Nephrology is Dead - stay away

[coroner]

Pathologist here who stumbled upon this epic, insightful, and somewhat entertaining thread almost 10 yrs running. I had no idea how bad the consensus on nephro is. Our field has its own problems too, so maybe it's human nature to complain or maybe misery loves company, dunno...
Jump over to the path forum if you need a pick-me-up sometime and click on any one of our numerous job threads! p.s. the Nuclear Med forum (residency not rads trained fellows) is one of the most abysmal I've read...that actually might make you feel like you hit Powerball.

Neph is in a bad place right now, and dialysis unit profit margins are worsening every year. And to think that 30 yrs ago it was one of the most competitive IM specialties; because it was very lucrative. How things have fallen.

So what happened 30 yrs ago that caused Nephro competitiveness to plummet? I'm guessing some type of major CMS cut to reimbursement that now pays pennies to the dollar for what your attendings/predecessors used to get...?

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[UPCR]

Don’t be so sure. There are plenty of applicants who couldn’t match GI as their first choice, who scrambled into Neph as a backup.

It happens, but that was not due to PD doing or fake promises.

 

[NewYorkDoctors]

It happens, but that was not due to PD doing or fake promises.

your n = 1 experience is noted and appreciated.

i'm sure your PD is a great individual based on the sound of things.

i just hope all other PDs (outside of the top academic tertiary care centers in whom they can act anyway they want as they are the legitimate ASN leaders) and follow suit

 

[CptNemo]

Pathologist here who stumbled upon this epic, insightful, and somewhat entertaining thread almost 10 yrs running. I had no idea how bad the consensus on nephro is. Our field has its own problems too, so maybe it's human nature to complain or maybe misery loves company, dunno...
Jump over to the path forum if you need a pick-me-up sometime and click on any one of our numerous job threads! p.s. the Nuclear Med forum (residency not rads trained fellows) is one of the most abysmal I've read...that actually might make you feel like you hit Powerball.

So what happened 30 yrs ago that caused Nephro competitiveness to plummet? I'm guessing some type of major CMS cut to reimbursement that now pays pennies to the dollar for what your attendings/predecessors used to get...?

I'll preface this by saying that I'm not as bearish on nephrology as some of the others in this thread, but the field has its issues.

RE: what happened. I've made some posts about it in the thread - it is a sore subject for me as I was finishing up my training at around the time these changes took place. The nutshell summary is that in the late 90s and early 2000s CMS noticed that while ESRD patients only accounted for ~1% of the Medicare population, about 9% of the budget was going to fund their care. They made various reimbursement reforms, culminating in the bundled monthly capitated payment (and prospective payment system) that was introduced in 2011 (that they also conveniently failed to index to inflation) . Basically, nephrology went from getting a generous lump sum per dialysis patient per month (with almost no strings attached) plus could charge for extra meds (epo, active vit D) in the dialysis unit to getting a barely/hopefully breakeven payment (with lots of strings attached) and losing the ability to bill for anything else in the HD unit (as it is all bundled). Also, in some states, we have a large undocumented population that we provide dialysis to - this is reimbursed by Medicaid programs at a rate that does not come close to covering costs - but what are you going to do? On the bright side, there are still some ESRD patients with private insurance that essentially subsidize the rest of the unit based on ~4x higher reimbursements than Medicare.

Unlike in certain procedural specialties where physicians can offset reimbursement cuts by doing more procedures per unit time, we are unable to speed up dialysis or to easily increase the number of patients on dialysis (if anything, our mission is to try to keep people off of dialysis - for which we can only bill the same low paying E&M codes as PCPs).

Even though residents swear that their fellowship choices are not driven by money (as that is taboo to say in medicine), their choices would indicate otherwise.

End result: It is going to take me a long time to save up to buy my Pagani...

 

[NewYorkDoctors]

PCps have quite a few "quality measure" CPT codes that allows the PCP to nickel and dime far more than a "nephrologist without a high HD census" can make.

Hence it makes zero sense to enter private practice nephrology unless you have assurances the senior partners will treat you equitably (i.e. friends/family) or you have a high patient census.

the other thing is what I always suggested. Do a blend of PCP + Nephrology. Do PCP more at first. Find an HD center to buy into if you can. Then once you begin to build up an HD census and get busy, hire a mid level to help you see the primary care patients you have established as you transition over to subspecialty. Sure you could hire another internist..... lol

 

[Renal_Prometheus]

It happens, but that was not due to PD doing or fake promises.

The only group of people who routinely get screwed by their partners are those needing J1 waivers. I’ve not seen one end well. Of course each time you try another neph group, you start at the bottom with low salaries and only a promise of fair partnership. People can waste many years at this. I’m sure you have calculated all the risks before going into nephrology.

 

[coroner]

I'll preface this by saying that I'm not as bearish on nephrology as some of the others in this thread, but the field has its issues.

RE: what happened. I've made some posts about it in the thread - it is a sore subject for me as I was finishing up my training at around the time these changes took place. The nutshell summary is that in the late 90s and early 2000s CMS noticed that while ESRD patients only accounted for ~1% of the Medicare population, about 9% of the budget was going to fund their care. They made various reimbursement reforms, culminating in the bundled monthly capitated payment (and prospective payment system) that was introduced in 2011 (that they also conveniently failed to index to inflation) . Basically, nephrology went from getting a generous lump sum per dialysis patient per month (with almost no strings attached) plus could charge for extra meds (epo, active vit D) in the dialysis unit to getting a barely/hopefully breakeven payment (with lots of strings attached) and losing the ability to bill for anything else in the HD unit (as it is all bundled). Also, in some states, we have a large undocumented population that we provide dialysis to - this is reimbursed by Medicaid programs at a rate that does not come close to covering costs - but what are you going to do? On the bright side, there are still some ESRD patients with private insurance that essentially subsidize the rest of the unit based on ~4x higher reimbursements than Medicare.

Unlike in certain procedural specialties where physicians can offset reimbursement cuts by doing more procedures per unit time, we are unable to speed up dialysis or to easily increase the number of patients on dialysis (if anything, our mission is to try to keep people off of dialysis - for which we can only bill the same low paying E&M codes as PCPs).

Even though residents swear that their fellowship choices are not driven by money (as that is taboo to say in medicine), their choices would indicate otherwise.

End result: It is going to take me a long time to save up to buy my Pagani...

Interesting share. I suspected it had to do with some kind of massive slash in reimbursement and you confirmed it.

I'll share a similar occurrence that happened to path. About 45 years ago, pathology was one of the most competitive specialties until the late 1970's when CMS eliminated laboratory medical directors i.e. pathologists' reimbursement for clinical laboratory tests (CBC, BMP, U/A, etc.). Prior to that, pathologists were getting a cut for every single CBC, BMP, U/A, etc. that was ordered on a patient because we were the laboratory medical directors and our name went on the report (even though we didn't really do anything). But back in the day, pathologists made a killing off it from sheer volume. It was basically zero extra work/time, and it added up, and was even more lucrative than the bread & butter of our field i.e. anatomic pathology diagnoses from cells/fluids/tissues.

Once CMS realized it's excessive/unnecessary for a pathologist to bill and collect for something that the machine is interpreting, they eliminated reimbursement for it. Subsequently, as one can imagine, pathology applications dropped overnight. It then became one the least competitive specialties. Today it still remains non-competitive and about half the field is made up of IMGs/FMGs. But, I never experienced the "glory days", so I guess you can't miss what you never really had. However, it's not all bad. I actually like it, feel reasonably well compensated, and have an excellent work/life balance. Though it still might also take me awhile before I'm able to afford a Pagani...haha

 

[deleted1164820]

Pathologist starts at $300k+ these days. They take no call, no frozens, and done by 5 PM. The job has better lifestyle than even hospitalist or primary care.

 

[NewYorkDoctors]

don't forget not having to talk to patients (alive ones anyway)

 

[void88]

I want to see one podcast or video episode of these Academic nephrologists discussing the lack of interest in Nephrology Fellowship. This year, @Kidney_boy from Twitter did recognize the issue, but all the nephrologists underneath the thread kept mentioning work/life balance as the main culprit. People intentionally ignore the reimbursement problem, like it should not be part of the equation or doesn't matter. Still, the reality is that Financing is the primary driver in career choice. I'm sure no one fancies scoping butthole day and night unless it pays them so well.

 

[Renal_Prometheus]

I want to see one podcast or video episode of these Academic nephrologists discussing the lack of interest in Nephrology Fellowship. This year, @Kidney_boy from Twitter did recognize the issue, but all the nephrologists underneath the thread kept mentioning work/life balance as the main culprit. People intentionally ignore the reimbursement problem, like it should not be part of the equation or doesn't matter. Still, the reality is that Financing is the primary driver in career choice. I'm sure no one fancies scoping butthole day and night unless it pays them so well.

I’m sorry, but the truth is academic nephrologist are biased. They need fellows to run the program, and cannot openly acknowledge the specialty is not worth doing. And when you bring up how younger nephrologists are leaving the field due to low reimbursement, they will deflect the question by pointing out how well senior nephrologists who are hoarding all the JVs/MDAs are doing. This is why i come to this thread to educate people on the importance of thinking for themselves. The only person looking after your best interest is yourself. At best, the academic nephrologist can only tell you part of the truth, but they cannot tell you the complete truth like I can.

 

[NewYorkDoctors]

what would academic nephrolgoists do without fellows?

see the patients themselves. lol

the attending practice usually has higher functioning patients there so it's easier to "see the patient yourself."

The fellows see the lower functioning patients who need a lot more time and effort to manage . Don't forget ESRD is primarily a disease of the lower SES. For the record I work in a low SES and economically marginalized area in NYC seeing a lot of Medicaid patients. I do my part. I am just saying it's more effort to see lower SES patients as there are just so many more barriers to "getting things done."

Hence withotu fellows the academic faculty hae to do less research and more clinical work

They can hire midlevels but no PA or NP will take night call EVER

 

[coroner]

No its not DO unfriendly but the kicker is most allergy programs are at big academic centers so coming from a community IM or peds program can make it more challenging than being a DO at an academic program. However, coming from a community program does not in any way shape or form preclude you from matching Allergy. I would suggest DOs who want to match Allergy prepare an app in med school that will be competitive enough for an academic program in peds or IM to maximize chances of matching. Allergy is middle competitiveness of all the subspecialties-in order of competitiveness I would say:
1. GI
2. Cards
3. H/O
4. PCCM
5. Allergy
6. Rheum
7. ID
8. Endo
9. Nephro

Regardless, the match rate for Allergy is actually quite high at around 80%

IM subspecialty competitiveness ranking from another poster...thoughts?

Earning potential in IM lifestyle specialities

How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine? That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably. Hours worked: 4-4.5 days a week...

forums.studentdoctor.net

 

[NewYorkDoctors]

IM subspecialty competitiveness ranking from another poster...thoughts?

Earning potential in IM lifestyle specialities

How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine? That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably. Hours worked: 4-4.5 days a week...

forums.studentdoctor.net

in private practice (which is what most people do anyway), the way to make more money is to see more patients and do more procedures in the office.

While ID itself has no procedures (the academics who do fecal transplant are not applicable to community ID doctors), ID usually does PCP as well and combines that together.

Endo actually has a few procedures they can string together in PP to make it happen
Thyroid sono and FNA come to find. Some dedicated endos start an IV bisphosphonate program as well as the usual SC injection medications for osteoporosis. The 24 hour glucometers can be billed for remote patient monitoring CPTcodes . Some endos do DEXAs in the office. I think that USED to pay now it's just something the older endos can still do because they still have the machine lying around.

Nephrology has no real OFFICE procedures. injecting Procrit for a 96372 does not count as PCPs can inject procrit and bill 96372
Heck PCPs bill 94601 (chemo SQ) for prolia...
All of nephrology billing outside of office visit and hospital visit are all tied to HD. That is like a "paywall" and a barrier. Plus it requires the ESRD patient. There is no way to hang a shingle and just make money from the nephrologist's office

Exceptions might be if one does renal bladder ultrasounds (like a cardiologist doing an echo). That requires USDIN certification and doing that emory course.
Doing urine microscopy only pays the same CLIA waived code that labs use of 81002.
but other real procedures otherwise unique to nephrology in the office

 

[Renal_Prometheus]

At least 1/3 of neph grads will leave the specialty at some point. Whether it’s right out of graduation or couple of years later after getting screwed in private practice. But when I talk to neph fellows, they are completely surprised that this is happening. It’s amazing how a specialty manages to keep a lid on their dirty laundry and blue pill fellows into taking their night calls. I truly do not think Neph applicants have all the information in front of them to make an informed decision to go into this specialty.

 

[NewYorkDoctors]

in residency i was sold how nephrology "marries endocrine, hematology, and rheumatology with nephrology. you are the super internist. you are adept in critical care (lol). you are the 'cardionephrologist.' you have amazing extracorporeal therapies that no other subspecialty has. you have a readily available organ for transplantation. you also marry infectious disease with nephrolgoy with transplant patients. glomerular pathology is a rainbow cornucopia of colors and wonders..."

loll


those are not untrue but.... if i aint getting paid for all that work... ain't worth it (outside of academics with a reasonable work life balance... and fellows doing the night calls)

 

[Renal_Prometheus]

in residency i was sold how nephrology "marries endocrine, hematology, and rheumatology with nephrology. you are the super internist. you are adept in critical care (lol). you are the 'cardionephrologist.' you have amazing extracorporeal therapies that no other subspecialty has. you have a readily available organ for transplantation. you also marry infectious disease with nephrolgoy with transplant patients. glomerular pathology is a rainbow cornucopia of colors and wonders..."

loll


those are not untrue but.... if i aint getting paid for all that work... ain't worth it (outside of academics with a reasonable work life balance... and fellows doing the night calls)

These academic nephrologists likely don’t even believe what they say. The reason I say so is because I have couple of friends in academic nephrology. In our private conversations, they all said they would never go into nephrology again if they went back in time. But in public, they still need to sell fellows on the wonders of nephrology. What people say in public and what they say in private are two different things.

 

[NewYorkDoctors]

if you get paid well for something boring, anyone will do it

how exciting is it REALLY to be scoping people nonstop for the same old nothing burgers and occassional dysplasia or barretts or something? and then follow up to see those IBS functional patients in the waiting room?
if GI did not pay so well, it would lose steam so fast

if cardiac caths did not pay well, cardiology would dump it to IR so fast lol... but thanks to the AHA and other lobbyists that wont be happening

 

[marsuki007]

Lmao. I just received a scholarship offer to pursue a Ph.D. in Nephrology. how ****ed am I? I will be researching the basis for proteinuria in glomerular disease. Unsure if this will add to humanity's knowledge, but regardless, wish me luck on the brink of extinction nephro bros!

 

[NewYorkDoctors]

Lmao. I just received a scholarship offer to pursue a Ph.D. in Nephrology. how ****ed am I? I will be researching the basis for proteinuria in glomerular disease. Unsure if this will add to humanity's knowledge, but regardless, wish me luck on the brink of extinction nephro bros!

congrats. make a breakthrough!

the basic science of nephrology needs more researchers like you to make a difference at the basic science level.



it's the medical practice of nephrology and payment structure that is utterly bereft of benefits as mentioned in his thread.

 

[NewYorkDoctors]

so im following up my legacy nephrology patients today for their q3 month labwork.
They are all on remote BP monitoring so my PA keeps track of that in case there are excursions in BP or HR that requires earlier visits

each visit is one hour and comprises of looking through charts like these (no PHI) and reiterating to the patient for the umpteenth time they their creatinine has not "normalized."
that acute bump was during a hospitalization for "sepsis due to cellulitis" in which the patient was blasted with vancomycin and zosyn without proper renal dosing and trough monitoring. nothing a little IV fluids and time couldn't help out

it's a lot of worried well
then small tweaks in the BP medications

then trying to explain to patient the 1+ protein on dipstick with a SpG of 1.030 reflects the patient fasted of water too long and that the UACR of 200mg/g is a better representation of the true situation. then the patient does not get it.

anyway I do not accept NEW nephrology patients anymore. but i have legacy patients whom I continue to care of.

it mixes up my brain a bit. but this visit pays less than a quick PCP visit and pays far less a pulmonary visit that has several procedures attached to it (some combination of PFTs, FENOs, 6MWT, CPETs, CPAP adjustments, sleep studies, sputum induction, chest physiotherapy etc...)

addendum: while I do not see NEW nephrology consults from outside my practice, I automatically manage all renal issues for the primary care patients that I over see (that I have an Internist and PAs manage in my practice).

 

[Renal_Prometheus]

They are all on remote BP monitoring so my PA keeps track of that in case there are excursions in BP or HR that requires earlier visits

Just curious. How much does remote BP monitoring pay? What diagnosis code do you use.

 

[NewYorkDoctors]

99453, 99454, 99457, 99458, 99491, 99487

a local third party company in NYC (i won't reveal name so as not to dox myself) has a staff of individuals who furnish and provide FDA approved remote monitoring BP machines that have cell phone signals on there which connects to a central portal for BP and HR

patients measure everyday ideally. the vitals get transmitted to them.
they keep track of the trends, averages, stats etc...
I set what the warning thresholds are

if something concerning is found, the company notifies my staff. I have the PA review the portal. then contact the patient to reconcile meds and make adjustments at my directions

(additional phone call codes 99441-99443 or video chat codes 9921X-modifier 95. after COVID waivers the -95 does not pay anymore but the phone call codes are still find)

honestly this is "my HD panel." I have 200 patients on this and I would like to think I have gotten their BP under control
"like to think."

There was that recent annals of IM article that saw that overall BP control with RPM was the same but cost more
but that was a registry study looking at codes billing and not a real clnical trial.
I have "interventions" in place.

i pull in about $40,000 a MONTH just with THIS alone. i have to give the company a cut of this but passive income baby

in a private practice were intrepid enough and had the funds, you could set up your own vital sign portal. design a website yourself. buy your own FD aapproved BP machines and give them to patients up front for free (or else they will NOT be paying for it as these things cost quite a bit unless bought in bulk) and hire your own staff to do this. you keep all the proceeds I suppose

 

[Renal_Prometheus]

You don’t want to be close to 50 years old and still haven’t found a fair neph practice. There’s nothing you can offer a group other than “sweat equity” for couple of years, and hope they treat you fairly. But as been said on this thread by other posters, exploitation is rampant in this specialty.

 

[NewYorkDoctors]

ESRD patients are a limited resource. Do the math.

 

[Renal_Prometheus]

it is greed and lack of trust that caused it to be this way

I assume you are referring to greed of the senior partners and them not wanting to share revenue with the new partner. Since the risk is so high, and you can potentially invest many years into this field and end up with nothing, wouldn't it better to not go into nephrology to begin with? Why take all this risk and be at the whim of a senior partner?

 

[NewYorkDoctors]

greed is always high in all private practice (or business in general)

the different is any other IM subspecialty (including GIM) can just operate independently and still make it work.

Nephrology is unique in that revenue is tied directly to the ESRD patient which is a "limited resource" and is "hoarded by the old doctors"

 

[Renal_Prometheus]

I find it amusing that academics come onto this thread to promote nephrology. A nephrology bashing thread. It has the eyeballs, but also shows how desperate they are to get somebody.

 

[NewYorkDoctors]

What I find more amusing is that this thread is not bashing their academic nephrology career yet this promotion is still ongoing? they have a pretty nice job with fellows doing the grunt work for them. Yes true other attendings have mentioned that having a bad fellow is more work
But comon now would you prefer zero fellows all the time like a community doctor?

This thread is warning against going into the dog eat dog private practice world of nephrology without having friends / family / connections helping you.

Going to do an academic job is nice and a good career. not the best paying but that's okay.

 

[Renal_Prometheus]

The nutshell summary is that in the late 90s and early 2000s CMS noticed that while ESRD patients only accounted for ~1% of the Medicare population, about 9% of the budget was going to fund their care. They made various reimbursement reforms, culminating in the bundled monthly capitated payment (and prospective payment system) that was introduced in 2011 (that they also conveniently failed to index to inflation) .

So as you say yourself, dialysis reimbursement is capped by medicare that does not adjust for inflation. We know that salaries of dialysis staff only go up with time, not down. So you have a situation where your revenue is capped, but your overhead expenses will rise with inflation, eating into your net margins every year. How sustainable can this be? If you look at income statement of a large dialysis company like Fresenius; 5 years ago they were operating at over 20% profit margins, now there profit margins are in the single digits, how about 5 years from now? How sustainable can the dialysis industry be? And when you have a specialty that is so heavily reliant on dialysis unit joint ventures to make up the income from poorly payed clinical work, is it really wise to go into nephrology. I'm really curious at what you really think.

 

[Renal_Prometheus]

This year, @Kidney_boy from Twitter did recognize the issue, but all the nephrologists underneath the thread kept mentioning work/life balance as the main culprit. People intentionally ignore the reimbursement problem, like it should not be part of the equation or doesn't matter.

Not mentioning reimbursement problem is still better than mentioning it in public. Reasons being:
1). You can’t do anything about it anyways

2). You still need to sell this specialty to incoming fellows. Imagine those neph fellows working their butts off, hoping for a sliver of light, when they see their PD post on twitter that the specialty isn’t worth doing and theirs no money at the end of the rainbow. Now in private, attendings will talk; I know very well because these are my colleagues.

 

[Renal_Prometheus]

My point is, not all PD's and nephrologists promote their specialty or try to actively recruit applicants.

Just get them in a room with an applicant and watch the sparks fly. It’s like a shark smelling blood in the water and circling its prey.

 

[EddieSpeddie]

I’m someone who is considering bailing from nephro fellowship after my first year. I don’t dislike nephro and the program is not bad but I always thought about private practice since I don’t wanna deal with academic medicine anymore and I don’t know if I want to do another year if the earning potential is going to be similar to what I would make as a hospitalist.

Fortunately this thread gave me serious pause about going into private practice. I’m thinking about just switching over to hospitalist after this year because tbh 7 on 7 off sounds like a lot less work than what I’m hearing is entailed by private practice nephrology. I asked some of the fellows entering private practice about this and they disagreed and said in private practice you determine your own schedule and have better hours than working as a hospitalist. Was wondering if anyone here could clarify if this is actually true? I heard this from at least 3 different fellows about private practice. Would love to hear the thoughts from regulars here.

 

[Renal_Prometheus]

I asked some of the fellows entering private practice about this and they disagreed and said in private practice you determine your own schedule and have better hours than working as a hospitalist.

Neph having better hrs than hospitalist is a laughable idea. It’s fairly well known that Neph has a bad lifestyle. Large cities you are hustling between 4-5 hospitals per day for consults. You think your group will give you partnership if you aren’t putting in the “sweat equity.” Rural areas where you are the only nephrologist, you may have more control in your hrs, but then you are on call every night. Your cofellows are in denial due to often cited sunken cost fallacy. This thread has been ongoing for many years and I’m surprised you didn’t bother reading it before plunging into the blackhole. Could have saved yourself a years worth of your time.

 

[Renal_Prometheus]

I don’t know if I want to do another year if the earning potential is going to be similar to what I would make as a hospitalist.

Just to clarify my position on neph salaries. I think the average nephrologist salary is no better than the average hospitalist salary if take into account how many more hrs the nephrologist is working. If you add the 2 yrs of fellowship plus x number of years as junior associate, with high potential to get screwed by greedy senior partners, it’s actually a much worse deal than people realize.

I think the top 10% of nephrologists make much more than the top 10% of hospitalists. The chances of a new grad coming out today and getting into the top 10% is very low, but not zero. This last tidbit is what continues to allow academic nephrologists to sale hopium to applicants about how much nephrologist CAN earn. It’s not a complete lie, but not entirely true either.

 

[EddieSpeddie]

Neph having better hrs than hospitalist is a laughable idea. It’s fairly well known that Neph has a bad lifestyle. Large cities you are hustling between 4-5 hospitals per day for consults. You think your group will give you partnership if you aren’t putting in the “sweat equity.” Rural areas where you are the only nephrologist, you may have more control in your hrs, but then you are on call every night. Your cofellows are in denial due to often cited sunken cost fallacy. This thread has been ongoing for many years and I’m surprised you didn’t bother reading it before plunging into the blackhole. Could have saved yourself a years worth of your time.

Lolol well I never said I was smart otherwise I would have known about this thread. Why do you think I want to bail from academics? lol. Despite my stupidity, I was never under the assumption that I would make bank in private practice as a nephrologist. Even though the mentor I had was a private practice guy who told me he and his partners made upwards of 500k. I figured that was because of were I did my residency: The population was 8 different types of f’d up with people in their 20s and 30s starting HD on top of the massive diabetic HD population. I didn’t plan on sticking around and knew that overall nephrology wasn’t in a healthy place.

What I did believe in foolishly was that private practice nephrology would have a better lifestyle than being a hospitalist based on working with just one group that has a large hd panel in an undesirable location; those guys were beyond laid back and they wrote the funniest notes (like 2 sentences in the plan). I realize now that even if you make partner you are grinding away constantly all year whereas as a hospitalist you work 7 on 7 off. I guess sometimes you need to cross over to see the grass isn’t greener on the other side. Fortunately I don’t have debts like a lot of people do and even with the earning potential I lost over this past year I’m not bitter about it. I just find it hard to make a call on whether I should just finish this fellowship out or move in asap. 2nd year is a lot easier than first year but you still have night calls and weekends…. Anyways, thank you for input on this matter. I appreciate it .

 

[Renal_Prometheus]

What I did believe in foolishly was that private practice nephrology would have a better lifestyle than being a hospitalist based on working with just one group that has a large hd panel in an undesirable location

Why do people still fall for a lie year after year when there's already this much information on the internet about this specialty. If applicant's know what I know about this specialty, neph applicants will further decrease by another 50%. People are misled into a specialty that will exploit them very hard. The only winners are fellowship programs looking for warm bodies and senior partners living off the backs on junior associates with no intention of sharing revenue equally.

 

[NewYorkDoctors]

where does revenue come from in private practice?

comes from your office codes 99202 to 99215, hospital codes 99221 - 99233 (if you round in the hospital), procedure CPT codes, and certain quality metric CPT codes (G2211 for complex care, G0420 for discussion about CKD care/manaegment, G0296 for discussion for lung cancer screening just to name a few).

the internist bills the same office and hospital codes as the subspecialists in IM
the internist usually has a few CPT codes to use in the office such as 93000 EKG, 36415 venous phelbotomy, 81002 U/A dipstick, 94664 inhaler etchnique, 94010 basic spirometry, 92552 pure tone audiometry (yes you can thank me later internists who never thought of this. i got inspired when I saw my kids pediatrician office using this device), and maybe a few others. But no "real procedures" for internal medicine

the specialists will vary
the nephrologist does not really any office based CPT codes different than what the internist could order. Oh sure one could get certified in diagnostic renal U/S and do a 76705, write a report, and collect a cool $100 or so (more than cardiologist's TTE) but that is the exception and not the norm. The nephrologist's key procedural CPT code is dialysis and can include chronic HD, acute inpatient HD, CRRT, home HD, and PD.
But what is the rate limiting factor for these procedures? the ESRD (or AKI requiring RRT for hospital patients) patient. These patients do not "grow on trees." These patients can be considered a "rare commodity." THose top ten% neprhologists who make a lot of money have a lot of this "rare commodity."

in contrast other IM subspecialties can do their procedure CPTs on every patient that walks in the door if desired
everyone gets an echo, EKG, treadmill stress with the cardiologist. then onto the nuclear money print machine, get a US carotid , US LEA, and Holter while you're at it.
everyone gets an EGD and colonoscopy with the GI doctor
everyone gets chemo or immuntoherapy with the oncologist (usually right?)
everyone gets PFTs and certain other tests with the pulmonologist.

just to name a few.

not everyone who walks into endocrine needs thyroid FNA or DEXCOM remote patient montioring
not everyone who walks into ID gets... anything beyond the office visit code
not everyone who walks into rheum gets an arthrocentesis or steroid injection or MSK ultrasound or biologic infusion.

so the logic comes out to be -
why do a tough renal fellowship that in some ways rivals cardiology in acuity (perhaps no CCU equivalent but no less daunting) but not get any promise of that rainbow and pot of gold?
sure money is not everyone's thing. so do a non procedure IM subspecialty then.

Renal without HD is not a viable career path unless you do GIM / hospitalist with renal knowledge as a secondary to "help yourself with tougher primary care / hospitalist patient cases." even then teh two year opportunity cost is nothing to scoff at.

 

[UPCR]

where does revenue come from in private practice?

comes from your office codes 99202 to 99215, hospital codes 99221 - 99233 (if you round in the hospital), procedure CPT codes, and certain quality metric CPT codes (G2211 for complex care, G0420 for discussion about CKD care/manaegment, G0296 for discussion for lung cancer screening just to name a few).

the internist bills the same office and hospital codes as the subspecialists in IM
the internist usually has a few CPT codes to use in the office such as 93000 EKG, 36415 venous phelbotomy, 81002 U/A dipstick, 94664 inhaler etchnique, 94010 basic spirometry, 92552 pure tone audiometry (yes you can thank me later internists who never thought of this. i got inspired when I saw my kids pediatrician office using this device), and maybe a few others. But no "real procedures" for internal medicine

the specialists will vary
the nephrologist does not really any office based CPT codes different than what the internist could order. Oh sure one could get certified in diagnostic renal U/S and do a 76705, write a report, and collect a cool $100 or so (more than cardiologist's TTE) but that is the exception and not the norm. The nephrologist's key procedural CPT code is dialysis and can include chronic HD, acute inpatient HD, CRRT, home HD, and PD.
But what is the rate limiting factor for these procedures? the ESRD (or AKI requiring RRT for hospital patients) patient. These patients do not "grow on trees." These patients can be considered a "rare commodity." THose top ten% neprhologists who make a lot of money have a lot of this "rare commodity."

in contrast other IM subspecialties can do their procedure CPTs on every patient that walks in the door if desired
everyone gets an echo, EKG, treadmill stress with the cardiologist. then onto the nuclear money print machine, get a US carotid , US LEA, and Holter while you're at it.
everyone gets an EGD and colonoscopy with the GI doctor
everyone gets chemo or immuntoherapy with the oncologist (usually right?)
everyone gets PFTs and certain other tests with the pulmonologist.

just to name a few.

not everyone who walks into endocrine needs thyroid FNA or DEXCOM remote patient montioring
not everyone who walks into ID gets... anything beyond the office visit code
not everyone who walks into rheum gets an arthrocentesis or steroid injection or MSK ultrasound or biologic infusion.

so the logic comes out to be -
why do a tough renal fellowship that in some ways rivals cardiology in acuity (perhaps no CCU equivalent but no less daunting) but not get any promise of that rainbow and pot of gold?
sure money is not everyone's thing. so do a non procedure IM subspecialty then.

Renal without HD is not a viable career path unless you do GIM / hospitalist with renal knowledge as a secondary to "help yourself with tougher primary care / hospitalist patient cases." even then teh two year opportunity cost is nothing to scoff at.

Very helpful information, thank you.
What is GIM?

 

[InternistDO]

Very helpful information, thank you.
What is GIM?

General Internal Medicine. Usually it refers to the outpatient IM department (Dept of General Internal Medicine) in an academic hospital in our era of hospitalists but it really just means internal medicine.

 

[sloh]

not everyone who walks into rheum gets an arthrocentesis or steroid injection or MSK ultrasound or biologic infusion.

Great post. Just to add that ultrasound MSK procedures are time consuming and don’t pay well per unit of time.

 

[Renal_Prometheus]

There’s a lot of manipulation and gaslighting of fellows to get them to take horrible night calls. Fundamentally it’s a bad specialty, that’s why it goes unfilled. So programs need to spin the truth to fill spots. And the type of people who will bite are desperate people looking for hope. The reality is the most vulnerable also gets screw the hardest in the end.

 

[MD46]

Have you guys noticed Internal medicine specialists for overseas, without residency training in the US getting the unfilled renal spots ? I heard a few people do that in ID and Endocrine not sure about nephro.

 

[NewYorkDoctors]

Have you guys noticed Internal medicine specialists for overseas, without residency training in the US getting the unfilled renal spots ? I heard a few people do that in ID and Endocrine not sure about nephro.

all the time.

this is how programs fill that cannot get scrambles.

the idea is that the overseas doctor will get "training at top academic program in US and bring knowledge back to home country."

but often it becomes an attempt to getting a backdoor residency spot and practicing in the US. it almost never works out that way as IM PDs do not want these backdoor candidates like this usually.

 

[deleted1164820]

Have you guys noticed Internal medicine specialists for overseas, without residency training in the US getting the unfilled renal spots ? I heard a few people do that in ID and Endocrine not sure about nephro.

There must be unfilled spots even now for anyone to grab. But you need all the USMLE steps cleared first.

 

[Renal_Prometheus]

You can make 300k/yr as hospitalist right out of residency without picking up extra shifts. people who go into nephrology are giving up the opportunity cost of 2 yrs of fellowship plus 3 years of indentured servitude, to ultimately work harder and make less money(per hr) than a hospitalist as a partner. And academics are actually surprised that nobody wants to go into this specialty? And for all those who say it’s not the money and people are choosing it for passion. Then tell me why there are so many Neph trained people working as hospitalist years later? Where’s the passion when you get tired of driving like a maniac around town for consults at 4 hospitals and round at 3 dialysis units on the same day, and still take night calls for a K of 7. Any reasonable size town you will have more than 1 Neph group competing with you for consults. You don’t just show up and accumulate ESRD population and make the money that fellowship programs sold you on. Welcome to the real world.

 

[NewYorkDoctors]

those who "love nephrology the discipline" exist and they can try to find a nice academic faculty job in which you can play Dr House and have the fellows do the night calls.

 

[Renal_Prometheus]

I’ve learned from my interactions with Neph fellows and attendings that the truth is uncomfortable and people will actively avoid it. People go along to get along, but the truth seekers are always ostracized. It’s unfortunate because as a specialty, when your senior leaders don’t want to face up to the reality of why people avoid nephrology, you cannot have a honest discussion of how to fix things. People are happier to live in a lie then confront the brutal reality of issues plaguing this specialty.

 

[georgestone]

After preparing for Nephro boards , I realized that 80 % of Nephrology faculty was garbage and lived in silos at best , didactics were very poor and fellows were scut monkeys to write more than 20 notes on service /day. I came from one of the best programs ( Allegedly ) but tis unfortunate that fellows weren't taught they way it should be .
Unfortunately this dearth of candidates has been going on for a decade and now lying , cheating and fabricating facts is now a integral part of DNA of Nephro fellowship programs & this is has been going on with out real consequence , now they have steady stream of IMG wo residency so even better so the current practices aren't gonna change

 

[NewYorkDoctors]

when the division of nephrology has to grind every consultation to maximize revenue to make ends meet, you cant/ expect fellows to be anything but scut monkeys who see every creatinine and follow up evvery day and are never allowed to sign off