Nephrology is Dead - stay away

[Tenesmus83]

---

Members don't see this ad.

In my city of 10 nephrologists, half of them are practicing a combination of ER/internal medicine/hospitalists. These kids going into nephrology who think they can still make it big are in for a rude awakening.

 

[Renal_Prometheus]

There are 3 nephrologists at my new job who are moonlighting as hospitalists. One has left nephrology entirely for time being not happy with his previous job while 2 others do hospitalist work in their off weeks. Thats 4 including me ( CC ) not practicing their primary speciality full time.

I’m sure these guys knew what they were getting into when they were applicants. I’m sure they all went into nephrology for the passion and they would not hesitate to do it again 😉

 

[NewYorkDoctors]

There are 3 nephrologists at my new job who are moonlighting as hospitalists. One has left nephrology entirely for time being not happy with his previous job while 2 others do hospitalist work in their off weeks. Thats 4 including me ( CC ) not practicing their primary speciality full time.

I would venture to say CCM is your primary specialty.

There's no way to make a Renal CCM practice work unless you have some arrangement to see the floor consults for renal while in house for CCM. Aint no way you can make to renal clinic and round in HD centers with a CCM census.

But the renal groups would NOT allow a CCM person to poach their renal consults. I guess you could offer your services to see floor consults for renal for a privategroup during vacation, Sabbath, or whatever.

 

[NewYorkDoctors]

I’m sure these guys knew what they were getting into when they were applicants. I’m sure they all went into nephrology for the passion and they would not hesitate to do it again 😉

If they make it into the ivory tower of academics and become an ASN leader, then that's a pretty sweet career as an academic nephrologist. But can everyone become a leader of the ASN? nope.

As I have mentioned in my previous posts, I do enjoy seeing some renal patients now and then. I have a small renal panel and manage Lupus Nephritis, IgA nephropahty, FSGS, DKD, hypertension nephropathy, proteinuria (without CKD), and secondary hypertension. But I would have to say that is primarily as a hobby as doing renal alone (without a giant HD practice) would not pay the bills. IT is far slower than GIM and does not have the same billing codes as GIM. (GIM has a variety of quality metric and screening codes which add a little here and there)

As GIM you could pick up additional procedures like suturing, basic spirometry, skin biopsies, arthrocentesis, and some other things with the proper trianing and certification.

Nephrology in office? nothing natural other than Procrit injections 96372 which anyone can do honestly. (the code that is)

some private nephs around here are giving Prolia for OTP (for someone who has no CKD or CKD-MBD ... even then questionable if its indicated and something like Forteo or Tymlos should be used first) because the 94601 chemotherapy code on top of 99213 is used to double the revenue. it's really sad

 

[Nephro critical care]

I would venture to say CCM is your primary specialty.

There's no way to make a Renal CCM practice work unless you have some arrangement to see the floor consults for renal while in house for CCM. Aint no way you can make to renal clinic and round in HD centers with a CCM census.

But the renal groups would NOT allow a CCM person to poach their renal consults. I guess you could offer your services to see floor consults for renal for a privategroup during vacation, Sabbath, or whatever.

I have a little advantage that I am hospital employed as are our hospitalists and the hospital wants me to be a face of inpt nephrology / HD. After not practicing nephrology for so many years I wouldn’t feel comfortable managing GN but I think I will be able to manage a little ICU HD / CRRT.

 

[NewYorkDoctors]

I have a little advantage that I am hospital employed as our hospitalists and the hospital wants me to be a face of inpt nephrology / HD. After not practicing nephrology for so many years I wouldn’t feel comfortable managing GN but I think I will be able to manage a little ICU HD/ CRRT.

that's nice.

at the end of the day, nephrology "can work" if you want it to. Whether this means academics, private practice, or part time.

However, "making it work" means there is no standardized way of making that happen. The traditional private practice model is predatory to new attendings and incentives those older docs at the top. It is a form of plutocracy just like our government.

Why would anyone want to deal with the renal private practice market to be used like that?

No one ever said you had to do renal private practice or academics only. You could do Nephrology for 2 years to become a "specialist" and then not be a nephrologist full time. My recommendation has always been be a PCP GIM and then you can also practice nephrology if you own the practice. As hospitalist, this is less of a thing as your delineation of privileges are tied to your malpractice.

 

[Renal_Prometheus]

Fundamentally, the market dynamics today in nephrology is so bad for new grads that they are essentially choosing to work harder for less pay than a hospitalist, with much worst lifestyle. They are also subjugating themselves to the whims of senior partners to grant them partnership, and I’ve brought up plenty of horror stories of exploitation in the past. No other specialty has this combination of bad income/bad lifestyle/bad negotiating leverage. So how do PDs sell this? By sidestepping the brutal truth and selling on hopium and half truth. They will raise the best examples but won’t tell people the number of their own grads who are not practicing nephrology. Every time I come across a naive resident on SDN saying things like my neph attendings look happy, my gut just churns in their foolishness and lack of awareness. I tell people what they need to hear, and not what they want to hear. People need to have some self awareness to know that when a specialty is this easy to get into, there are bad things that will happen down the road that you have not considered. There is no free lunch in this world. Remember this!

 

[NewYorkDoctors]

Fundamentally, the market dynamics today in nephrology is so bad for new grads that they are essentially choosing to work harder for less pay than a hospitalist, with much worst lifestyle. They are also subjugating themselves to the whims of senior partners to grant them partnership, and I’ve brought up plenty of horror stories of exploitation in the past. No other specialty has this combination of bad income/bad lifestyle/bad negotiating leverage. So how do PDs sell this? By sidestepping the brutal truth and selling on hopium and half truth. They will raise the best examples but won’t tell people the number of their own grads who are not practicing nephrology. Every time I come across a naive resident on SDN saying things like my neph attendings look happy, my gut just churns in their foolishness and lack of awareness. I tell people what they need to hear, and not what they want to hear. People need to have some self awareness to know that when a specialty is this easy to get into, there are bad things that will happen down the road that you have not considered. There is no free lunch in this world. Remember this!

I’m sure an associate or full professor of medicine at an academic renal center is quite happy . But can every renal fellow graduate end up in a nice career like that ?

Boy winning the lottery powerball 1.5 billion sure would be nice . I’m sure we can all win if we bought tickets

 

[Renal_Prometheus]

Let me give you guys a picture of private practice and what oversaturation has done to this specialty. In nephrology, this becomes especially noticeable as even in a small city, you will find at least 2-3 competing groups. Since nephrology has no procedures that generate significant revenue, it's a volume based specialty that relies on large referral base, accumulate a lot of ESRD patients quickly, then leverage those pts to get dialysis unit Joint ventures and medical directorship fees to supplement your income. You will not make money if you go to a large city where there's multiple competing groups and you have to drive to 4-5 hospitals per day just to see a few pts. This is very common in large cities. I have a friend in houston who tells me they are so desperate that some nephrologists would camp out in the ED just go grab a few ESRD consults. Imagine begging hospitalists for consults, even though you have done 2 more years of training. does that sound like the life you want to live?

 

[Renal_Prometheus]

Did you know that dialysis reimbursement has not adjusted for inflation? 30 yrs ago Medicare payed $240/treatment for each outpatient dialysis treatment to dialysis center. That was a lot of money back then and you can see if an nephrologist did a JV, he/she could make a lot of money 30 yrs ago. Fast forward today and Medicare is paying only $260/treatment; this is all while inflation has exploded and HD employee salaries have increased multiple fold. CMS does not believe in inflation. It’s costing the HD unit around $270 in overhead expenses just to deliver a dialysis treatment. Believe it or not, FMC/DaVita is actually losing $10 for every Medicare patient they dialyze. They are completely reliant on commercial payers to make up this difference and if the unit doesn’t have enough pts with commercial insurance, they will lose money and probably close the unit. So now, nephrologists who want to JV with FMC/DaVita need to think twice about risk and reward. Not a no brainer anymore. This used to be half of a established nephrologist take home pay, is from investment income. Profit margins at these HD companies are dropping at an alarming rate due to yearly increase in staff salaries, but Medicare is not paying more for dialysis. This is why it’s a dead specialty for anyone with an economic understanding where things are headed.

 

[NewYorkDoctors]

This post is so naive it’s sad if this is a real med student .

While I do not doubt the sincerity of this student and the love of nephrology the discipline , it’s clear this person has no idea about the true finances of nephrology .

Then again none of us thought about money in med school for fear of being seen as a mercenary. It was a big no no to talk about money in med school . Guess it was for fear of jinxing it . Lol .

If you have no student debt and don’t plan on making a lot of money to do things like buy a house , start a family , and pay for your kids future college funds and love nephrology , then by all means proceed and do academic nephrology and stay far far away from private practice nephrology

If you want to do any of those things above (as people in the real world do ) , then consider doing something else . You can always do a renal fellowship after doing another fellowship . It’s not easy to do the reverse.

 

[Renal_Prometheus]

many of my co-fellows were staunch pro-nephrology advocates until they worked couple of years in private practice and realized how bad it was and why it's non-competitive. It takes a few years to sink in. Initially, people are emotionally invested in a specialty and there's a sunken cost fallacy, so they don't want to hear what you have to say.. Eventually the school of hard knocks will force them to bow to reality.

 

[Renal_Prometheus]

The other thing I don’t like about nephrology fellowships is that they are embarrassed that private practice reimursement is low relative to workload and that many neph grads are no longer practicing nephrology. But rather than be upfront, they choose to hide it or mislead applicants into thinking theirs more money than there actually is. Some specialties are very open about the fact that there’s no money, so applicant are well informed going into it; this is why you rarely seen endocrinologist or rheumatologist choosing to go back to hospitalist. In nephrology, the intentions are a little bit more sinister and academics are less upfront about realities of private practice. Understandable, as they need warm bodies to feed their night call system, but at the detriment of some poor suckers career. Perhaps this is why so many nephrologists are not practicing nephrology; because they didn’t have the info to make an informed decision before joining fellowship. Because there are always some older nephrologist who are doing well, fellowship programs can always point to them as examples when in reality this is no longer achievable(I’ve explained reasons for this phenomenon in previous posts). This is why I believe my specialty can cause severe career damage to a naive resident who went into the specialty at the recommendation of some academic. The high attrition rates in private practice are a testament that you should not believe anyone except the rules of common sense: lucrative specialties are always competitive, the bad ones are always non-competitive.

 

[Renal_Prometheus]

good things sell itself. If someone has to work very hard to sell you on a specialty, you should stay away. This is the moral of the story.

 

[Renal_Prometheus]

Now that I’m many years post-fellowship, I’m looking back and seeing the destruction this specialty had on the careers of my neph friends. As I have stated before, over half of my neph colleagues, who went into nephrology around the same time as I did, are no longer practicing nephrology. I think there are several lessons that can be drawn:

1) sunken cost fallacy. Just because you invested many years into it, doesn’t mean it has to work out. The financially smarter play may be just be to foot your losses and move on.

2). Conflict of interest with the fellowship program. They would love for you to believe it’s still lucrative in pp. They need bodies for scut work and you just can’t believe what they say when others are avoiding this specialty.

3). Listen to the market. When everyone is avoiding this specialty, the market is telling you something you were not aware of.

Ultimately, this journey is actually a test of your ability to recognize a career trap, despite all the misinformation in fellowship, then make adjustments to your initial career plans to avoid further calamity. The ones who did this succeeded. The ones who did a 2 yr fellowship, then gave their pp group 3-4 yrs getting payed a low salary, then realized they weren’t offer partnership or treated fairly in terms of revenue distribution, failed this test. It’s actually a test of your ability to adapt to new information and see through the misinformation and crowd effect that you typically experience in fellowship.

 

[NewYorkDoctors]

if you go to a top academic renal program and are planning to be an academic nephrologist who works at a tertiary care center and who teaches fellows, then you will have a good career and be satisfied. you may not be paid the most but that's not what you signed up for anyway I'd bet. I am sure that these faculty members (who are probably leaders in the ASN) are sincere in their desire to want to help you become the best nephrologist you can be.

the same cannot be said for mid tier and lower tiered community based nephrology programs. they just want you to be the warm body at night.

but like i mention before, not EVERYONE can have this kind of nice academic career. career. most graduates in any specialty or subspecialty end up in private practice. if you think private practice is where you will likely end up, seriously consider another subspecialty or just do GIM / hospitalist. seriously...

Cardiology and PCCM fellows work veyr hard, if not harder than a nephrology fellow (debatable depends on program, # of fellows, acuity of MICU and CCU etc..) ... but they have a nice big pot of gold at the end of the rainbow if they opt to go into private practice. nephrology does not.

 

[Renal_Prometheus]

Unfortunately, despite all our warnings, people will be still tempted to take the plunge and get their hands burned. Some Lessons just need to be taught the hard way.

 

[Renal_Prometheus]

Interesting survey of med students and there perception of nephrology. It seems like “low prestige” is a major factor in deterring people from applying; this is certainly not helped by fellowship programs taking IMGs with no US residency. Sheer desperation doesn’t exude confidence. In addition, these med students are unaware of the the predatory nature of fellowship programs or the exploitation commonly cited in private practice. They have just touched the tip of the iceberg. It’s best they don’t know.

Internal Medicine Residents’ Perceptions of Nephrology as a ... : Kidney360

reer in nephrology among internal medicine residents. Methods We recruited focus groups of internal medicine residents (N=25) from the University of Colorado, and asked questions aimed at exploring perceptions, attitudes, and barriers to a career in nephrology, and ways to increase interest in...

kidney360.asnjournals.org

Abstract​

Background Interest in nephrology as a career has declined dramatically over the past several years. Only 62% of nephrology fellowship positions are filled for the upcoming 2020 appointment year. The purpose of this study was to identify perceptions, attitudes, motivators, and barriers to a career in nephrology among internal medicine residents.

Methods We recruited focus groups of internal medicine residents (N=25) from the University of Colorado, and asked questions aimed at exploring perceptions, attitudes, and barriers to a career in nephrology, and ways to increase interest in nephrology. All focus groups were conducted on the University of Colorado Denver Anschutz Medical Campus. Focus group sessions were recorded and transcribed. Thematic analysis was used to identify key concepts and themes.

Results Residents described many barriers to a career in nephrology, including lack of exposure, lack of advances in the field, low monetary compensation, high complexity, lack of role models/mentors, and low-prestige/noncompetitive nature of the field. Most residents had no exposure to outpatient nephrology. Lack of new therapeutics was a significant deterrent to nephrology. Nephrology teaching in medical school was described as not clinically relevant and too complicated. Several residents felt they were not smart enough for nephrology. Only three residents had a role model within nephrology. Residents used the word “stigmatized” to describe nephrology, and discussed how low prestige decreased their interest in a field. Participants expressed suggestions to increase interest in nephrology through earlier and more outpatient nephrology exposure, enhanced interactions with nephrologists, and research and advancements in the field.

Conclusions Residents identified several modifiable barriers to a career in nephrology. Changing how nephrology is taught in medical school, enhancing interactions with nephrologists through increased exposure, and highlighting research and advancements in nephrology may change the perception of nephrology and increase the number of residents entering the field.

 

[NewYorkDoctors]

The thing is what is prestige?
Patients who need help with their ESRD , CKD, or GN still give the appropriate degree of respect to the nephrologist to help with their "prestige."

For residents (at least it was for me anyway), the prestige factor may come from how much exposure they get. MICU and CCU are required rotations and residents feel empowered by how "awesome" it is to manage serious disease and escape the doldrums of general medical floors and the "ho hum" of IM floor admissions. Due to a form of selection bias, residents only see the ho-hum inpatient renal cases which is not terribly different from general IM cases if you think about it. Most of the "cool" renal cases are all outpatient based.

Then again this does not answer why hematology/oncology has more prestige. Inpatient oncology cases are always consequences of their cancer or chemo and is not particularly thrilling on the inpatient side.

Ultimately it might be the fact how AMGs only see "IMGs and FMGs" in most of these programs. Nothing against those doctors as individuals (they might be the brightest in their class back in their home country).

 

[Renal_Prometheus]

And I disagree with the statement that increasing nephrology exposure in med school/residency or having more nephrology mentorship will increase the match rate. Is there a lot of dermatology exposure in med school? They don’t have problems matching. 30 yrs ago, when nephrology was lucrative, it didn’t have problems matching. It’s all about the money. All these peripheral reasons are just nice way of telling you it doesn’t make enough money to be worth my time. But unfortunately, reimbursement is not a modifiable risk factor!

 

[NewYorkDoctors]

And I disagree with the statement that increasing nephrology exposure in med school/residency or having more nephrology mentorship will increase the match rate. Is there a lot of dermatology exposure in med school? They don’t have problems matching. 30 yrs ago, when nephrology was lucrative, it didn’t have problems matching. It’s all about the money. All these peripheral reasons are just nice way of telling you it doesn’t make enough money to be worth my time. But unfortunately, reimbursement is not a modifiable risk factor!

#Kidney TREKS #NephMadness lol. gimme a break ASN.

The degree of copium on display among the ASN leadership is staggering.

Then again, the ASN is powerless against market forces and they are just doing the only they can... appealing to the inner geek of IM residents.

Addendum:

If I may use a political analogy... the ASN is giving red meat to their base (left or right is irrelevant for the purposes of this analogy) with their strategy. They are focusing on the science and medical knowledge of nephrology and how wonderful it is. I agree it is quite wonderful. But it is like doubling down on Ukraine (which the left and right both do) while ignoring inflation and how the Federal reserve is ruining the fiat currency (which is applicable to all people regardless of political affiliation).

Nephrology has no trouble attracting those are who very interested in the field. The top academic centers always match and get good applicants (AMG vs IMG is irrelevant. A good resident / doctor is a good resident / doctor) The issue is not many are very interested. You need to attract the "swing voters" but this strategy does not lead to greater number of applicants.

 

[NewYorkDoctors]

Congratulations to all of the Nephrology applicants who got into their top dream academic ivory white tower program. You will have a great education.


For those applicants who did not match into Cardiology or PCCM, I implore you to re-evaluate your application and try again in the next cycle. Get some experience as hospitalist and make more cardiology or PCCM connections and do some projects. Things will work out in the end!

For the love of (whichever deity you might happen to believe in... if at all), do NOT take a cold call or email from a Nephrology program. Do not get swindled into joining a program that is mid tier or garbage (because the best renal programs have been matched already usually).

If you are having a crisis of faith right now, please through this entire Nephrology is Dead thread.

Do not be a pawn for these unmatched renal programs (they are unmatched for a reason) to mortgage your future career for the feeling of "not being left out."

PM me if you have any questions

 

[Renal_Prometheus]

I don’t think these neph applicants are aware of what’s happening in private practice. Many neph groups have a business model of hiring unsuspecting new grads and work them hard for low salary, then not offer partnership after x number of years. I used to think this is rare until it started happening to some of my friends; then I realize it’s very common. Even better if these new hires have visa issues because then they can’t leave the practice or be forced out of the country. Exploitation is rampant in nephrology and these applicants actually think they lucked out by getting into a specialty that others avoid. Just amazing the information disconnect.

 

[NewYorkDoctors]

There is virtually no chance that you go from Nephrology to PCCM or Cardiology from a scramble Nephrology slot. Don't even think about it. The PCCM and Cards programs will question your intentions on which subspecialty you really want if you accept a Nephrology scramble spot. Do hospitalist for a year and do more research.

https://www.nrmp.org/wp-content/uploads/2022/11/Medicine-and-Peds-Specialties-MRS-Report.pdf

Cardiology filled 100% in the match. For those who did not match, do NOT take a cold call from a Nephrology program.
GI virtually all matched with one unfilled position (which was probably done on purpose to scramble a nepotism candidate lol)
hemeOnc has two unfilled positions (again to allow nepotism scrambles in probably)

ID filled 74.4% of their positions . not too shabby

Nephrology did 72.8% of their positions. that's quite the increase.

My personal goal was never to get that nephrology match % to 0. That is asinine. We need nephrologists. I am happy for those who want to do nephrology and who matched.

What we do not need are unmatched cardiology and PCCM applicants going into a nephrology scramble program and potentially ruining their careers and happiness over a need to avoid the feeling of FOMO. 19% of all certified applicants did not match. You should all strengthen your applications and try again next year. Do NOT take that nephrology fellowship cold call or email. Do NOT fall for any traps regarding "Nephrology - CCM" unless that program guaran-dam-tees it on paper (not going to happen).

 

[Renal_Prometheus]

Fundamentally, the issue is that most people who apply for nephrology are hoping to be better off than a hospitalist. But the reality is that most neph grads will waste many years to be worse off than a hospitalist. This is why I’m passionate about educating people because I’ve seen too many who have fallen into these career traps.

 

[NewYorkDoctors]

For any unmatched Cardiology or PCCM applicants, take heed to this thread. In your darkest moment of sadness, uncertainty, and self-doubt, just know that doing hospitalist (or something else) for a year or two while doing more research and making connections to strengthen your resume will land you your desired fellowship spot next time.

Do not accept a cold call nephrology fellowship spot out of a feeling of FOMO seeing your coresidents all move to their desired fellowships.

 

[UPCR]

I scrambled **match, didn't like the field but was going for competitivness, prestige and money.
I always liked nephrology as a a science, didnt consider before because it is not competitive, no money or prestige.
After i didn't match, my pd encouraged me to apply to something i love which is nephro.
I took a nephrology position.
End of the story.

 

[NewYorkDoctors]

I scrambled GI match, didn't like the field but was going for competitivness, prestige and money.
I always liked nephrology as a a science, didnt consider before because it is not competitive, no money or prestige.
After i didn't match, my pd encouraged me to apply to something i love which is nephro.
I took a nephrology position.
End of the story.
I hope i don't regret.

I hope you matched at least a decent program from an academic standpoint. (Scramble usually does not have the top tier programs available)

If this was because you knew you were not competitive for GI (whether due to AMG vs IMG, connections / LOR, or research pedigree), then I understand how you might have come to this conclusion.

Good luck.

 

[Renal_Prometheus]

I scrambled GI match, didn't like the field but was going for competitivness, prestige and money.
I always liked nephrology as a a science, didnt consider before because it is not competitive, no money or prestige.
After i didn't match, my pd encouraged me to apply to something i love which is nephro.
I took a nephrology position.
End of the story.
I hope i don't regret.

Let me say congratulations on your match. Whether you will regret your career choice, it will take you a few years to find out.

 

[n2b8me]

Randomish side question related to nephrology…
Can a nephrologist run a dialysis machine with a regular floor nurse? or is this completely ludicrous?

Is managing a dialysis machine something that’s learned in fellowship?…

maybe it’s just my naïveté but I always thought of it as something like pulmonary running a vent (without RT).

 

[Nephro critical care]

Randomish side question related to nephrology…
Can a nephrologist run a dialysis machine with a regular floor nurse? or is this completely ludicrous?

Is managing a dialysis machine something that’s learned in fellowship?…

maybe it’s just my naïveté but I always thought of it as something like pulmonary running a vent (without RT).

I haven’t ever seen a floor nurse managing regular HD. ICU nurses can be trained to manage CRRT. Usually though that nurse then becomes 1:1 for nurse : pt ratio.

 

[NewYorkDoctors]

Randomish side question related to nephrology…
Can a nephrologist run a dialysis machine with a regular floor nurse? or is this completely ludicrous?

Is managing a dialysis machine something that’s learned in fellowship?…

maybe it’s just my naïveté but I always thought of it as something like pulmonary running a vent (without RT).

While monitoring an HD machine is not “hard” by any means , it does require special training by the nurse (primarily cannulating the fistula with a 16G horse needle without damaging the fistula, monitoring for filter clots , monitoring the Transmembrane pressures, managing the UF rate in case hypotension or cramping occurs , managing patient complaints …) and constant vigilant monitoring over the course of 3-4 hours . The biggest thing is to ensure the HD needles do not fall out of the fistula or else the patient could exsanguinate fairly quickly

A floor nurse has to see 4-6 patients , give the gigantic number of meds the doctors order , clean up poo poo in incontinent patient , occasionally have a psychiatrically unstable patient try to leave ama , listen to patient complaints , try to follow through with the giant number of mid day lab order requests from the doctors teams , etc … there needs to be a separate person for HD

 

[Nephro critical care]

I always wanted to do nephrology while in residency. After residency I opted to fix my green card and therefore was a hospitalist for 4 years. During my residency and during my hospitalist years all my research was targeted towards nephrology. I became quite good as an admitting hospitalist and was good at diagnosing stuff. After I got my green card while interviewing for nephrology fellowship I began to hear that the market for nephrology was worsening. However at that time I closed my ears and still applied and matched into nephrology. The first year was good as it was new stuff to me and rare GNs fascinated me.

However as a second year fellow I began to realize that had significantly declined as a physician. All I cared about was the creatinine and nothing much else. Somebody would come with AKI I would give fluids for 3 to 4 days patient will get pretty puffy however creatinine would improve. At that point once creatinine was better I would sign off not caring if the pt was grossly overloaded. There was little GN not much thinking/keeping up with guidelines and I was just a dialysis tech. The patient may have 10 different things wrong with him but all I cared about was the creatinine.

I became unsatisfied with myself as a physician at that time. I therefore look for an outlet and found that to be critical care. I asked my program director for a recommendation letter for critical care and was accepted by a program on the basis of that letter. In the second year of my critical care fellowship I tried hard to find a nephrology critical care job but it was very tough to get one. I finally got into a hospital as an intensivist where the nephrologist was somewhat receptive to me. However at the end once I started as an intensivist I was unable to practice nephrology due to some internal politics between nephrology and critical care. However I did not have a lot of regrets about not being able to practice nephrology. Critical care was much more fulfilling and I did not feel I was losing skills my internist skills.

Now I see some hospitalists turned nephrologists do some hospitalist moonlighting on the side. They are terrible hospitalists and do not know anything because from all the time they spent in nephrology they have learned to ignore the rest of the body.. I would never hire them as a hospitalist. Do not be a nephrologist if you think you might come back to hospitalist medicine later as you will certainly be a worse physician at that time.

 

[NewYorkDoctors]

I always wanted to do nephrology while in residency. After residency I opted to fix my green card and therefore was a hospitalist for 4 years. During my residency and during my hospitalist years all my research was targeted towards nephrology. I became quite good as an admitting hospitalist and was good at diagnosing stuff. After I got my green card while interviewing for nephrology fellowship I began to hear that the market for nephrology was worsening. However at that time I closed my ears and still applied and matched into nephrology. The first year was good as it was new stuff to me and rare GNs fascinated me.

However as a second year fellow I began to realize that had significantly declined as a physician. All I cared about was the creatinine and nothing much else. Somebody would come with AKI I would give fluids for 3 to 4 days patient will get pretty puffy however creatinine would improve. At that point once creatinine was better I would sign off not caring if the pt was grossly overloaded. There was little GN not much thinking/keeping up with guidelines and I was just a dialysis tech. The patient may have 10 different things wrong with him but all I cared about was the creatinine.

I became unsatisfied with myself as a physician at that time. I therefore look for an outlet and found that to be critical care. I asked my program director for a recommendation letter for critical care and was accepted by a program on the basis of that letter. In the second year of my critical care fellowship I tried hard to find a nephrology critical care job but it was very tough to get one. I finally got into a hospital as an intensivist where the nephrologist was somewhat receptive to me. However at the end once I started as an intensivist I was unable to practice nephrology due to some internal politics between nephrology and critical care. However I did not have a lot of regrets about not being able to practice nephrology. Critical care was much more fulfilling and I did not feel I was losing skills my internist skills.

Now I see some hospitalists turned nephrologists do some hospitalist moonlighting on the side. They are terrible hospitalists and do not know anything because from all the time they spent in nephrology they have learned to ignore the rest of the body.. I would never hire them as a hospitalist. Do not be a nephrologist if you think you might come back to hospitalist medicine later as you will certainly be a worse physician at that time.

totally agreed with your post spot on.

the older guard faculty in nephrology do NOT do MOC for Internal Medicine. They strut around thinking they are Sir William Osler reincarnated or something because they know the difference between the edema of nephrotic syndrome and CHF on touching the patient's skin. They can't even answer MKSAP questions correctly lol. They want you to "unlearn what you learned" in Internal Medicine and decry all hospitalist attendings as "untrained and incompetent."

It's seriously quite disgusting

When I was a resident in CCU, I learned from the cardiac intensivists that in pericardial tamponade you need to give fluids nonstop continuously to maintain preload to buy time before an interventionalist can arrange a pericardiocentesis or a surgeon to do a pericardial window.

In my first fellowship, I round with the director of nephrology (a fossil who is great-(lol)-grandfathered into IM and nephrology so no need for MOC) on a pericardial tamponade patient in CKD patient. He asks me what is the first step to do for a pericardial tamponade? I answered based on by training in residency. "NO WHAT A TERRIBLE IDEA. THE FIRST STEP IS A PERICARDIAL WINDOW! WHAT DID THOSE HOSPITALISTS TEACH YOU IN RESIDENCY?"

i knew to pick my battles and just let it go.

but needless to say i do not stay in touch with this fossil and i would not care to visit his funeral either.

this is not just due to this one encounter. let's just say the fossils in nephrology seem more malignant than the jollier fossils in other IM subspecialties.

 

[Renal_Prometheus]

I always wanted to do nephrology while in residency. After residency I opted to fix my green card and therefore was a hospitalist for 4 years. During my residency and during my hospitalist years all my research was targeted towards nephrology. I became quite good as an admitting hospitalist and was good at diagnosing stuff. After I got my green card while interviewing for nephrology fellowship I began to hear that the market for nephrology was worsening. However at that time I closed my ears and still applied and matched into nephrology. The first year was good as it was new stuff to me and rare GNs fascinated me.

However as a second year fellow I began to realize that had significantly declined as a physician. All I cared about was the creatinine and nothing much else. Somebody would come with AKI I would give fluids for 3 to 4 days patient will get pretty puffy however creatinine would improve. At that point once creatinine was better I would sign off not caring if the pt was grossly overloaded. There was little GN not much thinking/keeping up with guidelines and I was just a dialysis tech. The patient may have 10 different things wrong with him but all I cared about was the creatinine.

I became unsatisfied with myself as a physician at that time. I therefore look for an outlet and found that to be critical care. I asked my program director for a recommendation letter for critical care and was accepted by a program on the basis of that letter. In the second year of my critical care fellowship I tried hard to find a nephrology critical care job but it was very tough to get one. I finally got into a hospital as an intensivist where the nephrologist was somewhat receptive to me. However at the end once I started as an intensivist I was unable to practice nephrology due to some internal politics between nephrology and critical care. However I did not have a lot of regrets about not being able to practice nephrology. Critical care was much more fulfilling and I did not feel I was losing skills my internist skills.

Now I see some hospitalists turned nephrologists do some hospitalist moonlighting on the side. They are terrible hospitalists and do not know anything because from all the time they spent in nephrology they have learned to ignore the rest of the body.. I would never hire them as a hospitalist. Do not be a nephrologist if you think you might come back to hospitalist medicine later as you will certainly be a worse physician at that time.

You got lucky you got out early man. Some of us who went into private practice in nephrology got completely destroyed and left the specialty within a few years. Among my friends who made partner in their respective groups, and still practicing nephrology, they are making between 300-400k/year. Considering how many hours they are working, they would easily make over 400k/year as a hospitalist. And this is without having to drive to multiple hospitals/dialysis units per day or take night calls for your group. Without having to give your group 3 years of your life making a pittance to maybe(or maybe not) be promoted to partner. The academics completely lied in fellowship about the great opportunities to JV in new dialysis units or get medical directorship fees. The opportunities are not there any more and the specialty is dying a slow death.

 

[Renal_Prometheus]

Situation in nephrology right now is very unhealthy because it’s still hush, hush, don’t tell the fellows attrition rates are high in private practice. It’s understandable why PDs don’t want to be brutally honest given that they are already having a hard time filling spots. But it doesn’t allow for a healthy conversation about all the challenges with the specialty and many applicants are still misinformed about the realities in pp, thinking they will make bank after making partner. Ultimately it’s the fellows career that gets wrecked when they waste many years to figure out they are better off just taking a hospitalist job.

 

[NewYorkDoctors]

while I practice nephrology as a hobby (I refer the hardest cases to academic nephrology but can home my own just fine with bread and butter dkd HTN lupus nephritis IgA pulm-renal syndrome ) , I would not be finally solvent if I did not also do GIM . Even then I would not be financially profitable without a procedural subspecialty either .

As I keep saying while money isn’t everything , you should only do nephrology if you plan to do academics . Otherwise attempting the PP market is career and financial syicide . Don’t waste your prime earning years of your life .

 

[Renal_Prometheus]

I hope people do realize how much personal suffering and pain nephrology grads endure when they leave their own specialty to take a hospitalist job. It's essentially admitting you wasted all these years in training for nothing, because the realities in private practice was much worse than you had anticipated. Trust me, nobody would be doing this if neph private practice was lucrative. So for applicants who are thinking about applying, please look at what's happening around you, and stop listening to those desperate fellowship programs who can't get cheap labor and is promising the world to you. Use your common sense. What is the market telling you when year after year 30-40% of fellowship spots go unfilled. Trust me, it's not telling you good things on what's really been happening. A lot of people will get hurt. People should not knowingly lead others down a cliff. Telling a half truth is no different than telling a lie.

 

[Nephro critical care]

I wished nephrology was more hospital employed and less private practice groups. If we were more hospital employed then we would have to worry less about being cheated out of partnership after slaving for 3 to 4 years on a partnership track. Likely would have to only go to 1 or 2 dialysis units and become director of 1 unit. No driving to 3 or 4 hospitals just to see a few patients each but instead get to focus on one hospital.
That would not be a bad lifestyle. Would not make much more than endocrine or infectious disease but at least get to focus on 1 thing.

 

[Drrrrrr. Celty]

I wished nephrology was more hospital employed and less private practice groups. If we were more hospital employed then we would have to worry less about being cheated out of partnership after slaving for 3 to 4 years on a partnership track. Likely would have to only go to 1 or 2 dialysis units and become director of 1 unit. No driving to 3 or 4 hospitals just to see a few patients each but instead get to focus on one hospital.
That would not be a bad lifestyle. Would not make much more than endocrine or infectious disease but at least get to focus on 1 thing.

And then when that hospital is bought out by a financial group and they reduce your MA/RN staff, change your RVU negotiation, and make you adhere to obtuse rules?
Don't get me wrong. There are great hospital systems which really seek to make their specialists happy. Like the where I did residency in the Midwest they really bent over backwards to make the specialists happy. But I think these likely are rare in desirable areas or the coasts.

That being said I'm not Nephro. I'm Endo, my specialty is more outpatient than nephro which I think is inherently more mixed. But I think that maintaining the semi-private or private physician practice sector is our main bulwark against exploitation because of the ability to negotiate pay, benefits, and or conditions for employment better.

 

[Renal_Prometheus]

I wished nephrology was more hospital employed and less private practice groups. If we were more hospital employed then we would have to worry less about being cheated out of partnership after slaving for 3 to 4 years on a partnership track. Likely would have to only go to 1 or 2 dialysis units and become director of 1 unit. No driving to 3 or 4 hospitals just to see a few patients each but instead get to focus on one hospital.
That would not be a bad lifestyle. Would not make much more than endocrine or infectious disease but at least get to focus on 1 thing.

The only hospital employed nephrology positions I see are in rural areas where the hospital is desperate. When you have 2-3 neph groups competing for consults in a typical hospital, why would you hire a nephrologist and lose money on that person. The reason why hospitals hire cardiologists and GI people is because they generate revenue for the hospital from ancillary procedures. A nephrologist would cost the hospital money and they would need to supplement his/her billing akin to hospitalists. This all comes down to nephrologist not generating enough revenue from seeing pts and traditionally relying too heavy on investment income to make up the difference. News flash, profit margins at dialysis units are dropping and Fresenius/DaVita are cutting back on expansion. So if you are an older partner in a group and your JV money is declining every year, are you keen to promote a new guy to partner so he share your JV money?

 

[NewYorkDoctors]

ASN Data

My personal observations and thoughts are that the match #s are increasing. However, I wonder how much this has to do with just an increase in the # of AMG (MD or DO) medical graduates are entering the pipeline now since there are newer medical schools that have opened up within the past 10-15 years now. These applicants have to go somewhere. Moreover, this could also represent an influx of more hospitalists or applicants who have graduated residency for a number of years already. While this is good for the programs who get fellows, I wonder how these individuals will do post-graduation. Aside from those who are super-academic oriented who get a nice job at a large teaching hospital, I can only hope those who enter private practice have a clear career plan in place.

Those who did not match probably got cocky and just ranked 2-3 top academic programs. Pride comes before the fall as they say.

The offered positions continue to rise to 493 in AY2023. Gosh... lol

ASN can be quite proud of the increasing # of applicants who prefer Nephrology. Their educational initiatives may be working

Anyway, happy holidays to everyone.

 

[Renal_Prometheus]

ASN Data

My personal observations and thoughts are that the match #s are increasing. However, I wonder how much this has to do with just an increase in the # of AMG (MD or DO) medical graduates are entering the pipeline now since there are newer medical schools that have opened up within the past 10-15 years now. These applicants have to go somewhere. Moreover, this could also represent an influx of more hospitalists or applicants who have graduated residency for a number of years already. While this is good for the programs who get fellows, I wonder how these individuals will do post-graduation. Aside from those who are super-academic oriented who get a nice job at a large teaching hospital, I can only hope those who enter private practice have a clear career plan in place.

Those who did not match probably got cocky and just ranked 2-3 top academic programs. Pride comes before the fall as they say.

The offered positions continue to rise to 493 in AY2023. Gosh... lol

ASN can be quite proud of the increasing # of applicants who prefer Nephrology. Their educational initiatives may be working

Anyway, happy holidays to everyone.

I would like to see ASN conduct a study on the percentage of neph grads are still practicing nephrology 5 years post-graduation. And if those who left to do something else, what were the reasons for doing so. However, I doubt that they would do it as I think they will be scared of the results(and scare off applicants). Their own mantra is to increase the number of nephrology applicants irregardless whether the market needs this many, or what will happen to them post-graduation.

 

[NewYorkDoctors]

the closest thing is the fellow survey.

ASN Data

Fellows Perspectives on Procedures and the Nephrology Job Market

data.asn-online.org

Of course, this does not survey graduates. Therefore these fellows are still in the honeymoon phase and giving gushing reviews. Let's see how the marriage goes.

Median base starting salary for graduating adult fellows rose 9.8% to $219,500 in 2022, keeping pace with inflation (see VI. Focus on the Pediatric Workforce for data on pediatric nephrologists). Women respondents entering practice reported earning $1000 less on average starting compensation than their male colleagues (median $219,000 vs. $220,000, respectively).

Gosh... that's a pitifully low salary.

While "money isn't everything," you would be hard pressed to live on this salary (after taxes) unless you are outside of a large metro area and you do not plan on becoming a homeowner and having children.

A high educational debt burden—common among USMG fellows (Figure 8)—can discourage fellows from endorsing nephrology.

Good employment opportunities are tough to come by. The jobs just don’t pay well enough initially and also the work load is a lot to justify the low pay. It’s hard to feel enthusiastic about taking a job that pays $180,000, having you work over 60 hours per week while you graduate with loans of over $350,000.—3rd-Year USMG

While nephrology is interesting from a pathophysiology perspective, the day to day practice is demoralizing. On the inpatient side, primary teams are more focused on telling you what to do (start dialysis, start CRRT) rather than asking a consult question and on the outpatient side, the majority of the time is spent managing dialysis (a machine, not a patient) or completing non-interesting mild CKD consultations that likely could have been handled by a primary care doctor if there was more support and guidance for primary care. Overall, while nephrology is interesting in textbooks, the day to day practice of nephrology does not reflect the interesting cases we read about, is stressful, is full of demoralizing interactions with other healthcare providers, and is not rewarding.—2nd-Year USMG

Hook.. line.. and sinker.

I work 60-70 hours a week but I pull in an obscenely higher quantity than that. I won't mention the specifics since no one will believe me anyway. But the key is to have your own in office procedures and minimize travel time so you can maximize revenue. Hence, if you love nephrology then do academics. Stay away from the career death trap of private practice nephrology.

If you plan to do private practice in any capacity, stay away from nephrology.

It is a great field in which you can integrate knowledge from biology, physics, and chemistry to make sense of the physiology. The pathophysiology is interesting, and you get the opportunity to follow patients longitudinally, from the beginnings of CKD to post-transplant, which is really amazing to see.—1st-Year USMG

It is the most logical and objective field in medicine. The fundamental understanding of physiology you learn in Nephrology gives you the ability to understand the entirety of a patient’s management. If you like “every field of medicine” Nephrology is the ideal field, as you learn to manage many aspects of Cardiology, Hematology/Oncology, Infectious Disease, Endocrinology, Surgery, Critical care etc.—1st-Year USMG

The mystique of the kidney. Nephrology integrates with numerous other specialties so we are exposed to a broad range of pathology in other fields as well. Continuity of care in dialysis patients is unmatched in other specialties giving us the opportunity to connect with our patients.—1st-Year USMG

I would counter that every IM subspecialty and GIM has longitudinal care. This "benefit" is only valid when comparing to a surgical subspecialty in which a surgical issue is addressed and that might be the end of it. However, if you mean seeing the patient at least 4 times a month for on HD rounds, then you yes nephrology wins by a landslide lol... an poorly compensated landslide lol

 

[Renal_Prometheus]

To add to the above comments, same issues I've been repeating over and over again:

Work-life balance and starting compensation have been commonly cited demotivating factors, especially among IMGs seeking visa waiver positions.

Tough fellowship however at the end of it I get poor work life balance as an attending nephrologist, lots of driving around hospital/dialysis clinics and extremely poor compensation aka less than a IM hospitalist who has less training than a nephrologist and works less hours. This is especially true for IMGs on J1/H1 as they end up getting jobs with poor salary.—2nd-Year IMG

Long hours, poor compensation, tedious work (lots of driving during work day), high patient volume so not enough time to give to individual patients. You can make more as a Hospitalist with 7 on/7 off models without night shifts and brutal weekend calls. Big city jobs and dialysis center ownership seems saturated. Nobody seems to be doing anything to improve the quality of life of nephrologists or to improve compensation.—2nd-Year IMG

 

[forchinet121]

the closest thing is the fellow survey.

ASN Data

Fellows Perspectives on Procedures and the Nephrology Job Market

data.asn-online.org

Of course, this does not survey graduates. Therefore these fellows are still in the honeymoon phase and giving gushing reviews. Let's see how the marriage goes.


Gosh... that's a pitifully low salary.

While "money isn't everything," you would be hard pressed to live on this salary (after taxes) unless you are outside of a large metro area and you do not plan on becoming a homeowner and having children.





Hook.. line.. and sinker.

I work 60-70 hours a week but I pull in an obscenely higher quantity than that. I won't mention the specifics since no one will believe me anyway. But the key is to have your own in office procedures and minimize travel time so you can maximize revenue. Hence, if you love nephrology then do academics. Stay away from the career death trap of private practice nephrology.

If you plan to do private practice in any capacity, stay away from nephrology.



I would counter that every IM subspecialty and GIM has longitudinal care. This "benefit" is only valid when comparing to a surgical subspecialty in which a surgical issue is addressed and that might be the end of it. However, if you mean seeing the patient at least 4 times a month for on HD rounds, then you yes nephrology wins by a landslide lol... an poorly compensated landslide lol

How much do you make? I will believe you

 

[NewYorkDoctors]

let's just say even a GIM primary care physician who joins an IPA and sets up private practice in a dense urban area seeing zero copay/zero deductible managed medicaids can double what a junior nephrology attending associate in some private practice makes. some who run 99213 mills reach over 7 figures. hey i didn't ask anyone to believe me.

anyway, if you're in it for the money don't do renal (or at least not as your primary subspecialty)

if you're in it for the kidney, go academic and never enter the private practice market.

 

[Renal_Prometheus]

let's just say even a GIM primary care physician who joins an IPA and sets up private practice in a dense urban area seeing zero copay/zero deductible managed medicaids can double what a junior nephrology attending associate in some private practice makes. some who run 99213 mills reach over 7 figures. hey i didn't ask anyone to believe me.

anyway, if you're in it for the money don't do renal (or at least not as your primary subspecialty)

if you're in it for the kidney, go academic and never enter the private practice market.

Many Neph grads go into academics not because it was their original intention, but because they know they won’t be able to do much better in private practice. So they comfort themselves with the fact that at least they have a good lifestyle, living off the backs of some desperate fellow.

 

[NewYorkDoctors]

these individuals need to swallow their pride and just do GIM. You can set up your own shop do GIM and also have your patients respect you even more for being a "specialist." lol.

 

[Renal_Prometheus]

To add to the above comments, same issues I've been repeating over and over again:

Work-life balance and starting compensation have been commonly cited demotivating factors, especially among IMGs seeking visa waiver positions.

Tough fellowship however at the end of it I get poor work life balance as an attending nephrologist, lots of driving around hospital/dialysis clinics and extremely poor compensation aka less than a IM hospitalist who has less training than a nephrologist and works less hours. This is especially true for IMGs on J1/H1 as they end up getting jobs with poor salary.—2nd-Year IMG

Long hours, poor compensation, tedious work (lots of driving during work day), high patient volume so not enough time to give to individual patients. You can make more as a Hospitalist with 7 on/7 off models without night shifts and brutal weekend calls. Big city jobs and dialysis center ownership seems saturated. Nobody seems to be doing anything to improve the quality of life of nephrologists or to improve compensation.—2nd-Year IMG

Look at how closely the comments made by these 2 fellows align with what I have have been posting in the past. Did I not say that dialysis unit JVs are saturated and that new grads should not expect to make the same money as senior guys? I believe I also started a thread telling applicants who are IMGs with visa issues to not apply as you will get the worst jobs. The correlation to these comments are frighteningly accurate. All these guys had to do was read my posts before wasting 2 years to figure out what I’ve been saying was the truth.