Nephrology is Dead - stay away

[NewYorkDoctors]

I will just bump my algorithm. There will be those who go down the pathway to "Definitely apply to renal fellowship at the highest academic program you can get into and go onto the research track." I dont want to discourage those applicants. They should continue to pursue their pathway in life. They will find a way to make things work.

I just don't want unsold residents going into this pathway being hoodwinked with half truths and hopes of glory by unmatched program's PD who just want a warm body.

And personally I fall under the "Consider doing renal fellowship and doing a second subspecialty."

I like the discipline of nephrology. But the business aspects of it are horrendous in private practice. By piggybacking it to my main subspecialty (see my prior posts), I can see as much or as little nephrology and stayed interested in these cases but not be bogged down by the drudgery of chronic HD.

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[bronx43]

I will just bump my algorithm. There will be those who go down the pathway to "Definitely apply to renal fellowship at the highest academic program you can get into and go onto the research track." I dont want to discourage those applicants. They should continue to pursue their pathway in life. They will find a way to make things work.

I was in academia and I literally know no one who actually succeeded in academia as defined by securing a grant, who was:
1. Under age of 40
2. MD/DO without a PhD
3. Not already plugged into the research ecosystem with multiple NIH funded mentors

Even with all 3 above, the odds are stacked heavily against you.

Honestly, the academic landscape is total waste of time outside of the top echelon, and by the time you're in residency and applying to fellowship without 15 first author papers, it's already over. Your career trajectory at that point is to match into a top program, ask to stay for an extra 2 years, work full time in a NIH funded PI's lab, get lucky by publishing a handful of high impact papers as first author, apply for a K grant, secure K grant, continue to publish high impact papers, then apply for R01, and secure R01 (10-15% funding rate).

This road is close to impossible. You have a better chance at YOLOing into platypus coin and becoming a crypto millionaire.

 

[deleted941485]

I was in academia and I literally know no one who actually succeeded in academia as defined by securing a grant, who was:
1. Under age of 40
2. MD/DO without a PhD
3. Not already plugged into the research ecosystem with multiple NIH funded mentors

Even with all 3 above, the odds are stacked heavily against you.

Honestly, the academic landscape is total waste of time outside of the top echelon, and by the time you're in residency and applying to fellowship without 15 first author papers, it's already over. Your career trajectory at that point is to match into a top program, ask to stay for an extra 2 years, work full time in a NIH funded PI's lab, get lucky by publishing a handful of high impact papers as first author, apply for a K grant, secure K grant, continue to publish high impact papers, then apply for R01, and secure R01 (10-15% funding rate).

This road is close to impossible. You have a better chance at YOLOing into platypus coin and becoming a crypto millionaire.

There isn’t enough meaningful research going on to justify the sheer volume of would be academics. Literally all your doing is adding to the surplus army of underpaid clinicians who will spend more time in clinic than anywhere else.

 

[NewYorkDoctors]

I was in academia and I literally know no one who actually succeeded in academia as defined by securing a grant, who was:
1. Under age of 40
2. MD/DO without a PhD
3. Not already plugged into the research ecosystem with multiple NIH funded mentors

Even with all 3 above, the odds are stacked heavily against you.

Honestly, the academic landscape is total waste of time outside of the top echelon, and by the time you're in residency and applying to fellowship without 15 first author papers, it's already over. Your career trajectory at that point is to match into a top program, ask to stay for an extra 2 years, work full time in a NIH funded PI's lab, get lucky by publishing a handful of high impact papers as first author, apply for a K grant, secure K grant, continue to publish high impact papers, then apply for R01, and secure R01 (10-15% funding rate).

This road is close to impossible. You have a better chance at YOLOing into platypus coin and becoming a crypto millionaire.

yes that pretty much sums it up.

the flipside is not everyone has the capital to launch his/her own private practice. some might want to just be a permanent clinical instructor / assistant professor of medicine as a clinician-educator and do some low level publications with the fellowship. at least they have somewhat easy hours.

 

[bronx43]

yes that pretty much sums it up.

the flipside is not everyone has the capital to launch his/her own private practice. some might want to just be a permanent clinical instructor / assistant professor of medicine as a clinician-educator and do some low level publications with the fellowship. at least they have somewhat easy hours.

Agree, but then it goes back to the fact that they need to have a rich spouse or not live a middle class lifestyle. The idea that someone should excel academically and train for a decade just to eek out a substandard existence working for an academic hospital is abhorrent.

I think the wisest thing is simply not to do neph. A sub-specialty where private practice has been utterly destroyed should not be an option for any self aware internist.

 

[90sportsfan]

That's a good question, and it varies. The biggest drop-off I observed as in the 1-4 years immediately after clinical fellowship. At this point, folks held an instructor/assistant professor position and often worked with a senior mentor in order to get a K-grant (or equivalent). However, after a few failed attempts or disillusionment about a research career, more than half left to academic clinical faculty, PP, or industry without issue. The second drop-off was going from a mentored researcher on a K-grant to an independent (e.g. R01 funded) investigator. Most of them switched to academic clinical faculty without much issue -- with variable amounts of sustained research time and with some continuing to submit grants.

In terms of strength of training, I suppose your clinical training will be weaker than your purely clinical counterparts (e.g. less likely to get Level 2/3 in cardiology, less advanced procedures in GI, etc.) That being said, I haven't met anyone who had any trouble moving to a clinical position. Hope that helps.

Thanks so much for this information! I appreciate it.

 

[90sportsfan]

I totally agree with what @Seattlemdphd said.

I am currently finishing my fellowship and looking for academic jobs. And I got interviews for physician scientist (75% research) positions. You don't need to worry about transitioning to a clinical position if without funding, as this is the case for many (if not most) physician scientists. Some people go to private practice which is influenced primarily by the market force (demand and supply) and the only thing that most employers care is that you are board certified.

Regarding clinical competence, I believe you can continue to learn and grow as you go to practice, and this is what I am told by many of my physician friends.

Thank you!

 

[Renal_Prometheus]

Agree, but then it goes back to the fact that they need to have a rich spouse or not live a middle class lifestyle. The idea that someone should excel academically and train for a decade just to eek out a substandard existence working for an academic hospital is abhorrent.

I think the wisest thing is simply not to do neph. A sub-specialty where private practice has been utterly destroyed should not be an option for any self aware internist.

When you are a desperate applicant who can’t get into anything else and a PD from big name program comes calling with promises of lucrative career, you will be moved to act as well. Unfortunately, most will end badly, but it’s really the hope of an escape from a dreaded hospitalist job that propel many in their 40s to take the leap. Some lessons just need to be learned the hard way.

 

[bronx43]

When you are a desperate applicant who can’t get into anything else and a PD from big name program comes calling with promises of lucrative career, you will be moved to act as well. Unfortunately, most will end badly, but it’s really the hope of an escape from a dreaded hospitalist job that propel many in their 40s to take the leap. Some lessons just need to be learned the hard way.

I don't buy that most nephrology fellows couldn't have done ID, palliative, or geriatrics. I would bet that the top half of neph fellows can confidently secure a more competitive specialty.

And if one doesn't like hospital medicine, GIM is becoming a solid option for most people.

 

[NewYorkDoctors]

I don't buy that most nephrology fellows couldn't have done ID, palliative, or geriatrics. I would bet that the top half of neph fellows can confidently secure a more competitive specialty.

And if one doesn't like hospital medicine, GIM is becoming a solid option for most people.

Well it’s the folly of the uninformed resident that thinks a nephrologist can open an HD center or an infusion center for glomerular disease and print money like the cardiologist with the nuc and the echoes . That’s why some people buy the half truths sold to them and do not do ID Geri or palliative . Hopefully this thread has opened their eyes .

GIM can be quite good . As an employed physician , the revenue / effort ratio is rather good (better than hospitalist anyway depending on set up ). In private practice you can open a 99213 mill (a more profitable one than doing nephrology - see prior posts ) doing nothing but refilling meds , prescribing inappropriate antibiotics , referring to specialists Willy nily , and documenting “quality metrics .”

 

[Renal_Prometheus]

Agree, but then it goes back to the fact that they need to have a rich spouse or not live a middle class lifestyle. The idea that someone should excel academically and train for a decade just to eek out a substandard existence working for an academic hospital is abhorrent.

I think the wisest thing is simply not to do neph. A sub-specialty where private practice has been utterly destroyed should not be an option for any self aware internist.

When you are a desperate applicant who can’t get into anything else and a PD from big name program comes calling with promises of lucrative career, you will be moved to act as well. Unfortunately, most will end badly, but it’s really the hope of an escape from a dreaded hospitalist job that propel many in their 40s to take the leap. Some lessons just need to be learned the hard way.

I don't buy that most nephrology fellows couldn't have done ID, palliative, or geriatrics. I would bet that the top half of neph fellows can confidently secure a more competitive specialty.

And if one doesn't like hospital medicine, GIM is becoming a solid option for most people.

There’s also quite a bit of misinformation that academics throw at fellows/residents. They will say things like previous grads have done well. Yeah, like 10 yrs ago, when there was still opportunity to JV on new units. Anyone who graduated in the last 5 yrs and who have done private practice knows opportunities are not the same as people who started a decade ago. Dialysis units are not popping up like McDonald’s stands anymore. The market for dialysis is quite saturated and existing units profit margins have been declining every year. This is on top of a bad lifestyle with night calls for emergent HD. So if you are busting your ass, and making middle of the pack money(relative to all subspecialties), then at some point a light switch will turn on and say hey, it’s not worth doing this. Why don’t I just take a hospitalist job and get half of the year off.

 

[Renal_Prometheus]

Subconsciously, we all know that specialties who can’t fill are bad. But for some people who are desperate, they will trick their own minds into believing a certain narrative, in order to justify their poor decision making. I’ve seen this a lot in neph grads, who due to sunken cost fallacy, refuse to acknowledge that it was bad career choice despite being severely underpaid with no prospect for improvement. It’s like a bad stock trade, but the trader doesn’t want to sell and take the loss because he is too emotionally invested in it. The psychology behind this phenomenon is quite fascinating I must say.

 

[NewYorkDoctors]

When you are a desperate applicant who can’t get into anything else and a PD from big name program comes calling with promises of lucrative career, you will be moved to act as well. Unfortunately, most will end badly, but it’s really the hope of an escape from a dreaded hospitalist job that propel many in their 40s to take the leap. Some lessons just need to be learned the hard way.

There’s also quite a bit of misinformation that academics throw at fellows/residents. They will say things like previous grads have done well. Yeah, like 10 yrs ago, when there was still opportunity to JV on new units. Anyone who graduated in the last 5 yrs and who have done private practice knows opportunities are not the same as people who started a decade ago. Dialysis units are not popping up like McDonald’s stands anymore. The market for dialysis is quite saturated and existing units profit margins have been declining every year. This is on top of a bad lifestyle with night calls for emergent HD. So if you are busting your ass, and making middle of the pack money(relative to all subspecialties), then at some point a light switch will turn on and say hey, it’s not worth doing this. Why don’t I just take a hospitalist job and get half of the year off.

A nephrologist works as just as hard as a cardiologist in many respects. However, the nephrologist cannot collect as much revenue as the cardiologist due to how most nephrology procedures have an associated facility fee taking the cut from the CPT codes billed. Again, it's not all about the total money made. It's about the revenue / effort ratio. Many older docs despise this concept of "work life balance." Therefore, I do not even mention that aspect.

The Revenue / Effort ratio was quite high for the mercedes 80s doctors who sold their HD units and now live in luxury. Therefore, their opinion about the nephrology lifestyle should not be taken seriously.

That ratio is very low right now for most new renal graduates in private practice who are slaving away,

 

[Renal_Prometheus]

I don’t understand IMGs fascination with doing a subspecialty, even if it means worse reimbursement/lifestyle. It seems like USMDs have clearly figured out it’s not worth doing.

 

[georgestone]

I don’t understand IMGs fascination with doing a subspecialty, even if it means worse reimbursement/lifestyle. It seems like USMDs have clearly figured out it’s not worth doing.

There are plenty of USMD who follow the same route and get their Behinds Kicked , like me lol
but I agree IMG's predominate when it comes to choosing subspecialties of all sorts , It takes a serious beating or rude awakening to realize that one made a bad career choice !! , most of the Neph grads I came across who somehow were still practicing Nephro had basically settled with the fact that switching field or transitioning to IM/GIM was an option with Stigma so they opted to live and practice in misery rather than loving it , though there are some I know who still pretend that they Love it .
bad life style , little or no recognition, nothing ground breaking in the field and on top of that bad wages , Its a recipe for Disaster , but like me most of us realize after going thru it rather than being informed ahead of time .

That's why this forum is so VITAL !!

 

[NewYorkDoctors]

dunno why there is stigma associate with GIM. if that's the only reason why someone is staying in nephrology, that person should really do some deep introspection. there is nothing stopping someone from keeping the Nephrology BC for prestige and then doing more GIM like I mentioned in prior posts. a nephrologist can easily do a CME only obesity medicine course and get BC that way and be "triple BC" for more artificial sweeteners.

 

[Renal_Prometheus]

There are plenty of USMD who follow the same route and get their Behinds Kicked , like me lol
but I agree IMG's predominate when it comes to choosing subspecialties of all sorts , It takes a serious beating or rude awakening to realize that one made a bad career choice !! , most of the Neph grads I came across who somehow were still practicing Nephro had basically settled with the fact that switching field or transitioning to IM/GIM was an option with Stigma so they opted to live and practice in misery rather than loving it , though there are some I know who still pretend that they Love it .
bad life style , little or no recognition, nothing ground breaking in the field and on top of that bad wages , Its a recipe for Disaster , but like me most of us realize after going thru it rather than being informed ahead of time .

That's why this forum is so VITAL !!

I completely agree with you. People like myself and my cofellows were sold on complete lies when we’re lured into doing fellowship. A false optimism that traps you into years of indentured servitude. Real life private practice is much worse. In the end, the only winners are the fellowship programs and senior partners who you are slaving for and getting payed peanuts.

 

[NewYorkDoctors]

There is a reason why the academics and ASN leadership do not chime on this thread . They know we are right about private practice nephrology and the horrors there .

Moreover I’ve paid lots of lip service about how great academic nephrology can be for certain doctors and I have actively encouraged residents who really love nephrology to pursue it. It’s not just not for everyone . I don’t think any academic Nephrologist would (or openly admit ) want a non interested applicant for nephrology fellowship .

For those who are on on the non-academic track , there’s just not much there in this non - thriving subspecialty. See entire thread

 

[Renal_Prometheus]

If the specialty gets rid of some of the exploitation going on in private practice and if PDs are a little bit more transparent on the financial challenges that new grads will encounter, I actually think it’s a very much needed specialty. It just pays poorly relative to workload, and certainly relative to top specialties.

 

[The kitchen sink]

Does it boil down to this?: In pvt practice, with current reimbursement schemes, you have to see an unreasonable volume of patients to keep food on the table?

 

[Renal_Prometheus]

Does it boil down to this?: In pvt practice, with current reimbursement schemes, you have to see an unreasonable volume of patients to keep food on the table?

people do a fellowship to be better off than a hospitalist(either financially or lifestyle). Not to be worse off.

 

[NewYorkDoctors]

Does it boil down to this?: In pvt practice, with current reimbursement schemes, you have to see an unreasonable volume of patients to keep food on the table?

Somewhat.

The caveat is - if you are the owner of your own private practice and you have your own HD patients, then the current reimbursement scheme is not terrible. Somewhat better than PCP though you have to bust it to make the money.

If you are a contracted employee of a private practice whose contract is salaried, you are probably giving up 50% or more of the revenue you generate to the bosses. So you are working twice as hard for what you actually get paid. This is a form of paying tribute. This is not unique to nephrology but it is common in most private practice structures. The idea is that eventually you will make your due and prove yourself to the bosses and be made partner and collect a higher % of that revenue (some part always goes to overhead , mortgage, etc...)

But many times, you are not made partner and are just used and abused and forced to work twice as hard while the old docs collect your hard work. THIS is unique to nephrology as there is a lot of abuse.

But one might say, other private practices in other subspecialties also have this kind of abuse. True. But a cardiologist can open his / her own practice and start seeing patients right away (assuming an investment in echo machines, stress test, holter, etc...). A GI can invest in scopes and start right away.

A nephrologist CANNOT break free and start his/her own practice and see HD. HD privileges are very territorial and will NOT be granted to anyway. Therefore, this is all a racket designed to keep the HD patients concentrated around the well established private groups.

This is thesis of this entire thread. Private Practice (not academic) nephrology is a organized racket. Pay tribute to the bosses and know your role. If you dont, you may try to start up yourself. But without politicking and maneuver, you will be shut down.

 

[The kitchen sink]

Somewhat.

The caveat is - if you are the owner of your own private practice and you have your own HD patients, then the current reimbursement scheme is not terrible. Somewhat better than PCP though you have to bust it to make the money.

If you are a contracted employee of a private practice whose contract is salaried, you are probably giving up 50% or more of the revenue you generate to the bosses. So you are working twice as hard for what you actually get paid. This is a form of paying tribute. This is not unique to nephrology but it is common in most private practice structures. The idea is that eventually you will make your due and prove yourself to the bosses and be made partner and collect a higher % of that revenue (some part always goes to overhead , mortgage, etc...)

But many times, you are not made partner and are just used and abused and forced to work twice as hard while the old docs collect your hard work. THIS is unique to nephrology as there is a lot of abuse.

But one might say, other private practices in other subspecialties also have this kind of abuse. True. But a cardiologist can open his / her own practice and start seeing patients right away (assuming an investment in echo machines, stress test, holter, etc...). A GI can invest in scopes and start right away.

A nephrologist CANNOT break free and start his/her own practice and see HD. HD privileges are very territorial and will NOT be granted to anyway. Therefore, this is all a racket designed to keep the HD patients concentrated around the well established private groups.

This is thesis of this entire thread. Private Practice (not academic) nephrology is a organized racket. Pay tribute to the bosses and know your role. If you dont, you may try to start up yourself. But without politicking and maneuver, you will be shut down.

Well summarized

 

[Renal_Prometheus]

Trying to do solo nephrology now a days is very unrealistic. You will spend more time driving between hospitals then seeing patients. So the only way is to join a group, and agreeing to their rules on sweat equity. You will sweat for sure, you may or may not have equity after the sweating.

 

[Renal_Prometheus]

With the financial landscape in nephrology today, it really is a very high risk specialty with limited upside potential(from a financial standpoint). So the applicant really needs to ask himself whether it's worthwhile to invest this many years to potentially end up back as a hospitalist down the road. Whether that is an acceptable outcome if it comes to it. It is very real, and the sad part is that fellowship programs will try to hide and mislead them into doing what's in their best interest.

 

[Renal_Prometheus]

In Greek mythology, Prometheus was an entity who defied the gods and taught mankind the truth on knowledge and fire. This was always my intention. To unveal the facade and misinformation that applicants are being indoctrinated with by the academics. I want to show you the bare bones reality of private practice and why this specialty is not competitive so that you are not another warm body for a failing specialty that can’t get anyone else. The market is always right, but people will lie when it suites their best interest. I recall when I applied for fellowship, there was very limited information and many of it was untrue, which led to many career tragedies down the road. If you are dead set on this, make sure you can take the pain when nephrology doesn’t work out for you. Truth is always brutal, but someones gotta say it.

 

[NewYorkDoctors]

Yes. Don't be Icarus and fly too close to the sun. Dont be Persephone and fall for the forbidden fruit. (Half your life in Hades... sounds like private practice nephrology if you are not the boss). On the flip side, you can enter academia and be on Mount Olympus... a true Ivory Tower experience.

 

[georgestone]

Yes. Don't be Icarus and fly too close to the sun. Dont be Persephone and fall for the forbidden fruit. (Half your life in Hades... sounds like private practice nephrology if you are not the boss). On the flip side, you can enter academia and be on Mount Olympus... a true Ivory Tower experience.

If one really is inclined towards academics then is Nephrology really rewarding ??
the volume of landmark trials in critical care , cardiology or Heme/onc clearly show how dry/sterile Nephrology is ?
Nothing ground breaking recently where as other specialties are coming with a lot of new stuff , Nephrology came up with new K binders ,
LOL
that tells you the magnitude of potential

In my view there needs to be sharp reduction in fellowship spots so that oversupply vs demand can be reversed , but even that will not sort the extortion and non viable financial side of this Field

 

[NewYorkDoctors]

Well .. not everyone is qualified to become an academic in cardiology Heme onc etc . Anyone and I mean anyone who is better than mediocre can be a renal academic these days . Nothing against the older academics who are leaders of the ASN . They come from a different generation

 

[Renal_Prometheus]

Well .. not everyone is qualified to become an academic in cardiology Heme onc etc . Anyone and I mean anyone who is better than mediocre can be a renal academic these days . Nothing against the older academics who are leaders of the ASN . They come from a different generation

Seriously, couple of my buddies who couldn’t make it in private practice went back to academics. It’s also a common destination for IMGs with visa problems who were not offered partnership by their group as a way to escape the exploitation. The academics centers will sponsor the Visas, otherwise they would have been trapped by their employers. How many times do I need to keep saying that people with visa issues should definitely avoid nephrology.

 

[NewYorkDoctors]

This is a brief reddit thread from about 10 months ago. Based on reading the comments, it seems like the comments are from med students and PGY1 interns mostly. The negative nephrology vibes are already entrenched in this younger medical professional population. There is no hope for the ASN. #STARTreks and #NephMadness lol. please.

Let's dissect a few of these responses.

When it comes to newly minted clinical educators in an academic set up for a nephrology, this is a spot on statement. I will also add that the nephrologist is more at the mercy of the Cardiothoracic Intensivist (the extension of the surgeon) than the Cardiologist.
On the flip side, this is a M-4 who probably only sees the fellowship and large academic center faculty physicians. Therefore, I can see where this bias stems form.

Yep sounds like a med student who doesn't have any loans to pay back and whose parents have an educational savings fund. $175K in a large metro are will NOT cut it. One can argue that the residency /fellow salary like 60-80K might be better because they have education, food, and housing stipends.

The peds neph job sounds right on the money. Academics do pay less. It's not just nephrology. In general academics pays less than PP. Because in PP, you are the hunter and if you hunt more, you eat more. If the private groups are poaching consults from the faculty group, then the hospital cannot justify the (already low) salary of the academic group and will force cuts or force more business (hence the fellow comes in for all BS consults). As for those PP jobs... well yes... but not everyone can get those. See this entire thread.

You're not wrong about the first line. I often thought that the renal fellow works almost as hard as the cardiology fellow (CCU in house night call vs out of house night call but need to come in for HD is a toss... depends on volume) but gets far less kudos and reward down the line.
As for the ownership of the dialysis center, I will say Renal Prometheus will have more to say about this (see prior posts also)

This is probably the most accurate statement describing a "thriving" private practice nephrologist.

This is also a fair statement. But this is a med student who did an academic nephrology rotation. Therefore you bet they will have seen a lot of GN, transplant, and systemic "cool House MD" kind of cases. This is NOT what happens in private practice. One could be an academician, maybe do renal transplant subfellowship, etc... and then be a Dr House. House MD did "dual residencies" in Nephrology and Infectious Disease. That shouldn't be a very hard combination to achieve in real life.

Yep pretty much. Though to be fair, the inpatient HD patients are the real trainwrecks and IM residents often get a kind of selection bias that all HD patients are trainwrecks. There are "thriving" HD patients who actually avoid hospitalizations and seem "normal." But only the nephrologists see those patients outside.

Money cannot buy happiness. But being broke can lead to depression. Life's unfair.

Yes, this is the thesis of my posts within this thread.

 

[NewYorkDoctors]

There is another thread. I will just choose the replies with substance and not empty one liners.

Well this is called a thriving renal private practice. IT takes years to reach this level of success and you must have partners who you can rely on (and not backstab you). Again this is the pinnacle of renal private practice. But this is not something that everyone can achieve.

This is funny because it is not untrue. Maybe written for a cardiology or PCCM fellow at PGY6. Lol.

"indentured servitude." I wonder if this individual read this thread as my use of this term predates "3 months ago."

Well this is a true statement. But I will say, this is a fairly thriving nephrologist who already has accumulated 25 + HD patients. It will take some time to reach that number from when you start unless you are an ambulance chaser in the ER and smooch for consults. On the flip side, the patients on HD will STILL ask the nephrologist for PCP problems. Trust me on that one. Can you really turn them down? They will give you those big puppie eyes...

Yep pretty much. Unless the doctor has research grants or has a spouse who makes more money, going super academic is not meant to be a big moneymaker. Again money isn't everything, but can we really afford to go broke in the era of wild inflation?

I would say this is a fair point. But sounds like this doctor is not working in a large urban metro area. But I will say if you go rural, you can find good jobs in nephrology. But the same can be said for cardiology, heme onc, pulmonary, etc...

My ultimate counterargument is that a GIM physician who opens PP and joins an independent practice association in a large urban area and opens a 99213 mill can also make this amount (or even more) doing nothing more than screening, suboptimal management of chronic conditions, referring to specialists, and prescribing inappropriate antibiotics.

 

[Nephro critical care]

If I was a critical care program director and I had a choice of who I wanted to take for CC fellowship I would definitely not take a nephrology fellow. Looking at myself as a nephrology fellow suddenly applying for a CC fellowship in the last part of my second year as a nephrologist fellow I was a terrible candidate and should not have been taken but somehow I lucked out and got in.

I was a really cerebral person who had done extremely well in medical school exams and my USMLE boards. However I ended up taking a prematch for a community program IM offering H-1 visa. It was the post 9/11 era and all male candidates from my country had to go through FBI clearance and some of my co- medical school graduates were having J-1s denied by the embassy.

Anyway I was still drawn towards complex cases and in residency started getting drawn to nephrology. I was really interested in complex glomerulonephritis cases / thrombotic microangiopathies / immunosuppression in transplant patients etc. Anything cerebral. Those were my interest in my entire first year of nephrology and 3/4 of my second year. But when I got exposed to the job market in 2nd year I realized there was little cerebral that I would be doing. In my city there were 4 nephrology groups and these were all fighting over new consults for AKI/ATN. Once they got a consult they would never sign off from the patient even if creatinine was 0.9 for the extra billing. Nephrologists were driving to 7-8 hospital on weekends just to see 3-4 patients. That's not what I wanted to do.

I applied to critical care only because I was getting bored with the whole nephrology / dialysis set-up. My program director gave me a good LOR and somehow I matched at my first interview. Anyway I got in but struggled a lot in my first year. I hadn't done any lines in 6 years ; never had intubated a patient / done LPs / chest tubes etc. It took a lot of time for me to learn procedures and because of that it took me longer to learn the day to day critical care management. My only saving grace was that as a nocturnist I was good at diagnosing acute stuff quickly and deal with a high volume while being solo night attending managing both ICU and floor patients.

I wish I had wanted to do CC from the beginning. Then I wouldn't have wasted so many years of my life on a dead end field which didn't prepare me for what I am doing now.

If I was a CC PD I wouldn't take a nephrology fellow. I'd would though take a hospitalist who has worked 4-5 years in an open ICU / someone who has seen sick patients and can deal with volume.

 

[Renal_Prometheus]

It seems like most of the med students/residents had the belief that nephrology is poorly reimbursed with high work load. In my opinion, this is generally correct and they should be rightfully concerned about tying their future to a specialty like this. I'm just amazed that despite all the red flags, so many smart people still fell for the trap of chasing a failing subspecialty. In my case, it was a couple of trusted academics who basically lied to me about the financial picture in private practice. Nothing like pouring water on your head and learning lessons the hard way. School of hard knocks. You just can't trust anyone in this business, especially if they have something to gain from it. Whether its the older guys promising that they will make you partner(after x number of years), or slimy PDs promising critical care, they are profiting off you agreeing to a certain arrangement. The fellow is the one taking on all the risks. Unfortunately, what's end up happening a lot of times is that the only type people who agree to this are also the most desperate ones, who then get screwed the hardest in the end. Common sense will punish desperation.

 

[Nephro critical care]

I would especially warn burnt out hospitalists not to look into nephrology as an escape from a bad hospitalist gig. This is not an escape route and will set you further back in your career and cost you 400 K
(200 K loss per year of fellowship). You will be much better off trying to find a better hospitalist job.
I was lucky that I escaped into CC after my fellowship. I know two hospitalists who also tried the nephrology escape route and only realized after a couple of years of slaving at a PP job that they had jumped from the frying pan into the fire. They both contacted me while I was working at one of my smaller rural CC shop and were begging for hospitalist shifts so that they could come back to hospitalist medicine.
Once you go into nephrology its gonna be harder to come back to hospital medicine.

 

[NewYorkDoctors]

For any nephrologists who find themselves in a dead end non partner renal job and is non-academic (no fellows to see overnight patients and no cush amenities of a large tertiary care hospital) and who cannot get hospitalist shifts (sometimes the hospitals prefer easier to control recent IM graduates), I recommend looking into starting your own primary care GIM office. Maybe with a partner. Very low overhead. Sell your renal degree as a bonus for hypertension, T2DM management, and electroytes. Get obesity medicine board certified (check out ABOM - it is a CME pathway) for triple certification. If you still have your HD privileges, use it I guess. If you dont, don't worry. see my prior posts in this thread about how to be a primary care + physician and create a 99213 mill.

 

[Renal_Prometheus]

I would especially warn burnt out hospitalists not to look into nephrology as an escape from a bad hospitalist gig. This is not an escape route and will set you further back in your career and cost you 400 K
(200 K loss per year of fellowship). You will be much better off trying to find a better hospitalist job.
I was lucky that I escaped into CC after my fellowship. I know two hospitalists who also tried the nephrology escape route and only realized after a couple of years of slaving at a PP job that they had jumped from the frying pan into the fire. They both contacted me while I was working at one of my smaller rural CC shop and were begging for hospitalist shifts so that they could come back to hospitalist medicine.
Once you go into nephrology its gonna be harder to come back to hospital medicine.

People like us who have gone through neph fellowship, know that we are speaking the truth. But new applicants right out of residency might be swayed by an charismatic attending who would promise a highly lucrative career. They cannot believe that these respected figures will so blatantly lie to them in order to take advantage of their cheap labor in fellowship. I'm sure you consulted nephrologists prior to you joining fellowship. Why is there such a disconnect between what academics say and what really happens in private practice.

 

[NewYorkDoctors]

It seems there is another subset of applicants who exist that I should mention .

An IMG (with no student debt ) who has done hospitalist for A few years (and who has ample savings and no kids to pay college for )who feels disillusioned will scramble (why bother matching when scramble is easier for the IV schedule ) into a local nephrology program for the sake of specializing . He/she realizes this may not be a huge money maker but might have plans to try to do a hybrid IM / neph 99213 mill down the line . As long as this individual realizes that there is no easy big money in a traditional renal practice set up or if he she wants to go academic , then this is a reasonable avenue to get out of being a permanent resident as a hospitalist . But buyer should beware and have a clear cut plan in place and should accept the potential opportunity cost lost if this doesn’t go the way he she thinks .

 

[Renal_Prometheus]

If the average hospitalist works as hard as the nephrologist, they will make more. If the hospitalist picks up extra shifts, work the same number of hrs as the nephrologist, they should be able to hit 400k/yr(outside of a major metro city). This is without the need to do a fellowship or enter into an indentured servitude agreement with a senior guy hoping the be made partner down the road. I think especially for IMGs, the allure of wanting to be a subspecialist makes them tunneled vision and disregard financial opportunity cost.

 

[NewYorkDoctors]

Trust me there is no prestige to any sub specialty outside of being a top academician who publishes . I honestly don’t take any pride in being a physician . Meaning I don’t go around strutting how good I am . I just take care of my patients the best I can . Therefore anyone who thinks he she needs a subspecialty to validate himself or herself really needs to get a hobby. On the flipside , the doctors who go around thinking what a big shot he or she is should really find a hobby also.

 

[Renal_Prometheus]

The current landscape in nephrology is such that we are too underpaid for what what we do. Rely too heavy from investment income from JVs to make the difference. The difference between new grad and old timers are that they are the ones who own the JVs. They are not going to share in the revenue because they bought in years ago. And there are limited number of new dialysis units opening up, so new guy has no hope of matching the old timers in terms of income potential. So this is why you see the average income of nephrologist is pretty decent, but attrition rates among new grads are very high.

 

[Renal_Prometheus]

And then the other thing about nephrology that I don't like is that there is a culture of "hush hush", lets not tell applicants what we know and continue to market this specialty as if everyone is doing very well. A lot of half-truths and hoodwinking in the application process. Which is somewhat expected, what do you expect the PD to tell the applicants: "It's a bad specialty, don't go into it?" And even if you ask private practice nephrologist, they may not have the humility to admit their own mistake and tell you what they really think. I recall when I was in residency, their was this ex-nephrologist who was working as a teaching hospitalist, and this guy kept marketing to me how great nephrology is and how much money they were making. I was thinking this guy was crazy to be working as a hospitalist if nephrologists truly made that much money. In retrospect, everything made perfect sense why the specialty is at where it is today. But being young and impressionable, these misleading characters can really lead someone down a wrong career path unlike what they think they are signing up for. Hope younger generation can take heed of some lessons we learned the hard way.

 

[NewYorkDoctors]

Someone I know has had difficulty matching into a residency . Fmg who did a soap match into a medicine prelim year with no IM residency this year applied to a bunch of pgy 2 residencies but got no IVs. This asked me would it be worth it to do nephrology fellowship since he heard non IM resident graduates can do one . I told him that it will be painful and give you n o guarantees of an IM residency at pgy2 .

Rather I told him just use to soap again if no Iv or match to see what radiology neurology etc spot becomes available

 

[Renal_Prometheus]

Someone I know has had difficulty matching into a residency . Fmg who did a soap match into a medicine prelim year with no IM residency this year applied to a bunch of pgy 2 residencies but got no IVs. This asked me would it be worth it to do nephrology fellowship since he heard non IM resident graduates can do one . I told him that it will be painful and give you n o guarantees of an IM residency at pgy2 .

Rather I told him just use to soap again if no Iv or match to see what radiology neurology etc spot becomes available

It's just sad. Programs resorting to trapping desperate applicants and offer them nothing but hope. I don't know why any self respecting resident, with career options, would want to tie themselves to a specialty like this.

 

[NewYorkDoctors]

This person was under the impression that doing a nephrology fellowship would make him more advanced and make him more competitive for a pgy2 spot . I told him that would put him at pgy4 pay scale later on and that programs may decline based on the higher pay scale alone .

No one should ever do neph without residency unless they plan to go back to their home country and they just want the neph training for some kind of honorific or they have some special arrangement

 

[Renal_Prometheus]

The sinister part here is if these desperate fellowship programs get you to sign on, they got you for 2 years for cheap. They are the winners. You are the fool. They enjoy all the rewards of getting their nights covered and fellows doing all of the scut work. You spend the rest of your life trying to justify a bad decision and what's waiting for you in private practice is even worse exploitation.

 

[NewYorkDoctors]

Now if there were plenty of Cush academic jobs available (even those that pay low ) , then this whole thing with selling nephrology the discipline would be more palatable . Honest issue is there is a huge mismatch between supply and demand for nephrologist . Rural and underserved areas need them . Not so in the big urban areas.

 

[Renal_Prometheus]

The elephant in the room is that nephrology is just not worth doing anymore, financially speaking. That's why fellowship programs don't fill. That's why people don't want to go into it. That's why fellowship programs try to come up with all sorts of innovative ways to snatch a warm body. Promising applicants critical care, an IM residency afterwards?, good LORs for cardiology fellowship? The bottom line why fellowship programs need to do all sorts of innovative things to attract applicants is because the core product they are trying to sell, nephrology, is a bad product. It's like trying to sell a generic phone, but you have to attach coupons for a iphone with it. It's just not gonna work. You get a bunch of bottom feeders that's not going to advance your specialty at all, and potentially turn off higher quality applicant who may have a interest in the specialty.

 

[NewYorkDoctors]

When I see things like NephMadness and the an active social media presence for the ASN, I am not sure they are doing much to attract IM residents to the field. Most IM residents are NOT NERDS. Nothing wrong with a nerd. Nerds make good researchers. But you have to realize most IM residents are trained to be step down unit physicians and to have a pseudo-ICU mentality at all times for the ward patients. IM residency these days is primarily hospitalist training now. If the program is diverse with its training, the residents will have a 4+1 , 4+2 whatever set up to promote ample clinic time for outpatient medicine.


But because most IM residents have the "rapid response" mentality most of the time while inpatient, I do not think appealing to one's inner nerd is a successful strategy to recruit new applicants. Why else are PCCM and Cards so popular? The hectic urgent nature of the disease processes. Why is GI popular? money. Why is heme onc popular? money.

Does nephrology offer any urgency? Chronic missed HD. ill put the order and call the HD nurse. You guys put in the line. Real thriller there.
Does nephrology offer big money? no. see this entire thread. A highly ENTREPRENEURIAL nephrologist can make bank. Otherwise, nephrology itself does not make bank.
Does nephrology have lifestyle? No. You can give up HD to have a lifestyle but then you won't have much revenue.


The ASN should go back to the drawing board and making nephrology more... "rapid response" like. but outside of urgent HD, there really is no urgency to most of the disease processes.

Perhaps one suggestion is Nephrology should target residents who seem set on a PMD career and offer them training in the neph and maybe palliative subspecialty after to be quite a complete PMD Plus

 

[InternistDO]

Perhaps one suggestion is Nephrology should target residents who seem set on a PMD career and offer them training in the neph and maybe palliative subspecialty after to be quite a complete PMD Plus

Two (!) fellowships to get a primary care job, the career with the most wide open job market in medicine? This is on the same level as premeds who want say they want to dual specialize in neurosurgery and ophthalmology. Absolute insanity, and nothing more than taking advantage of trainees who don’t know any better.

The worst part is you could probably sweet talk some gullible residents into doing this, since academic IM residency tries to convince you that being a generalist is somehow shameful.