFICE and you can bill 99213 or more 4 times a month... without having to travel to the HD center. nice

 

[Top Gun]

well im sure it is a confluence of factors

the HD patients during their HD 3x a week (or more) are a captive audience. they dont care that the nephrologist is doing HD rounds. they see a Doctor and will ask all their medical questions. they got no where else to be anyway during those hours. only issue is you cannot be reimbursed for a clinic visit during this time so it's all free care if you choose to prescribe something or give advice

these patients are already going to the HD center 3x a week. so tey only have 2 or 3 weekdays available per work week to see the PCP (unless PCP has weekend horus). sometimes thye have to see cardiology, vascular surgery, radiology etc.... anyway

Maybe PCP did give the patient flonase or azelastine or something. but it did not work. the patients want a second opinion and know that nephrologists are trained as Internists.

maybe PCP referred to ENT but due to ENT's limited office hours and scheduling and the HD schedule, the patients cannot find a proper time to align everyhting.


bottom line you cannot "just be a renal specialist only" for your chronic HD patients. i mean you could try to be firm about it but if the patient cannot access PCP easily, you end up feeling guilty about it and give free care at the end of the day.

other subspecialists do not have to round on HD and talk to patient so often (4 times a month ... sometimes you see them more when you are rounding on other patients perhaps and are forced to say hello)

edit: for the PCPs in NYC who have a good IPA and see a lot of medi/medis or just managed medicaids (zero copay no deductible), these primary care patients can come four times a month to your OFFICE and you can bill 99213 or more 4 times a month... without having to travel to the HD center. nice

This is true. We are trained as internists and it is why I will give antibiotics if a patients has sinusitis or a UTI. Or will give Miralax if they’re having constipation. I do feel an obligation to address their “other” medical issues if they bring them up. To a point anyway.

 

[NewYorkDoctors]

This is true. We are trained as internists and it is why I will give antibiotics if a patients has sinusitis or a UTI. Or will give Miralax if they’re having constipation. I do feel an obligation to address their “other” medical issues if they bring them up. To a point anyway.

osmotic laxatives are nice. get some fluid out of the GI tract. improve dry weight that way slightly.

 

[Top Gun]

osmotic laxatives are nice. get some fluid out of the GI tract. improve dry weight that way slightly.

Do you round once a week at the dialysis units you go to? I thought I was the only one who did that! A lot of other nephrologists in my area will only round once a month at the dialysis units they go to. At least in my area. Then again, it could be because they’re part of a group, so they rotate rounding among themselves. I’m solo practice with only a PA, so I round weekly at each of the units I go to.

 

[NewYorkDoctors]

Do you round once a week at the dialysis units you go to? I thought I was the only one who did that! A lot of other nephrologists in my area will only round once a month at the dialysis units they go to. At least in my area. Then again, it could be because they’re part of a group, so they rotate rounding among themselves. I’m solo practice with only a PA, so I round weekly at each of the units I go to.

im BC nephrologist but i don't practice much nephrology.

it's currently a hobby of mine as I accumulate a few GN patients in the community that I like to spend some time seeing, If you look hard enough in the community then one could accumulate a handful of "easier" GNs to manage (i.e. primary membranous, FSGS, IgA, LN 3/4/5 ...)

PCPs always have UACRs of 3000 or more... usually chalked up to DM or HTN but... when those things get treated and its still not coming down that's when the serologies and biopsy are offered... but not every patient wants to take that step. oh well.

 

[Top Gun]

im BC nephrologist but i don't practice much nephrology.

it's currently a hobby of mine as I accumulate a few GN patients in the community that I like to spend some time seeing, If you look hard enough in the community then one could accumulate a handful of "easier" GNs to manage (i.e. primary membranous, FSGS, IgA, LN 3/4/5 ...)

PCPs always have UACRs of 3000 or more... usually chalked up to DM or HTN but... when those things get treated and its still not coming down that's when the serologies and biopsy are offered... but not every patient wants to take that step. oh well.

Love it when I get a GN. Those you can actually do something about! With big gun immunosuppressants like cyclophosphamide or rituximab! Plus, there’s something cool about autoimmune pathophysiology of GN.