Nephrology fellowship tips

[arda]

Hello All,

I know it is a very stressful period and especially harder for nephrology applicants. There are not a lot of recent experiences and information about programs. I recently matched to Nephrology and this is my 2 months in nephrology fellowship. I interviewed at many places so I wanted to share my experience and my recommendations for new applicants. I remember trying to reach out to people to get some information about programs and it seems like education in many programs has changed recently. I think there are some musts for a nephrology program and I would not go to a program that does not have these.

1) Vascaths should be placed by others, not nephrologists. It is very convenient to ask a procedure team to place the vascath, No one will say stop to you if you want to do your own vascath but having the option to call a procedure team to place the vascath is very nice. I have done so many during residency that i am not interested anymore being honest, but i know some fellows are and they do it. But this should not be a requirement of a nephrology fellow, should be an option for you if you are interested.

2)Night float system, I think this is a must. Many reasons, you go home and don’t get disrupted after 5 pm. I would not go to a program with no night float system.

3)Transplant center, this was a big thing for me in my selection, I would not do a nephrology fellowship in a program that does not have inhouse transplant.

4)NPs are helping you in chronic ESRD patients, I think this is a must as well and being implemented in many fellowships program I interviewed at. Having NPs backup for ESRD patients is very valuable to keep your census low.

There are some other things I looked when I was applying. These can change from person to person because I was more interested in clinical education rather than a research heavy program and most of the big programs are geared towards research especially second year. I really did not like that so wanted to have a balanced training. This can change from person to person but I think this is something to keep in mind. Some programs require you to do research, in some it is optional. I prefer optional. I also wanted to have a good CRRT and home dialysis experience.

Every program has advantages and disadvantages. But I think most of them do not have a great outpatient experience. This is something I would really pay attention during interviews. Specialty clinics like GN, fabry, rare genetics is important for outpatient experience. Continuity clinic is also very important, I think this is a problem for every program. Even during residency , I never saw a patient twice due to problems in our clinic. Some programs assign a set of patients to you to follow-up during your fellowship. I think this is very nice. Our program does not have nephrology stone clinic for example, it is an elective with urology department. Some big programs have onco nephrology as well, I think this is a nice experience to have because nephrology is being consulted on many cancer patients, there are many side affects of newer generation drugs on kidney, as well as BMT, sickle cell etc.

I would ask these during interviews, especially the first 4 that I explained above are I think must. Good luck, it is a stressful period.

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[arda]

Hope to see some of you during interviews.

 

[Chemist0157]

Hello All,

I know it is a very stressful period and especially harder for nephrology applicants. There are not a lot of recent experiences and information about programs. I recently matched to Nephrology and this is my 2 months in nephrology fellowship. I interviewed at many places so I wanted to share my experience and my recommendations for new applicants. I remember trying to reach out to people to get some information about programs and it seems like education in many programs has changed recently. I think there are some musts for a nephrology program and I would not go to a program that does not have these.

1) Vascaths should be placed by others, not nephrologists. It is very convenient to ask a procedure team to place the vascath, No one will say stop to you if you want to do your own vascath but having the option to call a procedure team to place the vascath is very nice. I have done so many during residency that i am not interested anymore being honest, but i know some fellows are and they do it. But this should not be a requirement of a nephrology fellow, should be an option for you if you are interested.

2)Night float system, I think this is a must. Many reasons, you go home and don’t get disrupted after 5 pm. I would not go to a program with no night float system.

3)Transplant center, this was a big thing for me in my selection, I would not do a nephrology fellowship in a program that does not have inhouse transplant.

4)NPs are helping you in chronic ESRD patients, I think this is a must as well and being implemented in many fellowships program I interviewed at. Having NPs backup for ESRD patients is very valuable to keep your census low.

There are some other things I looked when I was applying. These can change from person to person because I was more interested in clinical education rather than a research heavy program and most of the big programs are geared towards research especially second year. I really did not like that so wanted to have a balanced training. This can change from person to person but I think this is something to keep in mind. Some programs require you to do research, in some it is optional. I prefer optional. I also wanted to have a good CRRT and home dialysis experience.

Every program has advantages and disadvantages. But I think most of them do not have a great outpatient experience. This is something I would really pay attention during interviews. Specialty clinics like GN, fabry, rare genetics is important for outpatient experience. Continuity clinic is also very important, I think this is a problem for every program. Even during residency , I never saw a patient twice due to problems in our clinic. Some programs assign a set of patients to you to follow-up during your fellowship. I think this is very nice. Our program does not have nephrology stone clinic for example, it is an elective with urology department. Some big programs have onco nephrology as well, I think this is a nice experience to have because nephrology is being consulted on many cancer patients, there are many side affects of newer generation drugs on kidney, as well as BMT, sickle cell etc.

I would ask these during interviews, especially the first 4 that I explained above are I think must. Good luck, it is a stressful period.

I think that's a good list.

Heavy hitting items in my opinion would be the following in no particular order:
CKD management
Inpatient dialysis management
CRRT
PLEX - At my program, heme/onc ran the show, but in private practice now, it's nephrology. It was not a difficult transition, but I would have liked to have had more exposure to it in fellowship.
GN
Transplant - exposure to inpatient and outpatient management
Outpatient dialysis
Home dialysis home dialysis home dialysis. Home. Dialysis. There is a lot of emphasis from the powers that be to better promote PD and HHD, and it's a great option for many patients.
Pathology reviewed with a renal pathologist - We had this for most of my training time though there was a period of time where the pathologist retired, and we missed out on teaching while they hired another one. They sent out the biopsy samples during that time.

I am not a procedures guy. At my program, the primary team did lines. Only situation that ever caused any problems was if the patient was on a hospitalist service and IR was not readily available. In the real world, most of the time, nephrology is not doing the lines. That is generally not an expectation. I do think it's good to have your hand in it every once in a while in case it does come down to you, but I would be more than happy to not do any more lines. I think I have done just two this year out in practice. They do not pay well, and it's just another thing to think about.

I do think it's helpful to get some exposure to kidney biopsy, but moreso to have the knowledge and to be able to walk patients through what to expect. Most nephrologists are not doing their own biopsies. The logistics can be a hassle, and I suspect it probably is better to have a select few IR guys doing all the biopsies rather than each nephrologist doing just a few a year.

We did have a stone clinic/specialist which was good for teaching, but that does not translate that well into private practice.

I went to primarily a clinical program as my plan was for private practice, but many programs have up to half of second year of fellowship dedicated to research which makes more sense if someone is bound for academia. That was not for me.

The busier programs may have enough work to justify a night float system but not all. That may be hard to tease out when interviewing, but you can talk to the fellows. We could be busy at night, but it was sporadic. Same as private practice. It would not be an efficient use of a doc to have him or her just have work hours for a week at night where I am, but again, some programs may have the workload to justify that.

I am about 3 years out from fellowship, and I have often received messages from residents and fellows regarding programs and post-fellowship so I am available if anyone has any questions.

 

[NewYorkDoctors]

It sounds like you are having a wonderful time at your large well funded academic nephrology fellowship . I wish you the best and I am sure you will have a wonderful career joining faculty.
If you have transplant and night float you must be at one of the world class centers like Columbia or John Hopkins or a similar tier .

all of your points are salient and well thought out . I reiterate that I believe all candidates who really like nephrology and want to do it for the right reasons (being a clinician educator or physician scientist in this field ) should do so without hesitation and strive to join a top program as yourself .

I also reiterate that there are only so many programs like yours and some percentage of matched fellows (and probably most of the scramble ) will go to community programs (that have no night float , no specialty clinic , no procedure team , no NPs helping , no transplant in house ) and end up in private practice and may not get a fair shake. For those individuals , see the nephrology is dead thread .

the one thing I will say about the hd lines are that as an attending , if you do not also have critical care training and thus the malpractice insurance , your hosptial may not give you then Privileges to do this . As a renal fellow , you could always do it under the supervision of an intensivist or surgeon . Moreover , I personally feel that if you cannot place a chest tube yourself , then you probably shouldn’t be doing IJ or subclavian lines routinely . A femoral line sounds nice and all - but once you try to do it on a obese patients with a large pannus , you’ll wish you didn’t waste that 1 hour of your life . The same concept applies to renal biopsy . I mean as academic faculty , you can do anything you want . Negotiate and set up doing renal biopsies . One of the faculty where I did training had additional GN training year and thus supervised and did biopsies from thefellows clinic and faculty practice . iR appreciated this very much

bottom line outside of a large academic center . Nephrologists have other things to do than the temporary HD line. it really doesn’t pay much RVU wise or monetary wise and your hospital may not even let you do it based on malpractice insurance coverage .

 

[arda]

Actually there are a lot of programs with these when i interviewed last year so picked the one that has flexibility on research. Almost all the programs i interviewed had night float, I did not prefer programs that mandate you to do research during nephrology fellowship, i like it to be optional. Some programs even have mandatory year of research, those top tier programs especially. So i would be very careful if you want more clinically oriented fellowship. I would apply very wide, but i agree with you that i would not do a nephrology fellowship in a community program. There are unfilled university programs with night float and transplant that does not require you to place vascaths so i would go to one of these. But also would be careful because there are some top 5 programs which require you to do all the vascaths, no night float, home call all weekend and plus second year is mostly research. i would apply widely. I was very pleasantly surprised with many programs, but some top tier programs, i really did not like.

 

[Renal_Prometheus]

I think it’s also important to ask the during the interview whether they take applicants without IM residency. If they do, run. If they are doing this, their priority is to take any warm body to do scut work and likely place very little emphasis on education. You don’t want to go into a program whether they view you as a warm body. Again, see nephrology is dead thread for the horror stories.

 

[NewYorkDoctors]

Yes don’t let renal Prometheus and I dissuade people who really like renal from doing it . It just doesn’t make money in private practice unless you are connected (see other thread ) . While money is not everything , so renal if you plan on being a clinician educator (join academic faculty and do clinical research ) or physician scientist . Be a pure form of nephrologist . I like nephrology and I do practice it (non HD) and find it a good break in the action from pulmonary and icu.

RP and I just want those on the fence who think renal is an escape from hospitalist or renal is a pathway to try cardiology or pccm again to NOT make a lifelong mistake . See other thread .