Rupesh

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Hello guys,
I am currently doing renal fellowship in community program .I would like to know how many consults do we need to see in a day.
Thanx
 

rokshana

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Hello guys,
I am currently doing renal fellowship in community program .I would like to know how many consults do we need to see in a day.
Thanx
i would imagine all that are called in...there is no cap as a fellow.
 
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Rupesh

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Thanx for the reply .Thats the worst part.I think ACGME sud make rules for capping like 10 patients/day or something like that as a first year fellow.
 
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Nephro critical care

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Thanx for the reply .Thats the worst part.I think ACGME sud make rules for capping like 10 patients/day or something like that as a first year fellow.
That would probably impair your learning if you capped it at 10. Because out of them 7 might be ESRD pts on MWF dialysis on whom after a while there is nothing new to learn. I went to a rather s''''' university program which just wasn't geared towards fellow teaching. It was just completely screwed up. The university was competing with private practice groups at the private hospitals and to get more consults there was a rule that you had to come for any new consult at night. So q4 day for the whole year I spent to whole night in the hospital. And most of these consults were crap such as a psych pt on MWF HD who was admitted on Monday to psych floor after HD. At 12 midnight the psych residents in all their wisdom put in a nephro consult. He has no acute HD needs HD won't be done till Wednesday but since the consult was called I am driving 35 minutes at midnight to see the pt. And then whenever a kidney was available they would call 3 potential recipients for each kidney and you were called in to do a pre-tx evaluation on all. One day 2 kidneys came in and I had to dictate pre-tx consults on 6 potential recipients one evening . And turns out both kidneys were bad so all 6 went home . Pre tx evaluations have zero educational potential you are just assessing if pt needs dialysis prior to tx and if he has developed some new illness like a new skin CA or angina which would preclude him from tx. Post tx it's actually educational because you try to figure out if the tx kidney is working or not. Not surprisingly this program doesn't have any fellows now.
This is a buyers market. Get together with your other fellows and maybe set census 12 but only pts with educational value. So see the GNs , the weird electrolyte disorders and hyponatremia, the new AKIs , the PD pts, the CRRTs and insist that attendings teach you lines and biopsies. And don't see the MWF chronic HDs.
 

bronx43

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That would probably impair your learning if you capped it at 10. Because out of them 7 might be ESRD pts on MWF dialysis on whom after a while there is nothing new to learn. I went to a rather s''''' university program which just wasn't geared towards fellow teaching. It was just completely screwed up. The university was competing with private practice groups at the private hospitals and to get more consults there was a rule that you had to come for any new consult at night. So q4 day for the whole year I spent to whole night in the hospital. And most of these consults were crap such as a psych pt on MWF HD who was admitted on Monday to psych floor after HD. At 12 midnight the psych residents in all their wisdom put in a nephro consult. He has no acute HD needs HD won't be done till Wednesday but since the consult was called I am driving 35 minutes at midnight to see the pt. And then whenever a kidney was available they would call 3 potential recipients for each kidney and you were called in to do a pre-tx evaluation on all. One day 2 kidneys came in and I had to dictate pre-tx consults on 6 potential recipients one evening . And turns out both kidneys were bad so all 6 went home . Pre tx evaluations have zero educational potential you are just assessing if pt needs dialysis prior to tx and if he has developed some new illness like a new skin CA or angina which would preclude him from tx. Post tx it's actually educational because you try to figure out if the tx kidney is working or not. Not surprisingly this program doesn't have any fellows now.
This is a buyers market. Get together with your other fellows and maybe set census 12 but only pts with educational value. So see the GNs , the weird electrolyte disorders and hyponatremia, the new AKIs , the PD pts, the CRRTs and insist that attendings teach you lines and biopsies. And don't see the MWF chronic HDs.
Lol, how did you even finish fellowship? I woulda quit 6 months in and just been a hospitalist. This is the thing with fellowships - you're dealing with fully licensed and often board certified physicians. If there isn't a bright enough light at the end of the tunnel or if the tunnel is too dark and smelly, then people aren't gonna put up with it.
 
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Nephro critical care

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Feb 4, 2014
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Well at that time I didn't know better. I was a night hospitalist at a very busy hospital for years and had wanted to be a nephrologist during my residency. Nephrology was just an outlet for a burned out hospitalist. And initially it was nice that while I was working hard ( although not learning much ) at least someone else was in the end responsible although they only showed up for rounds ,hardly did any teaching and disappeared. My university program competed with 3 private groups for consults and the way they were able to show superiority was that they could get their fellows to see every crap consult called anytime. I just in the end slogged away seeing pre -tx BS and without that much knowledge re managing the really complex renal stuff. Job market was terrible and in the end the only real good thing my program director did for me was to give a glowing letter for a CC fellowship which I thoroughly loved and have no regrets in doing.
The fellows after me knew better and I think all the fellows quit my program went unmatched and has no fellows at present.
 

NewYorkDoctors

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Apr 5, 2012
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The problem is there is nothing at all appealing about being a community nephrologist compared to a community PMD. (Again, academic nephrology, transplant, research is a different cup of tea)

The same CPT billing codes as primary care internal medicine with infinitely more complex patients. I have done both.

Assuming you are independent and have your own private practice (hunt what you eat):
As an internist, you can:
- Opt to see no inpatients and just defer to hospitalist (often without even touching base with the hospitalist about the patient's medical issues/history/med list)
- Squeeze in 4-5 99213 DM,HTN,HLD well controlled patients q3 months for blood work - commend the patient on a job well done, increase doses of medications - done in 5-10 minutes - with a good EMR crank out a note that is meant for billing in 5 more minutes with maybe one or two lines that reflect what you actually did
- Making sure all age appropriate screening is UTD. You can actually put in CPT billing codes if the patient has their updated screening! And get paid!
- Giving advice about tobacco cessation, alcohol cessation, fall risk, dementia assessment with MMSE, debility/home care assessment. Although you may have to fill out forms for this, you can use CPT codes to get money!
- Do 5 minute pre-employment examinations for otherwise healthy young people who just need a PPD/QuantGold, hepatitis, and MMR, varicella serologies done.
- Do a 5-10 minute preoperative evaluation for a cataract in an otherwise healthy individual and get paid for a CPE with the preop CPT code!
- Make some extra change doing ECGs, giving vaccinations, AAA screening (there are dedicated machines that do this), ankle brachial indices, skin biopsies (can get some side training), stress ECG (in underserved areas), wound care (again, get some side training), arthrocentesis (again, get some side training), office spirometry (though granted most of these may be useless without the coaching of a seasoned respiratory therapist, but it still pays), pulse oximetry (it really pays with its own CPT code, you just need to ICD10 justify their pulmonary disease), 6MWT, teaching how to use an inhaler and Aerochamber. All of these things have CPT codes that pay.
- When a patient has multiple advanced chronic comorbidities, the consultants in private practice will take ownership of their disease process (for patient care and also to keep their business afloat. Neurology will take care of the CTS now. Cardiology will no longer trouble you with the AFib and the INR checks, Pulmonology will handle the inhalers, etc..)

As a nephrologist, you can:
- See busy clinic patients who complain that a $40 co-pay is too much and you are not doing anything radically different than their PMD (i.e. in that short of arranging for HD or maybe hooking a 24 hour ABPM monitor on a patient, everything a nephrologist does is the same thing an internist can PHYSICALLY DO, though there may be some subtle expertise involved. Such as knowing how to use diuretics in a CKD patient. Although patients may not appreciate this subtlety)
- Get woken up at odd hours of the night for your ESRD patients needing urgent HD.
- At best see 2 patients an hour who have advanced CKD and need a lot of education about diet, AV access, medication reconciliation, transplant, etc... for the same CPT codes as the internist
- Only the nephrologist has no business getting the extra change for the above mentioned CPT code earning potential the internist can, see above.
- Get to travel between your clinic, the HD unit(s), and the hospital. See the same cardiorenal, ATN, CKD5 no follow up consults over and over again. Chase down ATN patients on HD like a lawyer chasing an ambulance.
- Worry day in and day out about the permacath that continues to be in... while the patient's AVF fails to mature after multiple revisions... and then bacteremia from the catheter develops... or an atrial thrombus forms...
- Get docked by CMS yearly with diminishing payments for ESRD
- Struggle mightily to convey to patient's how to maintain a reasonable dry weight... when the hyperosmolarity of their blood from the BUN stimulates thirst nonstop... it's like talking to a brick wall.
- Struggle mightily to convey to patients to take their phosphorus binders with every meal... only to find that the patients are eating snacks with high phosphorus content and don't take an extra binder... and when you prescribe more... they cannot pick it up due to high copay costs.
- Be expected to take care of ALL of their primary care needs in the HD unit... when you don't have the time nor are you incentivized to do. Further by doing so, you jeopardize the relationship with that PMD who may no longer refer to you.
- Work up a RARE nephritic/nephrotic syndrome case... arrange an IR CT guided biopsy... get a diagnosis... only to find they have IgA nephropathy and nothing you do will stop them from going into ESRD in 20 years... or find they have LN Class 3 with low IFTA and chronicity scores... then you get to prior authorize 6 months of mycophenolate mofetil or you realize you need to send them for a referral to an infusion center and then get the prior authorization and then not get any infusion fee charges since it's the rheumatology or hematology infusion center ... then once you get a remission, you realize the evidence base is unclear on how long maintenance therapy is... then the patient has a relapse... and then you agonize day in and day out on how best to proceed.


Is that all?


Solutions are:
- Don't do community nephrology at ALL. Stay academic, or do hospitalist and keep your LOS down by taking care of your own acute renal issues, or find a way to get ICU training.

- Combine nephrology and primary care and get the both of best worlds... and then do not see any ESRD HD patients at all. Plus you can do a great service for the DM nephropathies if you single handedly control their DM treatment and CKD treatment. A CKD3 patient with an A1c of 8% and ACR of 500mg/g does NOT NEED a PMD, endocrinologist, podiatrist and nephrologist tweaking ACEi and spironolactone (the latter also has antiproteinuric effects), titrating allopurinol, comment on weight loss, counseling on a low salt diet, tweaking doses of the diabetic meds for the eGFR, titrating diuretics for BP control, sending to opthalmology, and doing a foot/neuro exam... this patient needs ONE DOCTOR doing these things. And ONE DOCTOR can do all of these things and there is NOTHING SPECIAL a nephrologist does other than feel confident that the higher dose of ACEi and diuretics won't lead to any potassium problems since there is always kayexelate or Veltassa.

As for not seeing ESRD patients, there is no abandonment because there is a medical director, who is a nephrologist, at every HD center who would be happy to bill for your patient's HD sessions. You can remain their PMD. In fact, this may solve the problem of the nephrologist running around all day. What currently limits this is that most nephrologists WANT to go to the HD center and deal with all of those issues to get the change as HD is a "procedure." Of course, this "combined model" all depends on if you can get a job set up like that. This may require you to be in an independent or non-hospital owned practice and this is becoming harder and harder to do for most people.

- Do another fellowship training (if you can make it work logistically, match-wise, and financially). Nephrology + Cardiology, Pulmonary, or Endocrine may be good fits that allow you to make nephrology (no ESRD) the value added component. However good luck doing this. It would be more likely for one to do the other fellowship then do nephrology... but again most people don't do these kind of combination because no employers willl hire you with these multiple board certifications.

COMMUNITY nephrology is rapidly contracting and becoming the sole caretaker of CKD and ESRD patients.
Interventional nephrology will never take off (even discounting turf wars from vascular and IR) because each individual IN procedure pays relatively peanuts and you need a LARGE patient base to make it work... IR and vascular offset these costs by having other more lucrative procedures keep the ship afloat.


Nothing I said is particularly new or revealing... but I believe I have shed more light on how much more CMS values PMDs than nephrologists.



And again.. academic nephrology is another cup of tea. Not necessarily a better cup, but for some, the flavor is irresistible.
 
Last edited:

Nephro critical care

5+ Year Member
Feb 4, 2014
228
129
Status
Fellow [Any Field]
The problem is there is nothing at all appealing about being a community nephrologist compared to a community PMD. (Again, academic nephrology, transplant, research is a different cup of tea)

As a nephrologist, you can:
- See busy clinic patients who complain that a $40 co-pay is too much and you are not doing anything radically different than their PMD (i.e. in that short of arranging for HD or maybe hooking a 24 hour ABPM monitor on a patient, everything a nephrologist does is the same thing an internist can PHYSICALLY DO, though there may be some subtle expertise involved. Such as knowing how to use diuretics in a CKD patient. Although patients may not appreciate this subtlety)
- Get woken up at odd hours of the night for your ESRD patients needing urgent HD.
- At best see 2 patients an hour who have advanced CKD and need a lot of education about diet, AV access, medication reconciliation, transplant, etc... for the same CPT codes as the internist
- Only the nephrologist has no business getting the extra change for the above mentioned CPT code earning potential the internist can, see above.
- Get to travel between your clinic, the HD unit(s), and the hospital. See the same cardiorenal, ATN, CKD5 no follow up consults over and over again. Chase down ATN patients on HD like a lawyer chasing an ambulance.
- Worry day in and day out about the permacath that continues to be in... while the patient's AVF fails to mature after multiple revisions... and then bacteremia from the catheter develops... or an atrial thrombus forms...
- Get docked by CMS yearly with diminishing payments for ESRD
- Struggle mightily to convey to patient's how to maintain a reasonable dry weight... when the hyperosmolarity of their blood from the BUN stimulates thirst nonstop... it's like talking to a brick wall.
- Struggle mightily to convey to patients to take their phosphorus binders with every meal... only to find that the patients are eating snacks with high phosphorus content and don't take an extra binder... and when you prescribe more... they cannot pick it up due to high copay costs.
- Be expected to take care of ALL of their primary care needs in the HD unit... when you don't have the time nor are you incentivized to do. Further by doing so, you jeopardize the relationship with that PMD who may no longer refer to you.
- Work up a RARE nephritic/nephrotic syndrome case... arrange an IR CT guided biopsy... get a diagnosis... only to find they have IgA nephropathy and nothing you do will stop them from going into ESRD in 20 years... or find they have LN Class 3 with low IFTA and chronicity scores... then you get to prior authorize 6 months of mycophenolate mofetil or you realize you need to send them for a referral to an infusion center and then get the prior authorization and then not get any infusion fee charges since it's the rheumatology or hematology infusion center ... then once you get a remission, you realize the evidence base is unclear on how long maintenance therapy is... then the patient has a relapse... and then you agonize day in and day out on how best to proceed.


And again.. academic nephrology is another cup of tea. Not necessarily a better cup, but for some, the flavor is irresistible.
Your nephrology is strong as is your knowledge about primary medical care. Are you sure you want to give all that up and do a 3 year pulm/CC fellowship ? You would be a great asset to teach fellows in a training program .
 

Rupesh66

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Fellas u r right.Its better to complete Fellowship / get board certified then hunt on either Endocrinology/Rheumatology to make your life easy.Its better not to get involved ESRD patient.
 
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