Nephrology is Dead - stay away

[collegestud2013]

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

Those are just base salaries, and do not include additional income from RVUs or other bonuses. 2021 MGMA data would suggest nephrology isn't doing too bad money wise: Median (50th percentile) is $375K, 75th percentile $465k, and 90th percentile at a whopping $612k. Even 10th percentile is still at $240k.These are are higher than the respective percentile pay for hospitalists. For reference, the 10th, 50th, 75th, and 90th percentile for IM hospitalists are $229k, $307k, $358k, and $422k, and for FM hospitalists it's a bit higher at $255k, $328k, $390k, and $471k. I suppose the data can be skewed as the ones on the higher percentiles are likely more senior and established PP partners, and doesn't account for RVUs or hours worked (which on average tend to be higher for nephrology than hospitalist), but doesn't seem to scream "stay away from nephrology." Maybe new grads should be more aggressive to negotiate compensation that is more line with the MGMA data.

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[NewYorkDoctors]

Those are just base salaries, and do not include additional income from RVUs or other bonuses. 2021 MGMA data would suggest nephrology isn't doing too bad money wise: Median (50th percentile) is $375K, 75th percentile $465k, and 90th percentile at a whopping $612k. Even 10th percentile is still at $240k.These are are higher than the respective percentile pay for hospitalists. For reference, the 10th, 50th, 75th, and 90th percentile for IM hospitalists are $229k, $307k, $358k, and $422k, and for FM hospitalists it's a bit higher at $255k, $328k, $390k, and $471k. I suppose the data can be skewed as the ones on the higher percentiles are likely more senior and established PP partners, and doesn't account for RVUs or hours worked (which on average tend to be higher for nephrology than hospitalist), but doesn't seem to scream "stay away from nephrology." Maybe new grads should be more aggressive to negotiate compensation that is more line with the MGMA data.

Well if that’s your solution then let’s just /thread

Happy New Years to everyone

 

[Renal_Prometheus]

Those are just base salaries, and do not include additional income from RVUs or other bonuses. 2021 MGMA data would suggest nephrology isn't doing too bad money wise: Median (50th percentile) is $375K, 75th percentile $465k, and 90th percentile at a whopping $612k. Even 10th percentile is still at $240k.These are are higher than the respective percentile pay for hospitalists. For reference, the 10th, 50th, 75th, and 90th percentile for IM hospitalists are $229k, $307k, $358k, and $422k, and for FM hospitalists it's a bit higher at $255k, $328k, $390k, and $471k. I suppose the data can be skewed as the ones on the higher percentiles are likely more senior and established PP partners, and doesn't account for RVUs or hours worked (which on average tend to be higher for nephrology than hospitalist), but doesn't seem to scream "stay away from nephrology." Maybe new grads should be more aggressive to negotiate compensation that is more line with the MGMA data

Have you ever practiced nephrology? If you have, you would know that the average compensation is skewed by older nephrologists who have dialysis unit joint ventures. The new grads don’t have those opportunities any more and once they realize they are not making the money, they leave the field to do hospitalist. This is why true compensation is not reflected in the data. So these numbers are an average of the winners. The losers have already left the game.

Negotiate higher starting salaries? Do you know how nephrology revenue generation works? New grads bring in no new dialysis patients and so their compensation is a reflection of that. Your revenue goes up as you accumulate more dialysis patients.

 

[Renal_Prometheus]

This is the problem with nephrology. People look at the online average salary and think going into nephrology is not a bad decision. People don’t know the nuances of how these numbers were derived. It’s skewed by senior guys with multiple JVs. New grads have no hope of reaching those numbers because dialysis units are SATURATED and no new ones are opening up. If the salaries are not that bad, why are fellowships spots unfilled? Would you expect match rate to be higher that 70% if its not that bad? By the time these new grads figure out the trap, they have already wasted 2 yrs of fellowship and multiple years in private practice. That’s why it’s so damaging because nobody is going to tell you what I’m telling you.

 

[NewYorkDoctors]

As someone who does non-HD nephrology (on the side) and dabbles in primary care (not just drive by primary care but like the whole PCMH set up kind of primary care), I will say that GIM is much easier and has more CPT codes to bill (for quality measures) than non-HD nephrology can.

If you cannot break into a profitable HD situation, then do not do private practice nephrology. Plus you will never see or enjoy the "wonderful discipline of nephrology in which you are the doctor's doctor and you know about every subspecialty because it all ties together... yadda yadda..." outside of an academic setting.

DO nephrology to become an academic physician and because you love the discipline of nephrology.

Do NOT do nephrology and enter the private practice market and think its an escape. You will be sorely mistaken and you will regret the loss of the prime earning years of your life.

 

[Renal_Prometheus]

Looking back, the career risks of someone going into nephrology is incredibly high. I don't think fellows truly appreciate the significance of being payed a low starting salary(200-220k/yr working full time, hard work, driving to multiple places per day) with only the promise of partnership after 3-4 years of sweat equity. Most people don't stay with their first job after training. So if your first job doesn't work out, are you doing to try another group and give them 3 more years getting payed the same low salary? What if the second job doesn't work out, are you going to try a 3rd neph group doing the same thing again? How many years do you have left before retirement? What I see a lot among my friends is that after 1st job doesn't work out, they end up going to hospitalist because they can't go back to working that hard for this little pay. Again, even if neph group gives you partnership does not mean they will share JV or medical directorship fee equally. The rules were written by the senior partners, so you can probably bet that they will benefit more than you. The career risks are incredibly high and some naiive resident comes to me ask why nephrology is non-competitive.

 

[NewYorkDoctors]

The naive resident is only exposed to academic nephrology. Academic nephrology does have a certain charm to it as a resident.

But the only charms you can eat are the Lucky kind. Private practice nephrology is less like a pot of gold and more like a chamber pot.

 

[Renal_Prometheus]

The market is brutal, but it’s honest. There’s no way a specialty can have 30% of its fellowship positions unfilled and still claim that new grads will do well in private practice. The market doesn’t lie, but people will. Like those desperate neph programs that are willing to take anyone with a heartbeat, including IMGs who couldn’t match into IM. The market doesn’t miscalculate, but desperate people will always grasp for straws, and end up hurting themselves in the long run.

 

[Renal_Prometheus]

how do you sell a bad specialty? if you were the PD of some program, how do you sell this specialty? By telling applicants the truth that you shouldn't be going into nephrology right now because private practice lifestyle is bad and the money isn't there any more? They say these things in private but not in front of the applicant. Of course you are going to dramatize the beauty of renal physiology and how incredibly interesting academic nephrology is, all to take away attention from the fact that applicant is signing up for years of indentured servitude and poor lifestyle/reimbursement. Fellows think they know what they are getting into, but trust me, there's plenty more shock waiting for them in private practice. This is why so many nephrologists leave the field after working for several years is that it takes that long to fully accept the realities of how bad of a situation they got themselves into.

 

[NewYorkDoctors]

Just because you do a renal fellowship does not mean you have to enter the quagmire of private practice nephrology

You have options after doing a renal fellowship

- Join academic faculty practice - perhaps the "easiest" thing to do if you can land one of these coveted jobs.
- Join private practice and struggle
- Do hospitalist work
- Do GIM for a large employer
- Start your own small business as a primary care physician while selling your nephrology degree and your 'hypertension expertise.' You could consider doing your own PD practice as that requires far less hassle than getting those coveted HD privileges.
- Do another fellowship (if you can spare the opportunity cost). You can try for CCM I suppose though that's a harder pathway now that CCM is all in on the match for a renal candidate. You could look to add another subspecialty that might complement nephrology. This is easier said than done but it something that can be accomplished.

 

[CptNemo]

A lot of the issues in nephrology aren't that private practice owners are greedier or less nice than in other specialties. It is simple economics (that I never really thought of until some time during fellowship).

Nephrology revenue comes mostly from 1) managing ESRD patients (both billing and revenue from dialysis unit joint ventures) and 2) E/M billing for seeing inpatients/outpatients.

It is hard to build up a practice in nephrology. People make predictions about how many nephrologists are needed based on increasing CKD prevalence. However, CKD 3A, 3B, and even 4 are often of no consequence to many patients (think an 85 year old with a GFR ~30). Chances are that he/she will die of something else prior to ever needing dialysis.

The prevalence of ESRD on dialysis has been flattening (and it actually decreased from 2019-2020 Annual Data Report | USRDS) and it takes a lot of work/time seeing patients in the hospital and in clinic to build up a large panel of dialysis patients.
-Based on this, I would argue that reducing the supply of nephrologists would be a good idea (but I guess the market is naturally doing this to some degree).

The corollary of this is that unless you are joining a practice to take over a large panel from a retired or moving physician, you don't really bring much value to the practice other than your EM billing for the first few years (and again, nephrology is more niche than general medicine, so the numbers will often be less). So even if I am a seasoned nephrologist moving to a new practice, from a money generating standpoint, I wouldn't really bring a lot of revenue to the practice.

Early in fellowship, I had the misconception that a private practice would highly value someone who is a GN expert or an electrolyte savant - not really. Yes, you need competent people on your team, but dealing with complex GNs or electrolyte problems generally is a money loser as you could likely bill more if you see a larger number of straightforward patients in that same time and just try to turf the complex cases to the university. Plus, the overall numbers of GN patients that are seen is not that high - so it is hard to justify an infusion center to give cytoxan or rituximab, etc. - even in our academic center, we send these to the heme-onc infusion center as our numbers aren't high enough to have our own.

In contrast, if you join a GI practice that has more EGD/colonoscopy referrals than they can handle, you can be much more valuable to them by scoping right away and expanding their business (so they can afford to pay you more to start). Similar deal in cardiology. Plus both those field have conditions with relatively vague and nonspecific symptoms - so it is easy to expand one's business by recommending additional revenue generating procedures for workup of said vague abdominal pain/dyspepsia/mild anemia or chest pain/palpitations, etc. Things are more black and white in nephrology, which also hurts us - saying "despite your concerns, your Cr is fine and you have no proteinuria, so you don't need further workup" is not a big money maker 😉

 

[NewYorkDoctors]

A lot of the issues in nephrology aren't that private practice owners are greedier or less nice than in other specialties. It is simple economics (that I never really thought of until some time during fellowship).

Nephrology revenue comes mostly from 1) managing ESRD patients (both billing and revenue from dialysis unit joint ventures) and 2) E/M billing for seeing inpatients/outpatients.

It is hard to build up a practice in nephrology. People make predictions about how many nephrologists are needed based on increasing CKD prevalence. However, CKD 3A, 3B, and even 4 are often of no consequence to many patients (think an 85 year old with a GFR ~30). Chances are that he/she will die of something else prior to ever needing dialysis.

The prevalence of ESRD on dialysis has been flattening (and it actually decreased from 2019-2020 Annual Data Report | USRDS) and it takes a lot of work/time seeing patients in the hospital and in clinic to build up a large panel of dialysis patients.
-Based on this, I would argue that reducing the supply of nephrologists would be a good idea (but I guess the market is naturally doing this to some degree).

The corollary of this is that unless you are joining a practice to take over a large panel from a retired or moving physician, you don't really bring much value to the practice other than your EM billing for the first few years (and again, nephrology is more niche than general medicine, so the numbers will often be less). So even if I am a seasoned nephrologist moving to a new practice, from a money generating standpoint, I wouldn't really bring a lot of revenue to the practice.

Early in fellowship, I had the misconception that a private practice would highly value someone who is a GN expert or an electrolyte savant - not really. Yes, you need competent people on your team, but dealing with complex GNs or electrolyte problems generally is a money loser as you could likely bill more if you see a larger number of straightforward patients in that same time and just try to turf the complex cases to the university. Plus, the overall numbers of GN patients that are seen is not that high - so it is hard to justify an infusion center to give cytoxan or rituximab, etc. - even in our academic center, we send these to the heme-onc infusion center as our numbers aren't high enough to have our own.

In contrast, if you join a GI practice that has more EGD/colonoscopy referrals than they can handle, you can be much more valuable to them by scoping right away and expanding their business (so they can afford to pay you more to start). Similar deal in cardiology. Plus both those field have conditions with relatively vague and nonspecific symptoms - so it is easy to expand one's business by recommending additional revenue generating procedures for workup of said vague abdominal pain/dyspepsia/mild anemia or chest pain/palpitations, etc. Things are more black and white in nephrology, which also hurts us - saying "despite your concerns, your Cr is fine and you have no proteinuria, so you don't need further workup" is not a big money maker 😉

I have a very small renal practice (which as I have mentioned in my other posts, I only do nephrology as a hobby and only to help out the internists in the building I work in) and I only have a handful of GN patients that I can probably count on my hand. I have a few patients who renal biopsy proven to have Lupus Nephritis Class 3+5 now in remission on CS + MMF , IgA nephropathy in remission on ARB alone, primary membranous nephropathy initially in remission after CS now recurrence and on CsA, Anti GBM disease patient who is on maintenance RTX q 6 months now (I wrote a prescription and order and sent to the local hospital's infusion center. they bill for everything I just follow the patient in my office), and a primary FSGS due to obesity (probably) who is getting better with weight loss.

These patients are a bit more complex and I can probably bill a 99214 sometimes if I address enough problems for them. But they are usually all just 99213 follow ups and no extra CPT code billing for them.

PMDs can bill 99213 and 99214 for "easier" things...

 

[Renal_Prometheus]

A lot of the issues in nephrology aren't that private practice owners are greedier or less nice than in other specialties. It is simple economics (that I never really thought of until some time during fellowship).

Nephrology revenue comes mostly from 1) managing ESRD patients (both billing and revenue from dialysis unit joint ventures) and 2) E/M billing for seeing inpatients/outpatients.

It is hard to build up a practice in nephrology. People make predictions about how many nephrologists are needed based on increasing CKD prevalence. However, CKD 3A, 3B, and even 4 are often of no consequence to many patients (think an 85 year old with a GFR ~30). Chances are that he/she will die of something else prior to ever needing dialysis.

The prevalence of ESRD on dialysis has been flattening (and it actually decreased from 2019-2020 Annual Data Report | USRDS) and it takes a lot of work/time seeing patients in the hospital and in clinic to build up a large panel of dialysis patients.
-Based on this, I would argue that reducing the supply of nephrologists would be a good idea (but I guess the market is naturally doing this to some degree).

The corollary of this is that unless you are joining a practice to take over a large panel from a retired or moving physician, you don't really bring much value to the practice other than your EM billing for the first few years (and again, nephrology is more niche than general medicine, so the numbers will often be less). So even if I am a seasoned nephrologist moving to a new practice, from a money generating standpoint, I wouldn't really bring a lot of revenue to the practice.

Early in fellowship, I had the misconception that a private practice would highly value someone who is a GN expert or an electrolyte savant - not really. Yes, you need competent people on your team, but dealing with complex GNs or electrolyte problems generally is a money loser as you could likely bill more if you see a larger number of straightforward patients in that same time and just try to turf the complex cases to the university. Plus, the overall numbers of GN patients that are seen is not that high - so it is hard to justify an infusion center to give cytoxan or rituximab, etc. - even in our academic center, we send these to the heme-onc infusion center as our numbers aren't high enough to have our own.

In contrast, if you join a GI practice that has more EGD/colonoscopy referrals than they can handle, you can be much more valuable to them by scoping right away and expanding their business (so they can afford to pay you more to start). Similar deal in cardiology. Plus both those field have conditions with relatively vague and nonspecific symptoms - so it is easy to expand one's business by recommending additional revenue generating procedures for workup of said vague abdominal pain/dyspepsia/mild anemia or chest pain/palpitations, etc. Things are more black and white in nephrology, which also hurts us - saying "despite your concerns, your Cr is fine and you have no proteinuria, so you don't need further workup" is not a big money maker 😉

It’s a dying specialty that has no fix and economics are against it. As profit margins of these HD units decline, so do the JV or medical directorship fees that nephrologist rely so heavily on historically. You will see nephrologists working as hospitalists in every major and minor town; common sighting these days. Decreasing supply would be helpful, but programs are too self centered on grabbing warm bodies for scut work to care what’s happening in the real world. There has been no shortage of neph grads as IMGs have an obsession to do a specialty, even the bad ones. 90% of the fellowship spots fill post-scramble and you can find this in ASN charts. It’s a specialty that can neither control its own over supply nor prevent the decline in revenue obtained from JV/medical directorship fees. Makes my blood boil even talking about it.

 

[happymd2000]

It’s a dying specialty that has no fix and economics are against it. As profit margins of these HD units decline, so do the JV or medical directorship fees that nephrologist rely so heavily on historically. You will see nephrologists working as hospitalists in every major and minor town; common sighting these days. Decreasing supply would be helpful, but programs are too self centered on grabbing warm bodies for scut work to care what’s happening in the real world. There has been no shortage of neph grads as IMGs have an obsession to do a specialty, even the bad ones. 90% of the fellowship spots fill post-scramble and you can find this in ASN charts. It’s a specialty that can neither control its own over supply nor prevent the decline in revenue obtained from JV/medical directorship fees. Makes my blood boil even talking about it.

I think one of the problems with the field is that I find there is very little shame in manipulation and playing to that dream people have of discovering a pot of gold. This isn't like investments in the early days of companies like apple and google lol where a decade or so later you are reaping the benefits. As a recent grad, I was amazed at how I fell for the trap and how much scutwork I did during fellowship. Shortly after I started I had to face some pretty harsh realities and was angry at myself for getting fooled. I still remember when I was trying to moonlight as a hospitalist during fellowship and how quickly my skills had deteriorated. One good thing I can say that I did was I cut my losses and moved on and since then I have done much better as a result. I find in general it is just really hard for people to hear the truth and face it so they often keep doing the same thing to their detriment. I did talk to a couple of my co-fellows about this in fellowship, and they kept telling me about "how good it was" and how much money there was waiting in a few years lol. And this was all in the setting of a 200K starting salary lmao where you are working on call 1 in 4 and multiple weekends a month. I will also say that while I did learn a fair amount in fellowship (a lot of my co-fellows got caught up in the scutwork and learning very little) it was because I did a lot of my own learning. The attendings I worked with were some of the poorest clinicians in the hospital and would be dangerous being primary for their own patients. All I will say is that in life you sometimes do get conned and nephrology program directors and faculty are some of the biggest cons out there for unsuspecting applicants.

 

[Renal_Prometheus]

I think one of the problems with the field is that I find there is very little shame in manipulation and playing to that dream people have of discovering a pot of gold. This isn't like investments in the early days of companies like apple and google lol where a decade or so later you are reaping the benefits. As a recent grad, I was amazed at how I fell for the trap and how much scutwork I did during fellowship. Shortly after I started I had to face some pretty harsh realities and was angry at myself for getting fooled. I still remember when I was trying to moonlight as a hospitalist during fellowship and how quickly my skills had deteriorated. One good thing I can say that I did was I cut my losses and moved on and since then I have done much better as a result. I find in general it is just really hard for people to hear the truth and face it so they often keep doing the same thing to their detriment. I did talk to a couple of my co-fellows about this in fellowship, and they kept telling me about "how good it was" and how much money there was waiting in a few years lol. And this was all in the setting of a 200K starting salary lmao where you are working on call 1 in 4 and multiple weekends a month. I will also say that while I did learn a fair amount in fellowship (a lot of my co-fellows got caught up in the scutwork and learning very little) it was because I did a lot of my own learning. The attendings I worked with were some of the poorest clinicians in the hospital and would be dangerous being primary for their own patients. All I will say is that in life you sometimes do get conned and nephrology program directors and faculty are some of the biggest cons out there for unsuspecting applicants.

These programs play on your desperation of escaping a hospitalist career and offering nothing but empty promises. In the end, you hurt yourself by trying to make it work when there’s already ample evidence it’s failing big time. It all circles back to the core question: “why is the specialty non-competitive if it was as lucrative as the academics claim?” Every year, I see fellows going into it with reasoning that defy common sense, and are actually surprised that at the end of the road, there is no pot of gold. At this point, I’m exasperated being the bad guy with all my warnings and people not listening to me, and then they get destroyed down the road. I feel like I’m fighting an hopeless fight to save others, but they rather believe the hopium that fellowship programs are selling.

 

[Test Boy]

These programs play on your desperation of escaping a hospitalist career and offering nothing but empty promises. In the end, you hurt yourself by trying to make it work when there’s already ample evidence it’s failing big time. It all circles back to the core question: “why is the specialty non-competitive if it was as lucrative as the academics claim?” Every year, I see fellows going into it with reasoning that defy common sense, and are actually surprised that at the end of the road, there is no pot of gold. At this point, I’m exasperated being the bad guy with all my warnings and people not listening to me, and then they get destroyed down the road. I feel like I’m fighting an hopeless fight to save others, but they rather believe the hopium that fellowship programs are selling.

Just curious, besides posting multiple warnings on this thread, are you doing anything else to get your message out to potential nephrology applicants? Probably most of them don’t even read this forum but I’m sure if they did, your multiple posts will dissuade most of them from going into nephrology.

 

[Renal_Prometheus]

Just curious, besides posting multiple warnings on this thread, are you doing anything else to get your message out to potential nephrology applicants? Probably most of them don’t even read this forum but I’m sure they did, your multiple posts will dissuade most of them from going into nephrology.

For years, neph grads have suffered in silence and shame of failure in private practice. At least, there is a forum now where they can express their true feelings. It’s unfortunate, but the specialty has deteriorated dramatically and fellowship programs have not acknowledged the extent of the problems or have been transparent to applicants. There’s only so much I can do. Hopefully these messages reach their intended audience so that applicants can weigh the risk and reward before embarking on this journey.

 

[NewYorkDoctors]

well this thread is in Year 9 and counting and has over 166K views. I do not expect (or want) the field of nephrology to die out. The goal of this thread was never to eliminate the nephrology fellowship. That is asinine.

The residents / applicants who are sold on Nephrology (maybe they have a master plan all lined up) should be encouraged to apply. But it is those who are on the fence and do not know what they are getting into who should be warned. This is especially true for those who failed to match into cardiology or PCCM and who get a cold call to scramble. I hope those individuals have read all of the warnings on this thread.

The goal is to ensure those who apply know what they are getting into. If that individual has done a pro / con evaluation and feels being a nephrologist specialist outweighs any financial burdens that may be present, then that person should be encouraged to go all in and join a top academic fellowship.

Otherwise, one should not have any delusions of "getting rich quick" as a nephrology specialist.

No in-office / or procedure center/ surgical center - procedures that the only the physician can do = no get rich quick

The hate on nephrology is really for the poor economics of it (which is not fault of the academic doctors or the ASN).

In this case, one should "hate the game and not the player."

 

[Renal_Prometheus]

The problem is that Neph programs are already having a hard enough time filling fellowship spots. There’s no way they will tell the applicant that the specialty has poor reimbursement and bad lifestyle, that most grads will end up worse off than a hospitalist. They will always point to the good examples and intentionally omit the bad ones. It’s just human nature when you are desperate that you will stretch the truth.

 

[NewYorkDoctors]

The problem is that Neph programs are already having a hard enough time filling fellowship spots. There’s no way they will tell the applicant that the specialty has poor reimbursement and bad lifestyle, that most grads will end up worse off than a hospitalist. They will always point to the good examples and intentionally omit the bad ones. It’s just human nature when you are desperate that you will stretch the truth.

To be absolutely fair, I would do the exact same thing if I were a nephrology PD. Money is tight and I would want free labor (well free for the Division but not free for the GME funding) that can help me do night calls so I don't have to be overworked and underpaid. Although I would make sure the fellows get the best effort and education possible.

Hence I recuse myself from being in that unethical position by not doing academic nephrology.

 

[Renal_Prometheus]

To be absolutely fair, I would do the exact same thing if I were a nephrology PD. Money is tight and I would want free labor (well free for the Division but not free for the GME funding) that can help me do night calls so I don't have to be overworked and underpaid. Although I would make sure the fellows get the best effort and education possible.

Hence I recuse myself from being in that unethical position by not doing academic nephrology.

you are talking about ethics. These guys are taking applicants with no US residency who are hoping to match into IM after fellowship. These people have not ethics. It's all exploitation. They are just taking any warm body to be used for scut work.

 

[NewYorkDoctors]

hence no one should scramble into an unmatched position for nephrology. the best nephrology programs with the top educators and the programs that can help you get a top academic job in the future all get taken in the main match.

 

[julius_pepperwood11]

This is the problem with nephrology. People look at the online average salary and think going into nephrology is not a bad decision. People don’t know the nuances of how these numbers were derived. It’s skewed by senior guys with multiple JVs. New grads have no hope of reaching those numbers because dialysis units are SATURATED and no new ones are opening up. If the salaries are not that bad, why are fellowships spots unfilled? Would you expect match rate to be higher that 70% if its not that bad? By the time these new grads figure out the trap, they have already wasted 2 yrs of fellowship and multiple years in private practice. That’s why it’s so damaging because nobody is going to tell you what I’m telling you.

Can you explain why 10th and 25th percentile mgma compensation for nephro also comfortably outearns the equivalent percentiles for hospitalists/pcps? Do they work more hours? Do you think the nonsuccessful nephrologists dropping out to return to hospitalist skews the data that much even at these percentiles? Genuine question.

 

[Renal_Prometheus]

Can you explain why 10th and 25th percentile mgma compensation for nephro also comfortably outearns the equivalent percentiles for hospitalists/pcps? Do they work more hours? Do you think the nonsuccessful nephrologists dropping out to return to hospitalist skews the data that much even at these percentiles? Genuine question.

I think a nephrologist works way more hrs than the average hospitalist, who works half the year. On income per hr basis, an average hospitalist makes more than the average nephrologist. However, data is skewed by older nephrologists with the JVs. The nephrologist who graduated in the last 6 yrs are making significantly less than nephrologist who’s been in practice for 10+ years, due to lack of new JVs opening up. Even in the same group, I have friends who earn half the income of the senior guys even though he is partner at this point. So data is very much skewed and even different for incomes for partners in the same group depending how long they have been in practice.

 

[NewYorkDoctors]

Many young individuals (including young doctors) often lament "we should have gone into business." But those salaries are skewed by the top CEOs who are probably corrupt in so many ways padding their salaries and subsequently padding the overall stats. Most entry level "business-industry" workers struggle and get paid zilch probably. This analogy probably also applies to private practice Nephrology

 

[georgestone]

Have you ever practiced nephrology? If you have, you would know that the average compensation is skewed by older nephrologists who have dialysis unit joint ventures. The new grads don’t have those opportunities any more and once they realize they are not making the money, they leave the field to do hospitalist. This is why true compensation is not reflected in the data. So these numbers are an average of the winners. The losers have already left the game.

Negotiate higher starting salaries? Do you know how nephrology revenue generation works? New grads bring in no new dialysis patients and so their compensation is a reflection of that. Your revenue goes up as you accumulate more dialysis patients.

I agree, new grads work their tails off to establish ESRD patients and once u have a privately insured ESRD patient , managed care ( Medicare/Medicaid ) takes over after 2 years , so as a young grad one has to work constantly to revitalize the pool , >40 % of ESRD patients are dead by year 5
so you can imagine the odds stacked against those poor fellows

Nephrology has fallen behind , apart from HD/RRT and GN , Nephrology offers little beyond that

I was told that Nephrology has strong overlap with Critical care , but this notion is dead wrong , nephrology training is archaic, dated and out of touch

I have plenty of Neph colleagues who have stated that majority of their faculty was crap and did not offer any skills in ICU .

when I was interviewing for CCM many years ago , I witnessed the Program directors clearly expressing their dissatisfaction regarding the skills and lack of depth of Nephrology Fellows in ICU , I see that even today Seasoned Nephrologists making terrible Judgement calls regarding volume status of critically ill Patients , its the same 2K, 2 Kg BS across the board .

Nephrology has NO future

 

[NewYorkDoctors]

I agree, new grads work their tails off to establish ESRD patients and once u have a privately insured ESRD patient , managed care ( Medicare/Medicaid ) takes over after 2 years , so as a young grad one has to work constantly to revitalize the pool , >40 % of ESRD patients are dead by year 5
so you can imagine the odd stacked against those poor fellows

Nephrology has fallen behind , apart from HD/RRT and GN , Nephrology offers little beyond that

I was told that Nephrology has strong overlap with Critical care , but this notion is dead wrong , nephrology training is archaic, dated and out of touch

I have plenty of Neph colleagues who have stated that majority of their faculty was crap and did not offer any skills in ICU .

when I was interviewing for CCM many years ago , I witnessed the Program directors clearly expressing their dissatisfaction regarding the skills and lack of depth of Nephrology Fellows in ICU , I see that even today when Seasoned Nephrologist making terrible Judgement calls regarding volume status of critically ill Patients , its the same 2K, 2 Kg BS across the board .

Nephrology has NO future

Squeezing for edema (trying to differentiate cigarette paper vs brawny edema from nephrotic syndrome versus lymphedema), trying to make sense of the BUN/Cr ratio, relying on AP X-ray films daily (which some ICUs do not even do) and trying to interpret (incomplete and inaccurate) I&Os is utterly and complete garbage in ICU patients in which there are too many variables that get in the way of a simple interpretation of volume status.

Ultimately it should boil down to (and often dose) the nephrologist asking the intensivist how much UF they want. Intensivist does not care much for the URR or KT/V.

The "nephrologist is the expert of volume status" notion is totally garbage as well. For less complicated patients with renal insufficiency on the floor or outpatient setting, the nephrologist is "more of an expert than the Internist." But that does not go very far in the ICU.

The "nephrologist is the expert of volume status for the IM resident because the hospitalist just wanna leave at 3PM" is the most accurate notion of thinsg.

 

[mszzeta]

Squeezing for edema (trying to differentiate cigarette paper vs brawny edema from nephrotic syndrome versus lymphedema), trying to make sense of the BUN/Cr ratio, relying on AP X-ray films daily (which some ICUs do not even do) and trying to interpret (incomplete and inaccurate) I&Os is utterly and complete garbage in ICU patients in which there are too many variables that get in the way of a simple interpretation of volume status.

Ultimately it should boil down to (and often dose) the nephrologist asking the intensivist how much UF they want. Intensivist does not care much for the URR or KT/V.

The "nephrologist is the expert of volume status" notion is totally garbage as well. For less complicated patients with renal insufficiency on the floor or outpatient setting, the nephrologist is "more of an expert than the Internist." But that does not go very far in the ICU.

The "nephrologist is the expert of volume status for the IM resident because the hospitalist just wanna leave at 3PM" is the most accurate notion of thinsg.

In big academic centers, nephrologist sees 40 consults per day. No way they could make good judgement for complex cases. A smart and careful IM resident can do well or even better for fluid management

Nephrologists are needed in rare kidney disease or HD. Most AKI or CKD can be handled by internist. And volume status assessment is a completely IM skill

 

[CptNemo]

I know this is a "bash nephrology" thread, but I can't say that I would agree that intensivists, cardiologists, or internists are superior at figuring out volume status than nephrologists. I've seen equally questionable volume assessments and techniques from all of these groups 🙂

I'm sure it is institution dependent, but we use a combination of crit-lines, bioimpedence, pulmonary and vascular US, not to mention other investigational sensors (the latter in the context of research studies) to get a better idea about volume status. This is in addition to the usual hemodynamic measurements and imaging studies, and echocardiograms that we have on a lot of our ICU patients. Volume status determinations are very difficult and context dependent. I've seen HD patients with normal IVCs, no LE edema, but with very significant signs of pulmonary edema on CXR and US without obvious intrinsic lung disease - seems like some of them just have "leaky" uremic lungs.

We have been studying many ways to better estimate a true dry weight on HD patients, but there are lots of roadblocks.
Outpatient: The flat monthly capitated payment limits what nephrologists and dialysis centers want to accept. Adding cost by requiring a new device (crit line or bioimpedence) and the requisite training for HD staff is not welcomed. Additionally, doing POCUS (even an abbreviated 4 zone lung US) is time-consuming on patients in street clothes reclining in their dialysis chairs - plus would require most community nephrologists to get trained in this, and per my understanding, we cannot bill for it separately as all outpatient ESRD care is covered by the MCP.

On the inpatient side, yes, as was alluded to, we often follow ~30 patients per day plus/minus do clinic and/or HD rounding, so we are not next to the patient at every moment of the day and things are dynamic, so I certainly do rely on the primary team to give updates and pay attention to hour-hour changes - I definitely take into account their input when adjusting CRRT or HD prescriptions, etc. I imagine that this would be even harder for a private practice nephrologist who has a significantly larger HD/PD panel and more clinic sessions scheduled than me.

 

[NewYorkDoctors]

All great points. I can tell you are both sensible modern nephrologists who are doing your personal best for your patients.

Sadly much of renal education still has fossils from the prior generation who just do not know when to get with the times or retire. Hopefully once you become the PD or the director of nephrology then things will become more modernized

 

[Renal_Prometheus]

All great points. I can tell you are both sensible modern nephrologists who are doing your personal best for your patients.

Sadly much of renal education still has fossils from the prior generation who just do not know when to get with the times or retire. Hopefully once you become the PD or the director of nephrology then things will become more modernized

Why would he want to be PD? You are basically asking him to beg applicants to join every year. Scraping the bottom every year gets old.

 

[NewYorkDoctors]

PD is a sweet job! "Teach" fellows while having them

Make the fellow go in for every overnight consult so you can get some extra RVU if it happened before midnight and call it education!

Need to check out the scenario!

Yeah in the old days before EMRs

For every borderline HD that the renal attending made me go into, I always pulled in the HD nurse. If I am going in, then the HD nurse is coming in also (getting paid some OT as well). Since I was already in house and not going anywhere, I figured someone should also join me overnight.

 

[Renal_Prometheus]

It still amazes me that applicants go into nephrology thinking they will make big bucks after making partner.
They don't seem to pick up the disconnect of how a once "lucrative" specialty can be this non-competitive when
it comes to the match. It will take them a few years into private practice before they realize that the opportunities
that were there for senior partners are no longer available to them anymore. Without someone like me telling fellows these
truths, they are strung along by academics on the hope of doing well down the road. So much exploitation with this specialty.

 

[georgestone]

I know this is a "bash nephrology" thread, but I can't say that I would agree that intensivists, cardiologists, or internists are superior at figuring out volume status than nephrologists. I've seen equally questionable volume assessments and techniques from all of these groups 🙂

I'm sure it is institution dependent, but we use a combination of crit-lines, bioimpedence, pulmonary and vascular US, not to mention other investigational sensors (the latter in the context of research studies) to get a better idea about volume status. This is in addition to the usual hemodynamic measurements and imaging studies, and echocardiograms that we have on a lot of our ICU patients. Volume status determinations are very difficult and context dependent. I've seen HD patients with normal IVCs, no LE edema, but with very significant signs of pulmonary edema on CXR and US without obvious intrinsic lung disease - seems like some of them just have "leaky" uremic lungs.

We have been studying many ways to better estimate a true dry weight on HD patients, but there are lots of roadblocks.
Outpatient: The flat monthly capitated payment limits what nephrologists and dialysis centers want to accept. Adding cost by requiring a new device (crit line or bioimpedence) and the requisite training for HD staff is not welcomed. Additionally, doing POCUS (even an abbreviated 4 zone lung US) is time-consuming on patients in street clothes reclining in their dialysis chairs - plus would require most community nephrologists to get trained in this, and per my understanding, we cannot bill for it separately as all outpatient ESRD care is covered by the MCP.

On the inpatient side, yes, as was alluded to, we often follow ~30 patients per day plus/minus do clinic and/or HD rounding, so we are not next to the patient at every moment of the day and things are dynamic, so I certainly do rely on the primary team to give updates and pay attention to hour-hour changes - I definitely take into account their input when adjusting CRRT or HD prescriptions, etc. I imagine that this would be even harder for a private practice nephrologist who has a significantly larger HD/PD panel and more clinic sessions scheduled than me.

No offense please !!

Instead of diagnosing Leaky Uremic Lungs ( if that entity even exists ) why dont you guys check B lines ( trust me its not that hard )? or check LVEDP non invasively, since a lot of HD patients tend to centralize volume rather than having peripheral edema .
How many HD units even check standing weights before and after HD ?- - - -> very few if any
its the same BS of 2k and 2 kg across the board , Nephrology attendings have morphed into urine / creatinine chasing , electrolyte replacing Jockeys , that's why this field is loosing its appeal bc of lack of depth in clinical practice and very poor training structure .

we aren't trying to bash Nephrology , its a dose of reality which needs to be administered to future grads , who will leave the field in droves as the previous ones and the ones before them , so shouldn't we hold the organization , programs accountable ??

 

[NewYorkDoctors]

No offense please !!

Instead of diagnosing Leaky Uremic Lungs ( if that entity even exists ) why dont you guys check B lines ( trust me its not that hard )? or check LVEDP non invasively, since a lot of HD patients tend to centralize volume rather than having peripheral edema .
How many HD units even check standing weights before and after HD ?- - - -> very few if any
its the same BS of 2k and 2 kg across the board , Nephrology attendings have morphed into urine / creatinine chasing , electrolyte replacing Jockeys , that's why this field is loosing its appeal bc of lack of depth in clinical practice and very poor training structure .

we aren't trying to bash Nephrology , its a dose of reality which needs to be administered to future grads , who will leave the field in droves as the previous ones and the ones before them , so shouldn't we hold the organization , programs accountable ??

to be fair, that's the only way to see a census of 30 patients while driving everywhere.
some more modern renal fellowships do teach POCUS from their younger renal attendings.

as a renal fellow, i used to use my pocket ultrasound (which I purchased of my own money. it was expensive then. but these days the butterfly IQ is the most affordable and cheap option) and scan certain patient on HD patients who were having trouble reaching dry weight and getting hypotensive. while the "easy" thing to do is raise the dry weight, I would confirm if there was any evidence of ECFV excess that would require an additional session at a lower UFR or not. While doing such a thing may not be EBM persay, is doing physical exam for DW estimation EBM? Yet we do it. POCUS (especially if you do not bill for it.. not that you can anyway) is merely an extension of physical exam and should be thought of as such.

alternatively it was useful for someone with edema thought to be venous insufficiency but was having IDH.

there still still a lot of gray area anyway that still required the good old fashioned dry weight challenge. so POCUS is not a panacea but just another tool when regular physical exam is not helpful

but IVCs are tough to measure in patients in the semi recumbent position and someone who ate or who is eating on HD (hopefully someone who is eating some L-carnitine perhaps... nah we all know its food with Na, K, and Ph). Moreover, it might be better to measure a few hours after the HD session after the volume shifts have occurred. But that's where the interdialytic nephrology office visit comes into play. I get it if the patient is elderly or has mobility issues and cannot go for ANOTHER office visit. But for those who can get around, doing a POCUS exam (if trained to do so) on an interdialytic day might shed light on planning their HD. It also gives a chance to review their on HD labs in greater detail instead of that "drive by" care that the patients on HD seem to expect...

 

[Renal_Prometheus]

To me, I just couldn’t stand all the lies the fellowship programs were promising in order to get fresh meat through the door. Years later, half of my neph friends went back to hospitalist, and of course, those academics take no responsibility for what they said. Just despicable.

 

[NewYorkDoctors]

the general private practice care of nephrology patients also leads to more unpleasant encounters than other specialties.

I practice about 5/6 pulmonary and 1/6 primarycare +/- nephrology

I have not had many patients from pulmonary ever leave unsatisfied and angry from telling them the truth about their disease. It might be because there are better defined diagnostics and management options for the pulmonary disease processes IMO compared to CKD and HTN.

Bad asthma suffering - anti IL5 - boom patient loves you

Lung nodule - scan them again in a few months! Perhaps do the lung cancer blood autoantibody test to further define their Mayo clinic risk score (And possibly see a 1% number that makes patients happier and more at ease).

Lung cancer - inform them their biopsy, thoracic surgery referral, eventual oncology referral will be expedited.

etc...

Bad HTN progressive CKD - patient hates you for giving them more meds.

Proteinuria - despite education about what this means, patient's don't feel anything wrong and often feel seeing you is a "waste of time."

For CKD, it's often just "tweaking things." Moreover, sometimes renal patients get sent by their PMD with the expectation of a "specialist curing your problem." It's just not the case with CKD.

Patients ask me why they are seeing me if their PMD can "do the same thing" (for DKD, hypertensive CKD)
Rather than my blurt out the truth (which would be unprofessional) that the PMD is pressed for time to deal with insurance mandates and "quality metrics" and is merely outsourcing "primary care nephrology" to myself, I just say it's because we are a team !

I would say the majority of my unhappy patients (primarily because I tell them they have progressive CKD and will need HD soon or c/w current management you're doing great. ) come from the nephrology side of things.
primary care patients are often quite pleased if you just refer (appropriately) or do some fancy test (appropriately) or prescribe some medication (appropriately - I never prescribe antibiotics for cough unless they induce me a purulent sputum sample which i run as lab culture... even then it might not have been bacterial akin to empiric antibiotics for presumed UTI before sending urine culture... but at least i tried...)

Nephrology patients tend to be rather miserable IMO and that leads to an unpleasant day to day physician patient interactions.

No amount of empathy and care can get that past the Kubler Ross stage of denial and anger... infact I would say many ESRD patients are still stuck in those stages. Being nice and caring is important but often cannot get the patients past those stages due to the loss of agency and independence...

 

[georgestone]

The Individuals who are doing bench Research /Translational research have failed to make a break through and lack of Innovation is obvious,
if nephrologist are so well equipped with US then why still 85% of HD patients have vol related HTN ?, I have yet to witness Nephrologists who use US for volume on a measurable scale , individual examples are Anecdotal unfortunately and instead of Intradialytic HD Clinics why is Ambulatory BP monitoring not a standard of care despite studies have shown its gold standard tool ?

we can disagree but the fact is that Nephrologist have done a lousy Job in controlling volume , when nephrologist round in my ICU , they never assess volume , its the same 2k , 2 kg BS across the board ( I have worked in academic and community centers both ) and most of my ICU colleagues share the same frustration

 

[NewYorkDoctors]

The Individuals who are doing bench Research /Translational research have failed to make a break through and lack of Innovation is obvious,
if nephrologist are so well equipped with US then why still 85% of HD patients have vol related HTN ?, I have yet to witness Nephrologists who use US for volume on a measurable scale , individual examples are Anecdotal unfortunately and instead of Intradialytic HD Clinics why is Ambulatory BP monitoring not a standard of care despite studies have shown its gold standard tool ?

we can disagree but the fact is that Nephrologist have done a lousy Job in controlling volume , when nephrologist round in my ICU , they never assess volume , its the same 2k , 2 kg BS across the board ( I have worked in academic and community centers both ) and most of my ICU colleagues share the same frustration

I totally agree

To be fair though , the “busy stretched out “ nephrologist would need the icu rounds info . After that the nephrologist should swallow his her pride and cede the volume management if the HD patient and HD nurse to the intensivist if the intensivist will take ownership of the UF during the procedure.

Also remote Bp monitoring 99453 99454 99457 99458 is reimbursed very well in my neck of the woods . Shame it’s not used more often

 

[georgestone]

I totally agree

To be fair though , the “busy stretched out “ nephrologist would need the icu rounds info . After that the nephrologist should swallow his her pride and cede the volume management if the HD patient and HD nurse to the intensivist if the intensivist will take ownership of the UF during the procedure.

Also remote Bp monitoring 99453 99454 99457 99458 is reimbursed very well in my neck of the woods . Shame it’s not used more often

I am in agreement with Nephro giving up vol management in ICU , unfortunately this was learned the hard way , we would have patients in hypertensive urgency and on drips to lower their BP and Nephro would write 2k, 2kg , this happened repeatedly, I have witnessed HD patients undergo tracheostomies because they were profoundly Vol overloaded during prolong ICU stay and their UF wasn't challenged and they consistently failed Liberation , its unfortunate and despite being a board certified Nephrologist I have completely lost faith , dont get me wrong the science of Nephrology is Fascinating but the training and practice is SAD

I am glad that you are one of the few who believe in Ambulatory BP monitoring

 

[NewYorkDoctors]

I am in agreement with Nephro giving up vol management in ICU , unfortunately this was learned the hard way , we would have patients in hypertensive urgency and on drips to lower their BP and Nephro would write 2k, 2kg , this happened repeatedly, I have witnessed HD patients undergo tracheostomies because they were profoundly Vol overloaded during prolog ICU stay and their UF wasn't challenged and they consistently failed Liberation , its unfortunate and despite being a board certified Nephrologist I have completely lost faith , dont get me wrong the science of Nephrology is Fascinating but the training and practice is SAD

I am glad that you are one of the few who believe in Ambulatory BP monitoring

the sad thing is it just requires communication

often times the nephrologist enters the ICU and sees the ICU team is rounding and can't quite find an opening to chat. So said nephrologist orders whatever and leaves.

I mean without a Foley (and again no Foley in ESRD patient most likely) to measure strict I&Os (and then estimating insensible losses), the nephrologist is probably unclear what is coming out. Moreover, a nephrologist may not know where to look in the EMR for all of the inputs (such as all those sedative and antibiotic carrier fluids or tube feeds). Most of the edema is in the dependent buttock region so the legs may look nice and thin....


the intensivist should also open a channel of dialogue with each nephrologist.

Nephrologist: so I was thinking 2kg in 3 hours today
Intensivist: I would like more UFR. I want 4L off.
Nephrologist: but the patient might go hypotensive!
Intensivist: that's okay. I will increase pressors to help achieve this goal
Nephrologist: I can also use cool dialysate and albumin 50% infusions
Intensivist: okay... cool. my fellow or myself will monitor the HD so you move on with your day and just peek in and bill the on HD note.
Nephrologist: If the BP falls and you increase pressors, I can come back and bill the second on HD visit.
Intensivist: okay... did you just say the quiet part out loud?
Nephrologist: Uhh.. I can also increase the duration of HD to 4 hours to make the UFR more tolerable.
Intensivist: I am glad we had this conversation. Maybe we can do this on consecutive days as well so I can wean this patient off the vent.
Nephrologist: We are a team. Let's exchange text messages.

HD nurse: 4 hours? Everyday? I am not cool with this.



The 24 hour ABPM does not pay well at all. Most carriers will let you bill for R03.0 when you want to assess for white coat vs sustained hypertension in a patient without known hypertension. It gives valuable data though. Even then it pays $50 at best.
For reference, a 95800 home sleep study pays $175-200.

It is the Remote patient monitoring that pays very well. It is basically home BP logs that automatically goes into the EMR and I get averages and trends. This is how I logically titrate medications every month accurately in hypertension patients.

No more "guessing" whether the patient just had a little physical activity before the office visit making the in office BP look a little high.

 

[Renal_Prometheus]

All great points made here. The challenges of private practice nephrology have been well documented on this thread. My biggest concern is that a lot people will get hurt by going into this specialty. Especially if applicants have a misguided expectation of what they see in academic center versus real world nephrology. I’m worried about applicants because I know fellowship programs will lie thru their teeth to get cheap labor through the door. Ultimately, it’s the people living on false hope who pay the price.

 

[NewYorkDoctors]

All great points made here. The challenges of private practice nephrology have been well documented on this thread. My biggest concern is that a lot people will get hurt by going into this specialty. Especially if applicants have a misguided expectation of what they see in academic center versus real world nephrology. I’m worried about applicants because I know fellowship programs will lie thru their teeth to get cheap labor through the door. Ultimately, it’s the people living on false hope who pay the price.

ultimately, it comes down to... can EVERY single nephrology fellow graduate get a nice cushy (though not necessarily the best paying) academic job with fellows doing the night work? nope. it's basic resource management.

Unless you are a top doctor who is going to a top academic renal fellowship to be a top academic doctor, that means you will likely be private practice.

Private practice GIM >>>>>> Private practice nephrology
Seriously


There's nothing stopping a renal graduate from doing primarily private practice GIM sprinkled with some non-HD nephrology on the side.

 

[NewYorkDoctors]

I will say by using a combination of remote patient BP monitoring, point of care U/S for the renal visits, and the ISTAT device for a quick BMP measurement, I have not yet run into an issue with "do I diurese or not?" in the office. I have also fortunately never caused iatrogenic prerenal azotemia before thanks to this method. This is especially useful since these patients may be on thiazides/thiazide like, loops, SGLT2 inhibitoirs, and aldosterone blockade (Kerendia in particular). All those diuretics and then we tell patients to reduce their sodium and water intake (which some patients do...) and that's a recipe for prerenal azotemia disaster!

While IVC size cannot be used in those with PH or TR (in particular), I seldom see these cardiology type of patients.

Therefore, IVC and lung US (along with the weights, edema squeezing, and BP trends on home remote BP monitoring) is really a very helpful means of volume management.

The ISTAT is poorly reimbursed and most practices probably do not need this. But I got it to run ABGs for my pulmonary function lab but found it helps quite a bit for the renal patients (naturally). I do use it on those CKD patients i put on sodium bicarbonate just to ensure they have not become primary metabolic alkalosis. I mean that's not really based on the studies but it just makes sense to do.

 

[CptNemo]

No offense please !!

Instead of diagnosing Leaky Uremic Lungs ( if that entity even exists ) why dont you guys check B lines ( trust me its not that hard )? or check LVEDP non invasively, since a lot of HD patients tend to centralize volume rather than having peripheral edema ."

I mentioned in my post that we use various methods to help gauge how much volume removal is necessary. When we do a 4 zone lung US, which I also mentioned above, we are counting B-lines. I don't do the 28 zone US that has been described in the literature because it takes too much time, and 4 zone seems pretty equivalent: DEFINE_ME

Lung US has been studied in ESRD patients. Nephrologists have been looking into this and other methods, but results have been mixed. See the LUST trial. A good summary is here: The LUST Trial: Lung Ultrasound in Patients on Dialysis to Guide Dry Weight
Unfortunately, it was a negative trial and didn't change mortality or a composite of mortality plus hard CV outcomes - but seems like it was underpowered and some post-hoc analysis showed potential CV benefits.

I find lung US helpful, personally, but it is not perfect as there are potential confounders - and it is just logistically difficult to do in the HD unit (not to mention we would get ZERO reimbursement for doing this in the HD unit). Same would go for any other US based estimates of LVEDP.

How many HD units even check standing weights before and after HD ?- - - -> very few if any"

Every single dialysis unit that I have ever worked in does this (unless someone is non-ambulatory or cannot stand due to a BKA/AKA, etc.). It is very crude, but easy.

Doing lung US in the HD unit would be prohibitively expensive give our current limited reimbursements. To my understanding, I don't think that billing for an extra visit for US would be audit safe as volume assessment is part of the ESRD MCP.

its the same BS of 2k and 2 kg across the board , Nephrology attendings have morphed into urine / creatinine chasing , electrolyte replacing Jockeys , that's why this field is loosing its appeal bc of lack of depth in clinical practice and very poor training structure .

Perhaps some people do this. This is not my experience at our institution.

we aren't trying to bash Nephrology , its a dose of reality which needs to be administered to future grads , who will leave the field in droves as the previous ones and the ones before them , so shouldn't we hold the organization , programs accountable ??

Nephrology has lots of issue, of course. The biggest one is that over a decade ago ~2011, Medicare decided to bundle more things into the monthly capitated payment for ESRD (while conveniently not even increasing this payment in line with inflation). This had a big trickle down effect - practices are less profitable -> need to cut payments to younger nephrologists and need to manage more patients per nephrologist to keep the same income -> then this trickles down to make things less popular -> unfortunately, a brain-drain follows...

Prior to this, when nephrology went into the match in 2009, its competitiveness was similar to PCCM and heme-onc (I still remember those times). If you don't believe me, see here: https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2010.pdf
There were 1.5-1.6 applicants per nephrology position and only a ~60% match rate, same as PCCM and heme-onc, and similar to cardiology.

It is hard to do a full apples to apples comparison over the prior years, as nephrology was very late to join the match and wasn't even all-in by 2009. Prior to that, applying to the nephrology was the wild west, and we'd get "take it or leave it" offers on the spot.

I have said this many times, and I will say it again. If colonoscopy reimbursements were cut by as much as Medicare cut dialysis reimbursements back then, GI would be in a similar boat to nephrology. Much like treating GNs, treating IBD may be interesting, but doesn't pay the bills.

I am in agreement with Nephro giving up vol management in ICU , unfortunately this was learned the hard way , we would have patients in hypertensive urgency and on drips to lower their BP and Nephro would write 2k, 2kg , this happened repeatedly, I have witnessed HD patients undergo tracheostomies because they were profoundly Vol overloaded during prolong ICU stay and their UF wasn't challenged and they consistently failed Liberation , its unfortunate and despite being a board certified Nephrologist I have completely lost faith , dont get me wrong the science of Nephrology is Fascinating but the training and practice is SAD"

At our institution, we now have a very strict policy about only nephrology being allowed to touch any dialysis or CRRT orders. This came about after some ICU teams convinced nursing to modify CRRT prescriptions leading to bad patient outcomes. Admittedly, we had the most issues with the surgical ICU teams and anesthesia critical care (less so PCCM).

We talk at least daily to the ICU teams and try to get on the same board - sure sometimes there are disagreements, but I'm willing to try things as long as they are reasonable requests. Basically, I try to see what the ICU team is trying to achieve and I work with them to figure out the best modality/prescription to implement that.

The main issue was intensivists who were convinced that the understood CRRT, when they really only partially understood one particular flavor of CRRT that was run at their prior institution. For example, we had a couple people discontinue replacement fluid orders for CVVH because they "didn't want their patient getting so much extra fluid" - and then would get angry that CRRT made their hypotensive patient even more massively hypotensive and didn't improve electrolytes when they were basically just doing a continuous 1 L/hr UF. Or, they would mess with the UF/blood flow/dialysate rates, consequently screwing up our FF and clearance.

I'm not blaming them, but I feel that unless you do a nephrology fellowship at a legit university program, it is hard to know all the differences between CVVHDF, CVVHD, CVVH, SCUF, PIRRT, etc. (I don't blame them - but, for the same reason, I don't mess with vent settings). We now have developed an elective for the critical care fellows to round with us, which I think is very valuable and I enjoy talking to them and seeing their approach to things too.

I am glad that you are one of the few who believe in Ambulatory BP monitoring

I love ambulatory BP monitoring too! Unfortunately, when we tried to implement it in our institution about a decade ago, it turned into a big cluster. We got excited and invested in the machines (which were pretty expensive back then) - then the patients would take them home and either break them or lose them. With the poor reimbursements, we ended up losing money on the whole endeavor - have been too scarred by that experience to try again.

 

[NewYorkDoctors]

All excellent points . Seems like you run a tight ship at your program and are one of the top and model training programs. None of these criticisms are directed toward you .

As for pocus , the butterfly iq (not that I am shilling for them ) costs 2K only. That’s hardly “prohibitively expensive .” I think of it as a “very fancy stethoscope” when I justified buying it . Yes there is a 400 annual fee but that essentially serves as a cloud based PACs service. This easily gets billed back with just a handful of 76705 (limited pocus renal bladder US) which I bill for (I did the Emory course )

I use a third party company who purchases the remote BP machines . They also perform monitoring and call the patients and notify me when certain parameters are exceeded . I pay them about half of the RPM codes bill for. In that sense , it’s “free money” and a good patient service . I will admit it’s easier for a private practice like mine to quickly add on this third party service . I understand all the red tape and intermediate steps it would take to get a third party on board for a large hospital based group .

Yes intensivists that are not renal trained should only request additional UF from IHD and should not be messing with the other crrt modalities
Perhaps this is one reason why many programs have gone to using the home HD NxStage machine for CVVHD . The other reasons being cost and how higher clearance rates have not shown any mortality benefit outside of roncos initial trials. The prismaflex machine seems to be what it’s name suggests - a flex

 

[Renal_Prometheus]

Nephrology has lots of issue, of course. The biggest one is that over a decade ago ~2011, Medicare decided to bundle more things into the monthly capitated payment for ESRD (while conveniently not even increasing this payment in line with inflation). This had a big trickle down effect - practices are less profitable -> need to cut payments to younger nephrologists and need to manage more patients per nephrologist to keep the same income -> then this trickles down to make things less popular -> unfortunately, a brain-drain follows...

Prior to this, when nephrology went into the match in 2009, its competitiveness was similar to PCCM and heme-onc (I still remember those times). If you don't believe me, see here: https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2010.pdf
There were 1.5-1.6 applicants per nephrology position and only a ~60% match rate, same as PCCM and heme-onc, and similar to cardiology.

It is hard to do a full apples to apples comparison over the prior years, as nephrology was very late to join the match and wasn't even all-in by 2009. Prior to that, applying to the nephrology was the wild west, and we'd get "take it or leave it" offers on the spot.

I have said this many times, and I will say it again. If colonoscopy reimbursements were cut by as much as Medicare cut dialysis reimbursements back then, GI would be in a similar boat to nephrology. Much like treating GNs, treating IBD may be interesting, but doesn't pay the bills.

My question to you is what do you think about the ethics of some fellowship programs hiring IMGs who are unable to land a residency in order to exploit them for cheap labor. I bet you didn't think the specialty has sunk to this level of desperation when you first went into fellowship. In addition, newer neph graduates choosing to return to hospitalist positions is a common sightings these days. What do you think about the ethics of PDs promising naiive applicants how amazingly lucrative the specialty is, getting cheap labor for 2 years, and then take no responsibility when things go south for the neph graduate when they realize real world nephrology is nothing like what they were promised.

 

[Renal_Prometheus]

Big picture, going into a nephrology today is a actually test of your ability to recognize a career trap and make adjustments accordingly. It's a test of your ability to be flexible and also your ability take pain, realize you got duped, and foot your losses and move on. Those who made adjustments to their initial career choice(NYD, georgestone, nephro critical care), have done well for themselves. Those who try to make it work in private practice, when market conditions are clearly against them, will pay a even a higher career price than the 2 yrs of fellowship they invested in. At some point, you would have to acknowledge reality and move on. Yes, it was unethical for PDs to lie to you about the financial realities of private practice; but would did you expect from a specialty that couldn't get fellows?

 

[NewYorkDoctors]

I was sold a bill of goods that went along the lines of

- You are the doctor's doctor
- Nephrologists were the ones who started Up To Date
- You get to combine the best parts of various subspecialties including cardiology, rheumatology, hematology, and endocrinology with nephrology
- You get to be the Super-Internist
- You get to practice in so many varied clinical arenas such as the outpatient, the HD center, the hospital floors, all of the ICUS, nursing homes, etc.
- You get to be the Cardio-Nephrologist when it comes to the CHF patients.
- You get to be the master of diuretics
- You get to make meaningful life long connections with patients.
- There so many areas ripe for research
- Your services are in great demand. A hospital always needs dialysis.
- You are providing a special extracorporeal service that the other specialties cannot match or offer to the patient.
- Homer Smith pioneered the field of renal physiology at New York Hospital. Chloride was the first electrolyte to be measured on the renal panel. Nephrology pioneered the subspecialty field. Back then subspecialists were seen as those doctors who were "not good enough clinicians to be internists." But Nephrology changed all that.
- Clyde Shields went before Congress to show what a life saving invention hemodialysis was.

Feel free to add any more

These are all true statements... from a certain point of view.
You mean Darth Vader was never meant to be Luke's father in the original draft and Leia was not meant to be his sister (hence why the kiss in the beginning of ESB) but George Lucas made it up as he went along?
Precisely. A certain point of view.

 

[CptNemo]

All excellent points . Seems like you run a tight ship at your program and are one of the top and model training programs. None of these criticisms are directed toward you .

As for pocus , the butterfly iq (not that I am shilling for them ) costs 2K only. That’s hardly “prohibitively expensive .” I think of it as a “very fancy stethoscope” when I justified buying it . Yes there is a 400 annual fee but that essentially serves as a cloud based PACs service. This easily gets billed back with just a handful of 76705 (limited pocus renal bladder US) which I bill for (I did the Emory course )

I use a third party company who purchases the remote BP machines . They also perform monitoring and call the patients and notify me when certain parameters are exceeded . I pay them about half of the RPM codes bill for. In that sense , it’s “free money” and a good patient service . I will admit it’s easier for a private practice like mine to quickly add on this third party service . I understand all the red tape and intermediate steps it would take to get a third party on board for a large hospital based group .

Yes intensivists that are not renal trained should only request additional UF from IHD and should not be messing with the other crrt modalities
Perhaps this is one reason why many programs have gone to using the home HD NxStage machine for CVVHD . The other reasons being cost and how higher clearance rates have not shown any mortality benefit outside of roncos initial trials. The prismaflex machine seems to be what it’s name suggests - a flex

I agree that the cost of the US isn't a big issue (tough I still haven't been able to convince the university to pay for my butterfly...) For inpatient, we can bill the limited US codes, making US profitable (even though each code doesn't pay very much, it does add up). However, for outpatient, I don't think that any of this is separately billable. So, it would be an issue of unreimbursed time (as doing US on HD patients would likely at least double my rounding time).

Yeah, we probably make CRRT more complicated than it has to be... I actually have never used an NxStage machine in an ICU - mainly just for home hemo. We now switched from Prismaflex to fancier Prismax! 🙂