Nephrology is Dead - stay away

[Renal_Prometheus]

sample7:

In a remote hospital - 4 nephrologists working as hospitalists and all private groups fighting with each other for consults/not have their patients seen by nephrohospitalists. Hospitalist groups dont want to employ anymore nephro trained people, to avoid the politics.

What a situation to be in !!! pathetic and we see absolutely no action from ASN or the programs. do a fellowship and diminish your chances even for a hospitalist job!!!

sample8:

Nephrology has a terrible attrition rate . In my group of 3 fellows I know 2 are no longer practicing nephrology. Unfortunately because of the drop in quality applicants nephrology programs are resorting to picking up burnt out hospitalists or applicants who couldn't make it into competitive specialities and who then accepted a position without having any interest in nephrology . But then academic attending nephrologists don't want to see patients or get phone calls at night and therefore they keep taking substandard applicants.

I think if there were to drop the number of positions to about half i.e 150/200 the quality of applicants would automatically rise and then with the reduced supply job market prospects would improve , salaries would rise . But that will lead to pain for the training programs in the short run but with long term gain for the speciality. But it's not human nature to usually take short term pain for long term gain.

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[Renal_Prometheus]

pretty much the same problems we talk about now. Nothing ever gets changed as long as fellowships can get a warm body. Human suffering just piling on year after year. And their are some nephrologists who will come on this thread and claim that nothing is wrong with this specialty. Everything is perfect and everyone will make partner and make lots of money.

 

[NewYorkDoctors]

In general if you apply that same hard work to building a solo primary care private practice after building savings as a hospitalist (thne build up partners ) , you will have more lifestyle and more money than most nephrologists out there . No overnight call as internist . Defer all admissions to hospitalist if you are solo or small group

The most realistic benefit of doing neph aat a big institution is the “easier way” of becoming a top academician.

 

[NewYorkDoctors]

At year 10, competitive NephMadness still delivers winners to the hoop

Yeah ... no

Cant fault the younger academicians from trying to make nephrology more interesting though. Plus this does nothing to increase nephrology applications. More reimbursement and work life balance will .

It does improve morale among those already in fellowship though

One comment caught my eye

The specialty of nephrology is facing an identity crisis. Applications to fellowship programs are declining, leaving even well-established programs unable to fill allotted positions,” according to the website. “Further threatening the specialty is loss of expertise as aspects of nephrology practice are being absorbed by hospitalists, intensivists, rheumatologists, interventional radiologists and cardiologists

How does a hospitalist absorb nephrology ? By taking care of prerenal azotemia and hypotonic hypovolemic hyponatremia so you don’t have to ? I know you want those RVUs but come on ...

How does an intensivist absorb it ? By managing fluid balance and only calling you for RRT? If you volunteer to be on the icu all day and night to monitor the fluid balance then fine ...

Rheumatologists seldom fully manage lupus nephritis unless the patient is going into CS and MMF anyway . Someone else still needs to follow proteinuria and titrate RAAS blockade

IR ? Are you serious ? Then go do IN and see how that turns out

Cardiology - huh ? They call nephrologist all the time before contrast and for diuretic assistance

The old guard just miss the time when they were the “smartest Docs .” A time before uptodate (which ironically was started by nephrologists)

 

[NewYorkDoctors]

69% of Fellowship Positions Filled, Down 5% Over AY 2021​

https://data.asn-online.org/briefs/12_ay-2022-match/

I would like to think this thread had something to do with it. But I’ll never prove it.

Fewer fellows obtained their fellowship in the post-Match scramble in the current academic year (AY 2021-2022) according to new data from the ASN Nephrology GME Census. This year, 109 PGY-4s entered after the Match, the lowest number since AY 2013, and down 24% over last year.

This is the key stat that makes me think this thread has been successful. But those poor souls who still took the scramble spot better have no student loans .

 

[Renal_Prometheus]

I would like to think this thread had something to do with it. But I’ll never prove it.



This is the key stat that makes me think this thread has been successful. But those poor souls who still took the scramble spot better have no student loans .

I like to think I contributed in saving some of those poor souls. I know some people think I’m bashing my own specialty, but it’s done for a reason. You have to believe that I’m doing in the best interest of the applicants. You just cannot believe what fellowship programs tell you about private practice especially when they are desperate for workhorses.

 

[NewYorkDoctors]

Nah no one thinks we are absolutely wrong or else more would come out of the woodworks to challenge our claims and would not yield to the retort of “you are successful becuase of your own efforts and not because the field of nephrology “

I don’t want the main match numbers to go down (those who wanted to enter renal ). I merely want the scramble numbers to go down as it reflects heartbroken a desperate cardiology pccm rejects and perhaps an older hospitalist who figured to give renal a try without having to commit to the “rigors” if the main interview season. This population is seriously being exploited to be a warm body .

 

[Renal_Prometheus]

Specialty is a sad state right now. Enter nephrology with the full understanding of the risks and be willing accept failure if it doesn’t work out for you.

 

[Renal_Prometheus]

You and I are in similar positions. My practice also hires people with the EXPECTATION that they will be partners. This has been the case for the past 30+ years except for 2 instances (one person left during the pathway as spouse got a different job and other opted to not become partner but wanted an employee contract of 40 hours week outpatient only work). Otherwise, people do a 2-year track to partnership and retire as such.

It probably takes 1-2 years to find a candidate. Nephrology graduates are in a commanding position these days. I continue to wonder if some areas are just too hard to be successful however. There has to be some due diligence on the side of the applicant, but to some degree, it seems like it should be like shooting fish in a barrel if geography or citizenship status are not issues.

I think nephrology historically has not done very well to make itself known. At my medical school, there was the month block of nephrology during second year. Some students rotated through nephrology during years 3-4, and some didn’t. Some did it during residency, and some didn’t. I’d say cardiology, icu, and leukemia or heme/onc were universally experienced, but that was not the case for nephrology, rheumatology, infectious disease.

My home program saw more interest (and later more applicants) after trying to make more effort with students and residents. Sounds simple, but I think a lot of programs have been slow to react to the current nephrology climate.

I think nephrology, dialysis, outpatient work, all of that is just such a black box for residents. For me personally, following a PP nephrologist was especially powerful, but I had to go looking for that. It didn’t fall in my lap.

There is definitely something (poor) to be said about having to push off a more immediate return…again…after all the schooling and training, but it made sense for me if I wanted to practice nephrology and do so with private practice. Not everybody wants the entrepreneurial side of it, but it makes sense to me to do it.

Sure, someone could put in the same work and do well with cardiology or something else instead, but I find myself talking to residents who want to do nephrology or folks who are already in nephrology fellowship so that’s a moot point.

Your perception of the job market is inaccurate. What you describe is not the norm, and more like what fellowship program sell you on as an applicant. False hope that must graduates cannot attain. Reality in private practice is a reflection of the market(people avoiding nephrology). Nephrology graduates are not in commanding position, because there was never a shortage of graduates(still 400+ graduate per year as you well know). There is a shortage of nephrologist only in the sense that many quit to take on hospitalist jobs because the reimbursement/lifestyle ratio is not acceptable. You are lucky that you landed well, but that is not the representation of the norm. And many people will damage their own careers by taking your advice. Because you know why? if most neph grad did as well as you are describing, there would be no shortage of applicants to nephrology. The market always tells truth. 20 yrs ago, nephrology was one of the most competitive specialties and their was no shortage of applicants. Were people complaining back then nephrology was poorly taught in med school or we need to raise more awareness of the specialty because there are no applicants? No, because 20 yrs ago nephrology had money. The market is telling you that no applicants = lack of money. This is true in every specialty. So, the fact that applicants are not going into nephrology, the market is telling you somethings has gone really wrong with this specialty. The market is always right. People can give their own experience, but that doesn't mean it is generalizable to everyone or even the norm.

 

[NewYorkDoctors]

Yep exactly. I am happy for Chemist's success and I hope he/she thrives and does well with the new residency program starting at his/her hospital.

But for one successful nephrologist (or any physician) to say "hey everything is fine for me. what's the big deal?" is akin to saying "it is super cold where I live. what global warming?"

As in my previous algorithm slide, if you like nephrology and don't have the objective of making the most money in the world, go ahead and do nephrology and be an academician. you will be happy with your choice.

If there is any potential thought of being more than a clinician educator or research, seriously think long and hard about this choice.

For the love of whoever you believe in, do not SCCRAMBLE into nephrology unless you have a very clear plan in place.

Do research and work as hospitalist and try cardiology or PCCM again, Trust me it will be owrth it

 

[Tenesmus83]

Your perception of the job market is inaccurate. What you describe is not the norm, and more like what fellowship program sell you on as an applicant. False hope that must graduates cannot attain. Reality in private practice is a reflection of the market(people avoiding nephrology). Nephrology graduates are not in commanding position, because there was never a shortage of graduates(still 400+ graduate per year as you well know). There is a shortage of nephrologist only in the sense that many quit to take on hospitalist jobs because the reimbursement/lifestyle ratio is not acceptable. You are lucky that you landed well, but that is not the representation of the norm. And many people will damage their own careers by taking your advice. Because you know why? if most neph grad did as well as you are describing, there would be no shortage of applicants to nephrology. The market always tells truth. 20 yrs ago, nephrology was one of the most competitive specialties and their was no shortage of applicants. Were people complaining back then nephrology was poorly taught in med school or we need to raise more awareness of the specialty because there are no applicants? No, because 20 yrs ago nephrology had money. The market is telling you that no applicants = lack of money. This is true in every specialty. So, the fact that applicants are not going into nephrology, the market is telling you somethings has gone really wrong with this specialty. The market is always right. People can give their own experience, but that doesn't mean it is generalizable to everyone or even the norm.

You make some good points. I live in a city where half of the Nephrologists are working as hospitalists/internists, and not in the specialty that they trained it. I doubt these people would have done nephrology if they knew the job market was this bad. I just don’t see this happening in other specialties, even the low paying ones(ID, endo). So I agree it’s immoral to tell applicants an overly optimistic view of private practice without mentioning the negatives. Just my 2 cents.

 

[Chemist0157]

Yep exactly. I am happy for Chemist's success and I hope he/she thrives and does well with the new residency program starting at his/her hospital.

But for one successful nephrologist (or any physician) to say "hey everything is fine for me. what's the big deal?" is akin to saying "it is super cold where I live. what global warming?"

As in my previous algorithm slide, if you like nephrology and don't have the objective of making the most money in the world, go ahead and do nephrology and be an academician. you will be happy with your choice.

If there is any potential thought of being more than a clinician educator or research, seriously think long and hard about this choice.

For the love of whoever you believe in, do not SCCRAMBLE into nephrology unless you have a very clear plan in place.

Do research and work as hospitalist and try cardiology or PCCM again, Trust me it will be owrth it

For the record, it's not just me...The fellows I worked with from my year and before and after me landed well. You would know the name of the program, but it is not a top program. I am not calling from an ivory tower... I have contacts from other programs as well. People have done well in both academics and private practice. And now, I'm in private practice, and it seems more difficult to find good candidates compared to historical experience.

I suspect it has something to do with IMG status or strength of program or geography. There are too many spots. The demographics of the applicant pool are also quite different compared to 10+ years ago. There are definitely poorer candidates that scramble into desperate programs. Why else would the testing be worse other than a worse fellow pool? From a jobs standpoint, there are 100% areas of the country that are saturated. You have to go where the jobs/patients are, and I do think nephrology requires some flexibility.

But I sort of stepped away from this conversation because it feels like we are from different planets given our experiences. I am not trying to mislead anyone. I just think in the quest to stop just about anyone from going into nephrology there is collateral damage as there 1) are people who would do fine given their situation and 2) are people who have already made up their minds. So I offer advice in red flags for programs and jobs, things I watched out for myself.

After all, I think we are (mostly) on the same side...I said a while ago, I wish the powers that be would go on a fact finding mission to guesstimate what the nephrology workload is going to be in coming years, account for retiring nephrologist, then adjust fellowship spots for that. Maybe easier said than done, but I pointed out a while ago they expanded spots around the same time applicant pool was shrinking. ???

As far as the market goes, it comes in cycles. Nephrology is in it. Radiation oncology and emergency medicine are more recent examples. This is not a new phenomenon. Calling it "dead" makes no sense however. Y'all brought up the ASN data and mentioned filled spots were down, but they were down a little after a big jump from 2019->2020 after low and flat numbers for years. MD/DOs were up, IMGs down. Numbers jumped back to 2014-2015 levels. Now what does it mean? I don't know for sure if that is a new trend or not. I don't get that excited because the number are still not great. However, I do think the job market eventually adjusts to account for the graduate pool. That is how markets work.

So we'll see. Keep telling the people who are trying to scramble into another subspecialty after not making it into their first choice to just go do something else, but residents who know they want to do nephrology can reach out to me for advice.

 

[NewYorkDoctors]

Keep telling the people who are trying to scramble into another subspecialty after not making it into their first choice to just go do something else, but residents who know they want to do nephrology can reach out to me for advice.

Yep that is the crux of my position on this thread. My mission is to reduce the cardiology and pccm rejects from scrambling in as they will most likely not be happy with their choice and it will not help them into CCM.

Also your colleagues may have found good jobs also but again that’s still anecdotal and that’s good for all of you. Though to be fair , all of this thread is anecdotal including mine . But there will never be a double blind RCT on this topic. We can just put the cards on the table and let the applicants decide .

 

[Chemist0157]

Yep that is the crux of my position on this thread. My mission is to reduce the cardiology and pccm rejects from scrambling in as they will most likely not be happy with their choice and it will not help them into CCM.

Also your colleagues may have found good jobs also but again that’s still anecdotal and that’s good for all of you. Though to be fair , all of this thread is anecdotal including mine . But there will never be a double blind RCT on this topic. We can just put the cards on the table and let the applicants decide .

That is exactly right.

 

[Renal_Prometheus]

You make some good points. I live in a city where half of the Nephrologists are working as hospitalists/internists, and not in the specialty that they trained it. I doubt these people would have done nephrology if they knew the job market was this bad. I just don’t see this happening in other specialties, even the low paying ones(ID, endo). So I agree it’s immoral to tell applicants an overly optimistic view of private practice without mentioning the negatives. Just my 2 cents.

The problem is, who is incentivized to speak the truth? Fellowship programs will always give a positive spin on the specialty, because they need the cheap labor. Private practice nephrologists who have done poorly may be too ashamed to speak up, and certainly doesn't help their careers by warning off applicants. So do we just not say anything and watch programs mislead applicants into a dead specialty and let them figure out years later it was a trap and they wasted years of their lives?

 

[Tenesmus83]

The problem is, who is incentivized to speak the truth? Fellowship programs will always give a positive spin on the specialty, because they need the cheap labor. Private practice nephrologists who have done poorly may be too ashamed to speak up, and certainly doesn't help their careers by warning off applicants. So do we just not say anything and watch programs mislead applicants into a dead specialty and let them figure out years later it was a trap and they wasted years of their lives?

just let it go man. I agree with your sentiment but people are not stupid. They know that good specialties are competitive and the bad ones go unfilled. They know they are taking on a lot of risks, deep down inside. Let them have their day in the sun.

 

[NewYorkDoctors]

Hopefully the ones taking the risk are those without student debt who will at least feel proud of being a “specialist .”

 

[Renal_Prometheus]

People get tired of being sold hopium all the time.

 

[Renal_Prometheus]

I’m starting to see more academic nephrologist leaving academic jobs to seek higher pay in private practice doing guess what? Hospitalist Medicine. It must be so hypocritical for there guys to woo applicants with false claims of great job market and high pay, only for them demonstrate these lies when it comes to their own future. Irony is so biting.

 

[Renal_Prometheus]

One more caveat to applicants. If a specialty needs to beg applicants to join, it’s not a specialty worth joining. You just don’t know all the traps that come with it, but trust me, it’s not a coincidence certain fellowships don’t get filled.

 

[voxveritatisetlucis]

is it possible to go back to being an internal medicine attending after doing a nephrology fellowship if nephrologists do in fact get paid much less than internists?

What are some other IM fellowships to stay away from (aside from nephrology)

 

[Renal_Prometheus]

is it possible to go back to being an internal medicine attending after doing a nephrology fellowship if nephrologists do in fact get paid much less than internists?

What are some other IM fellowships to stay away from (aside from nephrology)

I would say avoid all fellowships that are easy to get into. It’s self-explanatory, but some people still need to be reminded of to use common sense.

 

[Renal_Prometheus]

is it possible to go back to being an internal medicine attending after doing a nephrology fellowship if nephrologists do in fact get paid much less than internists?

What are some other IM fellowships to stay away from (aside from nephrology)

If you just spend some time reading this whole thread, nephrologists going back to work as hospitalist is so common nobody will bat an eye. 30-50% of the grads will leave nephrology within 5 years of graduation.

 

[voxveritatisetlucis]

I would say avoid all fellowships that are easy to get into. It’s self-explanatory, but some people still need to be reminded of to use common sense.

True but sometimes match rates don’t necessarily correlate with competitiveness due to self selection.

In your opinion, would IM fellowship difficulty rank like

Cardiology > hemonc > pulmonary > gastro > endocrinology > nephrology > infectious disease > geriatrics

 

[Splenda88]

All I can say is that there are 2 nephrologists and 1 endocrinologist in my hospitalist group.

 

[Renal_Prometheus]

True but sometimes match rates don’t necessarily correlate with competitiveness due to self selection.

In your opinion, would IM fellowship difficulty rank like

Cardiology > hemonc > pulmonary > gastro > endocrinology > nephrology > infectious disease > geriatrics

I would put nephrology behind ID, and ahead of geriatrics. Don’t underestimate what the market is telling you. The fact that nephrology and geriatrics have so many unfilled positions each year, the market is telling you something about those specialties income potential, lifestyle, and job satisfaction. You gotta read the tea leaves. As an example, if nephrology became the most lucrative specialty tomorrow, I have no doubt it will also be the most competitive specialty. There is no arbitrage opportunity.

 

[Renal_Prometheus]

After 137k views, this thread must be the most read SDN thread of all time. I’m glad I am able to do some good for this world. After watching my friends and colleagues go through the full rollercoaster of initial optimism, fall for the empty promises in fellowship, preyed on by greedy employers, worked hard to be partners but don’t share equally with old timers, to ultimately accepting reality and returning to hospitalist medicine, I’ve witnessed more than my share of horror in this specialty. I hope by shining a light on this situation, future generations can learn from our mistakes. Doesn’t the old saying goes “you get what you payed for”? Does joining a specialty that others avoid really an escape from your current career situation? Is it worth wasting many years of your life to figure out why people are not going into nephrology?

 

[Splenda88]

After 137k views, this thread must be the most read SDN thread of all time. I’m glad I am able to do some good for this world. After watching my friends and colleagues go through the full rollercoaster of initial optimism, fall for the empty promises in fellowship, preyed on by greedy employers, worked hard to be partners but don’t share equally with old timers, to ultimately accepting reality and returning to hospitalist medicine, I’ve witnessed more than my share of horror in this specialty. I hope by shining a light on this situation, future generations can learn from our mistakes. Doesn’t the old saying goes “you get what you payed for”? Does joining a specialty that others avoid really an escape from your current career situation? Is it worth wasting many years of your life to figure out why people are not going into nephrology?

Let's be honest here! The whole medical education system is just a joke. No need to spend 11 yrs to become a practicing physician.

The whole thing can be 2 yrs prereqs, 3 yrs medical school and 2+ yrs residency. A lot of the 2 yrs fellowship can be accomplished in 1 yr. I bet some of the 3 yrs can be accomplished in 2 yrs.

Do you really need to do a 4-yr of residency to become a good a psychiatrist?

Geriatric fellowship for IM/FM docs... Really!

Ped hospital medicine fellowship after doing a peds residency... Seriously!

The problem is 50%+ of medical students and residents buy into these BS...

 

[Renal_Prometheus]

I don’t think many neph applicants know this, but a lot of nephrologists go into academics because they have trouble finding a lucrative private practice worth joining. These people want to make money, but like I said before, the number of worthwhile nephrology jobs are very limited. So these people who cant find a good job, are the same people who are saleing this specialty to applicants with tales of amazing job opportunities. The farce and hypocrisy of the whole thing is incredible. I know because I’ve been around the block a while. But some of these graduating residents still fall for the smiles and lies.

 

[NewYorkDoctors]

If you are in a literal ivory tower and see the super rare nephrology diseases and transplant and do research , you will be happy and satisfied . But most academics are clinician educators with the associate or assistant professor title who don’t do hardcore research and don’t make the big bucks and always lament one way or the other . But it’s better than the dog eat dog life of the private practice nephrologist who does not already own the local HD market . New blood not welcome


Addendum:

one of my medical student research mentees (yeah although I not a big time NIH research. but I do still stay active in helping the fellows and residents at one of the hospitals I am voluntary faculty at get things published as a hobby. This way I can remind myself I am not JUST a private practice monkey) was unable to match into residency this week. His SOAP is not going well. I mention this to one of my neph colleagues who is a nephrology fellowship PD at a nearby university affiliated community tertiary care program and jokingly asked him if he would take this individual who is not renally trained internationally. He said it is not ideal as he would like someone who finished residency versus someone who is internationally trained in nephrology. He said he would like to have at least a medicine preliminary year done and would take someone who finished a medicine preliminary year at least to go straight to neph fellowship. Well I can't fault the PD for trying. I would probably do the same thing if I were in the PD's shoes. Anything to fill fellows.

Addednum 2
The IMg student soaped into IM . Good for him . The IM program there has core faculty who are all renal board certified . Guess a neph can also join IM residency as well as clinics faculty and make a nice career as a …. Hospitalist

 

[Renal_Prometheus]

If you are in a literal ivory tower and see the super rare nephrology diseases and transplant and do research , you will be happy and satisfied . But most academics are clinician educators with the associate or assistant professor title who don’t do hardcore research and don’t make the big bucks and always lament one way or the other . But it’s better than the dog eat dog life of the private practice nephrologist who does not already own the local HD market . New blood not welcome


Addendum:

one of my medical student research mentees (yeah although I not a big time NIH research. but I do still stay active in helping the fellows and residents at one of the hospitals I am voluntary faculty at get things published as a hobby. This way I can remind myself I am not JUST a private practice monkey) was unable to match into residency this week. His SOAP is not going well. I mention this to one of my neph colleagues who is a nephrology fellowship PD at a nearby university affiliated community tertiary care program and jokingly asked him if he would take this individual who is not renally trained internationally. He said it is not ideal as he would like someone who finished residency versus someone who is internationally trained in nephrology. He said he would like to have at least a medicine preliminary year done and would take someone who finished a medicine preliminary year at least to go straight to neph fellowship. Well I can't fault the PD for trying. I would probably do the same thing if I were in the PD's shoes. Anything to fill fellows.

It's all too common. Fellowship programs that don't fill try to lure in IMGs who weren't able to match into IM residency, with the promise that once they finish fellowship the program will strongly recommend them to a IM residency. It's all empty promises and exploitation basically. IM now a days is way more competitive than nephrology. The ones who have tried this, that I know, have not been able to match into IM residency after finishing fellowship. Just despicable they play on the heart strings of the desperate. It tells you the state of this specialty. These are the same people who are telling applicants about the amazing long term financial prospects of this specialty. So great that 30% of the fellowship spots are unfilled? So great that only 45% of the neph grads are going into private practice based on the most recent statistics. People need to stop falling for these traps and academic nephrologists needs to stop lying. Some of these "sales pitch" are so outlandish that even the person pitching them don't believe them.

 

[Renal_Prometheus]

I don’t understand why people think that going into a specialty, with no barrier to entry, will end well for the fellow. Wasting years of your life to realize you are just better off taking a hospitalist job is the more likely outcome.

 

[Renal_Prometheus]

For those neph fellows who are living in the academic bubble. I wonder if you stop to think. If the specialty is really as good as the academics are telling me, why is it that fellowship spots go unfilled?. Can the market really misprice this specialty this badly? I can tell you that 20 yrs ago, when nephrology was lucrative, it was one the most competitive specialties. So clearly the market is efficient and always accurate reflection of financial realities on the ground. So what is the market saying right now when 30-40% fellowship spots has been unfilled for the past decade? It’s telling you that there are problems way beyond your initial understanding of private practice. It’s telling you these academics are living in a bubble and giving you a biased version of reality. That is the truth. The market is never wrong. Only people are wrong.

 

[NewYorkDoctors]

Again for those who don't care about making money (or don't need to the primary breadwinner in the family - this can mean male or female) and who like the discipline of nephrology, then please go for this specialty and get the best training you can get at a top academic center. We definitely need nephrologists (just not ambulance / ATN chasing dialysis doctors). But if there is any consideration that you need more revenue (like to pay off student debt or you have 3-4 kids or something) , then really stop and think about an alternate subspecialty. The worst thing in life is to end up with debt. Money cannot buy happiness persay. But lack of money can indeed cause hamper the ability to be happy.

 

[Renal_Prometheus]

I want to give another piece of advice for neph grads looking for jobs. It will come in handy as a red flag. First of all, you should never trust completely what an employer tells you. He is the one getting the deal. You are working for cheap(starting salary of 200k/yr) for 2-3 years with only the promise of making you partner. And believe me, I’ve seen my fair share of broken promises. A common statement is that employers will say the last person who joined left after a couple of years “due to family reasons”. This is a red flag in nephrology. It’s a diplomatic way for the both parties to part ways, but trust me, there is a lot more to the story. And the reason why it’s a red flag in nephrology can be understood from a financial standpoint. Imagine yourself working couple of years with a low starting salaries only to pick up, leave, and start over again at another group? Does this make any financial sense? Most people that I know, where things didn’t work out with their group and had to move, went back to hospitalist medicine. The financial penalty to start all over again is too high that people are not gonna go through the BS of starting at 200k/yr all over again. So now imagine if a group trying to recruit you tells you multiple former partners left for “family reasons”. Things start to get suspicious doesn’t it? One of my friends who left his group and gave the reason as “family reasons” was actually dissatisfied with how money was shared among the partners. Another friend, who also left his group and gave “family reasons” as his excuse, left because he didn’t think the group was gonna make him partner, so he cut his losses. So leaving “due to family reasons” is a diplomatic way for both parties to move on without badmouthing each other. But this does not mean these people really left due to “family reasons”. And in nephrology, due to the financial arrangements stated above, this is actually a red flag.

 

[NewYorkDoctors]

In general , if you are the owner of a private practice you make so much more money than a hospital employed physician because yo y don’t have to pay for all the ancillary staff of a hospital , clinic , or administration . All the revenue flows to you to use on your overhead . As a result you get to keep much more disposable income . Therefore there is no incentive for a private practice to hire you and allow you to “collect all.” You are designed to make X revenue and give Y % of revenue to the senior partners as a form of tribute . This is not just nephrology but all kinds of businesses in general . The old wants the young to pay tribute .

Unfortunately pure nephrology is not conducive to a pure solo private practice for the all of the aforementioned reasons

If you had a choice between private nephrology or private internist , go with the latter . Easier pay (as in you can always refer hard cases ) and less (or no travel ) 99213 pays the same for a healthy person who needs a work form filled out as it does for a ckd hypertensive diabetic non adherent patient

 

[Renal_Prometheus]

For those die hard neph applicants, one good way to screen out the good vs bad programs is to ask the PD straight up: “ why do nephrology programs go unfilled?” It’s a fair question, especially if the PD is claiming how well their grads have done. The bad programs will give you long winded answer, because they are trying to hide something. The good programs will give you a short answer.

If you want to know the program even better, ask the PD: “ in the last 5 years, how many of your grads have chosen to be hospitalists?”. Any hesitation or long winded answer is a sign of concealment. You want to go to a program where faculty is open about the problems with this specialty. Not try to hide the truth and take you for a sucker.

 

[NewYorkDoctors]

Honestly most of the top academic programs have a pretty good track record for getting an academic job or getting a not too shabby private practice job. Hence the true nephrology applicants wil have a good time anyway finding their careers . It’s really those low tier programs that get people in the scramble that are trying to sucker you. In general do not scramble into an open renal program in the soap . See entire thread

 

[Renal_Prometheus]

Another job hunting from me. Absolutely DO NOT join a solo nephrologist! They are solo for a reason. It does not matter how reasonable they sound or what they promise you. They are looking to take advantage of you. None of my friends who joined solo nephrologist ended well. A lot the older nephrologist, about to retire, are hoping to get you on board so they can cash out and sell their practice to you. Any fair practice group does not require junior guys to buy out senior guys. They are inherited for free and senior guys retire with nothing.

 

[Renal_Prometheus]

Let’s be frank. The reason residents choose to not go into nephrology is because opportunity cost is way too high, with uncertain upside of whether they will even be better off than a hospitalist, post-partnership. All these ex-nephrologist who are working as hospitalists are examples of people misguided by their perception of this specialty. Reality is much crueler. Stop chasing a specialty just because it’s easy to get into. The market is all knowing. There is no specialty that is easy to get into and also lucrative at the back end. Just look all the nephrologist who are working as hospitalists as warnings. Don’t believe what fellowship programs are telling you about private practice. Listen to common sense.

 

[Renal_Prometheus]

I still have friends who are practice nephrology, are partners in their respective group, and are not making much money and not happy with their career decisions. The problem is sometimes you have invested too much into it and hard to pull out, despite objectively they would be better off financially just taking a hospitalist positions. This is while their working years are wasting away. It's called sunken cost fallacy and why I push so hard for applicants to avoid falling to this trap. Looking at my personal experience, most fellows don't know how bad private practice is until they take a job. It's better to completely transparent up front and make sure applicants are aware of the risks they are taking before even embarking on this road.

 

[NewYorkDoctors]

I’ll reiterate that private practice GIM can more easily do a 99213 mill and make more than the non - boss nephrologist and do it easier as well without the call emergencies .

So unless one plans to be an academic nephrologist (nothing wrong with that . We need all the bright minds in the field ) , I see no reason why anyone would choose private practice nephrology over private practice GIM (unless you are the boss who inherits all the HD patients )

 

[Renal_Prometheus]

The competitiveness of a specialty is always congruent with earning potential of a specialty. There is no exception to this universal fact. So I am really perplexed when these neph fellows graduate and are surprised that specialty actually struggles to make money. It’s like “why do you think it’s easy to get into to begin with”. Of course your attendings will lie to you about the job market. How else is he supposed to fill fellowship spots in a failing specialty. By telling you the truth? These people are so ignorant.

 

[voxveritatisetlucis]

The competitiveness of a specialty is always congruent with earning potential of a specialty. There is no exception to this universal fact. So I am really perplexed when these neph fellows graduate and are surprised that specialty actually struggles to make money. It’s like “why do you think it’s easy to get into to begin with”. Of course your attendings will lie to you about the job market. How else is he supposed to fill fellowship spots in a failing specialty. By telling you the truth? These people are so ignorant.

Peds? Seems somewhat popular

 

[Renal_Prometheus]

Looking back at my decision to do nephrology, there was some major miscalculations. The most damaging misconception, was that I thought once you payed your dues to a group and became partner, you will do well financially. That’s what academics try to sell you on. It actually turned out to be a half-truth. You can read the thread “why neph graduates will not make the same as their partners”. Some of my friends were lied to by their group and was shown the door after hustling for their group for many years. Others were given “partnership”, but money was not shared evenly with the senior guys and so essentially partner in name only. Very few did well enough to say it was a worthwhile investment of ones time. Quite an investment if you think about it. Two years of fellowship plus 3 years of indentured servitude so that you will make the same to a little less than a hospitalist on a per hr basis. In other words, If the hospitalist worked the same number of hrs as the nephrologist, the hospitalist will make more. This is why the specialty is non-competitive. But the resident and fellow in me was too naive to question the misleading intentions of my attendings. From their perspective, half-truth are not technically lying as a small percentage of grads can still do well. That’s the only thing they can still sell applicants on. Bunch of hopium. Otherwise it’s just a horrible specialty.

 

[NewYorkDoctors]

Private practice is only profitable and worthwhile to do if you are the boss . It’s much easier to go solo as a PCP , cardiologist , GI , pulm , AI , rheum since you can do procedures and turf all inpatient management to the in house hospital team. Yes technically pcp who gets proper additional training can do and bill for arthicenresis , knee injections , exercise stress ecg , basic spirometry , skin biopsies z

Nephrologist cannot easily go solo as you are enslaved to the HD machine (in more ways than one )

Either go academic Or don’t bother to do private practice if you aren’t the boss / family connections .

 

[Renal_Prometheus]

I could have, like many nephrologists, sat back and just watch more applicants fall into the same trap and lies over and over again. It's not like other people ruining their own careers is gonna affect me. It's their decision. But I chose to stand up and state the obvious because too many of my friends have been harmed by this specialty. It is a real shame that people really don't know what they are signing up for. I wanted the applicants to see all the negatives before making this type of career decision, because clearly their academic attendings are not telling them this for reasons we have discussed before.

 

[NewYorkDoctors]

I have received several PM from lurkers on here thanking me for providing such unabashed advice . One individual said he she was torn but really liked nephrology due to hisher persons background as a fluid engineer . I encouraged this candidate to apply to the best nephrology program out there and to get top academic training

But there were many others out there who wanted to try to just be a specialist and could not get cardiology pccm or gi and thanked me for the cold hard advice regarding how bad non academic nephrology is out there for new graduates and opted not to apply or scramble to a renal fellowship .

Some took my advice and said he she will do the renal training but focus in GIM primarily with nephrology (no or minimal HD ) as a secondary .

The goal here is not to eliminate nephrology as a discipline . That’s silly . The goal is to save the careers of those who do not plan for an academic nephrology career from going into a fellowship with cold feet

 

[Renal_Prometheus]

And I’m completely fine with people who want to do nephrology for the interest. But when you look around to see this many ex-nephrologists who are now hospitalists, clearly these people had no idea what they signed up for.

 

[Kaustikos]

And I’m completely fine with people who want to do nephrology for the interest. But when you look around to see this many ex-nephrologists who are now hospitalists, clearly these people had no idea what they signed up for.

I don't think you're being mean. This honesty should be brought up more and more. I would hate for people to tell me to go into ID with lies/empty promises and I show up with this completely different training and also poor outlook for job prospects when I graduated. 2 years of my life wasted? I already wasted 7 with med school and residency, let's not make it any worse.