Nephrology is Dead - stay away

[MD46]

one of the renal attendings I trained under at a large academic upper east side academic renal program.. use to be a director of renal in the 70s and wrote lots of papers on renin and angiotensin1/2 went full private some time ago.

currently has a park avenue office. rounds at two hospitals in upper east side
the renal fellowship handles the renal fellowship.
the other "not learning cases" go to privates. he is one of the privates and goes around putting orders for HD, CRRT, etc... all the intensivists, surgeons, hospitalists love him as he is very receptive and gives his cell phone out.
he has 200 HD patients spraed across 4 HD centers - all within fair walking distance

he is in the 70s and took a career accumulating this

he made it big.

he is a "senior partner."

though he is solo. oh sure he has other solo doctors cover his patients if he is away and the such. but he does not employ junior partners to exploit. that is respect

Ball park of how much he makes doing this?

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[NewYorkDoctors]

Ball park of how much he makes doing this?

dunno he does a lot of hospital consults and followups (all himself he does not bother the fellows unless its a glomerular case or something interseting)

he told me before he just bills 99204 in the office and calls it a day. does not spend too much time in the office.

if we just did the ESRD panel 200 patients 4 visit a month = 200 * $400 a month * 12 months in a year = $960,000
that is without even accounting for his hospital consults, billing critical care time for ICU patients, billing for CRRT and acute HD.

so im sure he's banking good bank.

 

[NewYorkDoctors]

anyway one of patient's with nephrotic syndrome and primary hypoparathyroidism just got a renal biopsy back as primary membranous nephropathy PLA2R positive (I call this "plotter positive"). intriguing.

Kidney biopsy:-Diffuse membranous glomerulonephritis, stage 2-3, PLA2R positive.-Global glomerulsclerosis (3/30).-Rare foci of tubular atrophy.-Mild arterio- and arteriolosclerosis.-No segmental or global proliferative lesions noted.

here is some "beautiful" renal path images

diffuse glomerulosclerosis

look at that spike and domes!

look at that podocyte effacement!

now its time to update his age appropriate cancer screening and investigate his hypoparathyroidism a bit more deeply (as his PCP isn't following my reccs)

anyway this patient's insurance will cover calcitriol but not Tums go figure

This patient won't spend money on Tums so I've had to give calcium acetate (not indicated for his Ph of 5.5 I know and it has low elemental calcium compared to carbonate. but hey if hes not shelling out for Tums gotta do something)


anyway i find the rat inside this same patient's lungs far more interesting

addendum: this patient has nephrotic syndrome due to primary membranous nephropathy

he also ha tuberculosis 2 years ago treated. he has a cavity and now he has been diagnosed with chronic cavitary pulmonary aspergillosis
this might be hard to treat. doing okay on voriconazole at the moment
he is considered "moderate risk of progression" for his membranous so just doing ARB and dietary control at the moment
I'd hate to see what happens to his CCPA if I arranged rituximab (not in my office but a NY blood and cancer - third party infusion center) for him.

this kind of case really needs a multidisciplinary approach but this patient is.... not documented.... refuses to go into tertiary care center .... has managed Medicaid though (nice for this patient).... I am solo-ing this case. wish me luck.

 

[Renal_Prometheus]

I spoke to a nephro fellow who picked it because you start at 250k but I’ll be a partner after 2 years and I’ll be good. I don’t think sdn has a strong IMG/FMG presence. Definitely think there’s utility in keeping this thread alive.

And if neph applicants actually read through this thread, they will realize there’s a lot more to the story than I will make partner after 2 years and make a lot of money. In fact, they will discover they have fallen into a scam perpetuated people who have a vested interest in having a continual supply of fellows.

 

[Renal_Prometheus]

You know Nephrology is in a bad place when academics have to post on a nephrology bashing thread(this one), to recruit fellows.

 

[NewYorkDoctors]

if the "academic" program in question were a good one, they would have no need to worry as they will get their fellows no problems.

There are still AMG who enter nephrology and they go to the best of the best


The "rest" are garbage programs that have no business existing other than to get some free labor (paid by CMS)

 

[Renal_Prometheus]

I’ve often encountered this type of neph applicant. They say they know it’s a bad specialty(do they really?) but have a reason for applying. It’s basically someone who is desperate who doesn’t want to be a hospitalist and wants to take a gamble with their careers. 5 yrs later, they are back to hospitalist work. The repetitive nature which these scenarios play out is predictable at this point. People really don’t know the nuances of how bad the specialty is until they went into it and experienced all lies, half-truth, and rampant exploitation in pp. Then they look back and it now makes perfect sense why the specialty goes unfilled.

 

[NewYorkDoctors]

I’ve often encountered this type of neph applicant. They say they know it’s a bad specialty(do they really?) but have a reason for applying. It’s basically someone who is desperate who doesn’t want to be a hospitalist and wants to take a gamble with their careers. 5 yrs later, they are back to hospitalist work. The repetitive nature which these scenarios play out is predictable at this point. People really don’t know the nuances of how bad the specialty is until they went into it and experienced all lies, half-truth, and rampant exploitation in pp. Then they look back and it now makes perfect sense why the specialty goes unfilled.

Though if this person derives personal satisfaction and “achievement “ by getting certified as a sub specialist , then that might be worth it for said individual .


It makes zero financial sense though

 

[NewYorkDoctors]

Look at the bright side , the remaining half are those who truly want to do nephrology and will thrive in their careers . Isn’t this what the academics want ?

Addendum: call us Thanos lol. No sacred timeline nonsense this time to correct the snap.

What? Only the top ivory tower academics want that ?

What ? Those bottom barrel programs with no reason to exist other than to get cheap labor don want that ?

Salty is the wrong word .
I enjoy the brain stimulation of a GN case . That’s all .

More like “even my primary care practice blows renal out of the water . “


One can peruse reddit and there is far more activity on reddit than on this thread (though the views on this thread continues to increase so this is not a case of "necro-bumping." After all, even loves to watch a train wreck in progress!)

but those recent graduated young attendigns, current renal fellows, IM residents, and med students all voice similar issues on that platform as this thread. This thread is just very visible given the fact it is 10 years strong now and has over 240K views. (everyone loves to watch a pile up on the interstate!)



the root issue here is how there are no office procedures to do.

do general cardiologists complain about how the interventional docs are "doing all teh caths?" heck no. they would rather NOT be on call and get orthopedic problems by doing their nucs and echos in their office.

do community GI complain about the advanced endo docs going all the cool ERCPs? heck no. they never want to go to the hospital again lol.


if nephrology had office procedures to do themselves, then it would thrive in the community.

no such luck exists as no such procedures exist

only thing somewhat close would be taking the USDIN emory course to get renal bladder sono certified and then you can go bill some renal bladder U/S 76705 in office.

 

[Renal_Prometheus]

I’m paraphrasing a bit, but there’s a common saying that good specialties sell itself. If a specialty needs to be “sold” to applicants, then there’s probably something seriously wrong with it.

To add things further, a specialty can’t be both lucrative and noncompetitive at the same time, as some academics claim. These 2 claims are inherently antithetical that defies common sense. It’s possible that a few people do well, but you may be sacrificial lamb that’s needed to balance the equation.

 

[NewYorkDoctors]

as there are 39 pages to this thread and most doctors have no time to read through this all, I just want to reiterate in every page that the goal of this thread is not to say "DIE NEPHROLOGY DIE." The reason is to ensure those who are bought in should join a top academic fellowship program and become a top doctor in nephrology.

But no ONE should join a useless bottom barrel program to become a community nephrologist as there is little to be gained in non-academic nephrology other than headaches and heartache.



The only individual who MIGHT actually read the whole thread are the residents who failed to match PCCM and Cardiology who get cold called by Nephrology PDs being sold a "bag of goods."
That is the individual I am trying to reach to ensure no one matches into Nephrology like that.
From multiple DMs over the years, I would say I think I have reached my target audience.

 

[chessknt]

View attachment 386963
Look at the bright side , the remaining half are those who truly want to do nephrology and will thrive in their careers . Isn’t this what the academics want ?

Addendum: call us Thanos lol. No sacred timeline nonsense this time to correct the snap.

What? Only the top ivory tower academics want that ?

What ? Those bottom barrel programs with no reason to exist other than to get cheap labor don want that ?

Salty is the wrong word .
I enjoy the brain stimulation of a GN case . That’s all .

More like “even my primary care practice blows renal out of the water . “


One can peruse reddit and there is far more activity on reddit than on this thread (though the views on this thread continues to increase so this is not a case of "necro-bumping." After all, even loves to watch a train wreck in progress!)

but those recent graduated young attendigns, current renal fellows, IM residents, and med students all voice similar issues on that platform as this thread. This thread is just very visible given the fact it is 10 years strong now and has over 240K views. (everyone loves to watch a pile up on the interstate!)



the root issue here is how there are no office procedures to do.

do general cardiologists complain about how the interventional docs are "doing all teh caths?" heck no. they would rather NOT be on call and get orthopedic problems by doing their nucs and echos in their office.

do community GI complain about the advanced endo docs going all the cool ERCPs? heck no. they never want to go to the hospital again lol.


if nephrology had office procedures to do themselves, then it would thrive in the community.

no such luck exists as no such procedures exist

only thing somewhat close would be taking the USDIN emory course to get renal bladder sono certified and then you can go bill some renal bladder U/S 76705 in office.

I honestly think it isn't even that--the big problem is that ESRD triggers medicare at any age and as a result the payor mix is terrible, probably the worst of any specialty, because it selects for Medicare. If medicare didn't cut reimbursements by record amounts in the face of rising inflation this wouldn't be so bad but here we all are.

Yes procedures help immensely in terms of upping revenues but even an E/M only clinic that runs lean can be very profitable but if you are taking 80-90% CMS that cuts reimbursement by 2-6% annually you are doomed. As an example, I bill a chest ultrasound, CMS pays $50, private insurance pays anywhere between $150-600. I have to do a minimum of 3x the amount of work on CMS patients for a single private patient. This internal mental calculus absolutely comes in to play when I am considering coming in for work on a day off. Not worth it to see a 65+ year old, but a private insurance patient absolutely can be. System is beyond ****ed, can't wait for it to implode.

 

[NewYorkDoctors]

I honestly think it isn't even that--the big problem is that ESRD triggers medicare at any age and as a result the payor mix is terrible, probably the worst of any specialty, because it selects for Medicare. If medicare didn't cut reimbursements by record amounts in the face of rising inflation this wouldn't be so bad but here we all are.

Yes procedures help immensely in terms of upping revenues but even an E/M only clinic that runs lean can be very profitable but if you are taking 80-90% CMS that cuts reimbursement by 2-6% annually you are doomed. As an example, I bill a chest ultrasound, CMS pays $50, private insurance pays anywhere between $150-600. I have to do a minimum of 3x the amount of work on CMS patients for a single private patient. System is beyond ****ed, can't wait for it to implode.

good point, that definitely plays a big role


but the way nephrology as a practice is structured just adds additional barriers to financial success in the private practice market

if we did a comparison of nephrology to general cardiology (which one thinks about it is analogous in practice in certain ways though different in many ways)

let's use a private practice model and not an employed hospital employee model since usually its the private practices that run lean and try to cut overhead and have the doctor do more tasks than just being the doctor.

Both see inpatient consults and both see outpatient consults. They often see the same patients as well that overlap.

Inpatient is inpatient. The same hospital codes. When a private cardiologist who rounds inpatient orders inpatient tests, that cardiologist is probably not the one billing for those echos, EKG, nucs, caths etc... the same goes for the private nephrologist who rounds inpatient and orders renal sono, NM lasix scan, CTAP etc...

As for outpatient , both see office consultations.

The cardiologist usually does a 12L EKG and takes a history and exam. Then orders TTE, Holter, US Carotid, US LEA, and treadmill stress test to be done in the same office by technician and cardiologist interprets (if has vascular medicine board which certain cards programs will have the fellows get during their 3 year gen cards fellowship then can do those vascular sono studies). Sure prior auth is needed for TTE and those others can bed one over the course of several visits. The cardiologist sits there writing reports and then sharing result swith patient on alternate days.

The nephrologist has no such office procedures. If the nephrologist has an HD panel, the nephrologist then travels to the HD center. If lucky and has a good set up, then can go to the center nearby without too much travel time. But always hustling around. If unlucky, then one has to hustle around and all that productivity is given to the senior partners who are using you as a glorified midlevel in terms of revenue sharing

For a solo provider (rare but it happens), when starting a practice without ESRD patients, who has to literally go to the hospital setting, hang out by the ER and the ICU and be available and be a "doctor's doctor" to get those ATN patients who might need HD or to get those CKD5s who are close. Yes every specialty has to work at it to get referrals and consults.

But least other more comfortable subspecialties can just "do everything when the patient walks into the office." A doctor with office procedures can hang the shingle and advertise and eventually will build up patients.

Even if a nephrologist hung up a shingle, one gets a lot of non-procedural AKI, CKD< electrolyte, issues

a GN is interesting enough but it's a lot of work. arranging a renal biopsy is not bad. but arranging for Rituximab at an infusion center when you do not have one is just a lot of extra uncompensated work.

That whole "you have to travel around everyday to make your money" is really not something I can think of is present for any other subspecialty.


anyway the point remains

If you love the beans do it and go academic. You will have a great career.

If you don't love the beans and think you can make it rich as nephrologist, you better have a plan in place or else you may end up losing the gamble and losing prime years of your life

If you are a resident who failed to match PCCM or cardiology, it is illogical to take a scramble spot for nephrology. Even if you can see yourself doing academic nephrology and have second thoughts about your competitiveness for cards or PCCM, you would want to apply NEXT YEAR and go into the top academic renal programs instead.

 

[chessknt]

good point, that definitely plays a big role


but the way nephrology as a practice is structured just adds additional barriers to financial success in the private practice market

if we did a comparison of nephrology to general cardiology (which one thinks about it is analogous in practice in certain ways though different in many ways)

let's use a private practice model and not an employed hospital employee model since usually its the private practices that run lean and try to cut overhead and have the doctor do more tasks than just being the doctor.

Both see inpatient consults and both see outpatient consults. They often see the same patients as well that overlap.

Inpatient is inpatient. The same hospital codes. When a private cardiologist who rounds inpatient orders inpatient tests, that cardiologist is probably not the one billing for those echos, EKG, nucs, caths etc... the same goes for the private nephrologist who rounds inpatient and orders renal sono, NM lasix scan, CTAP etc...

As for outpatient , both see office consultations.

The cardiologist usually does a 12L EKG and takes a history and exam. Then orders TTE, Holter, US Carotid, US LEA, and treadmill stress test to be done in the same office by technician and cardiologist interprets (if has vascular medicine board which certain cards programs will have the fellows get during their 3 year gen cards fellowship then can do those vascular sono studies). Sure prior auth is needed for TTE and those others can bed one over the course of several visits. The cardiologist sits there writing reports and then sharing result swith patient on alternate days.

The nephrologist has no such office procedures. If the nephrologist has an HD panel, the nephrologist then travels to the HD center. If lucky and has a good set up, then can go to the center nearby without too much travel time. But always hustling around. If unlucky, then one has to hustle around and all that productivity is given to the senior partners who are using you as a glorified midlevel in terms of revenue sharing

For a solo provider (rare but it happens), when starting a practice without ESRD patients, who has to literally go to the hospital setting, hang out by the ER and the ICU and be available and be a "doctor's doctor" to get those ATN patients who might need HD or to get those CKD5s who are close. Yes every specialty has to work at it to get referrals and consults.

But least other more comfortable subspecialties can just "do everything when the patient walks into the office." A doctor with office procedures can hang the shingle and advertise and eventually will build up patients.

Even if a nephrologist hung up a shingle, one gets a lot of non-procedural AKI, CKD< electrolyte, issues

a GN is interesting enough but it's a lot of work. arranging a renal biopsy is not bad. but arranging for Rituximab at an infusion center when you do not have one is just a lot of extra uncompensated work.

That whole "you have to travel around everyday to make your money" is really not something I can think of is present for any other subspecialty.


anyway the point remains

If you love the beans do it and go academic. You will have a great career.

If you don't love the beans and think you can make it rich as nephrologist, you better have a plan in place or else you may end up losing the gamble and losing prime years of your life

If you are a resident who failed to match PCCM or cardiology, it is illogical to take a scramble spot for nephrology. Even if you can see yourself doing academic nephrology and have second thoughts about your competitiveness for cards or PCCM, you would want to apply NEXT YEAR and go into the top academic renal programs instead.

Cardiology and pulm both get to see and do procedures on patients who on private insurance though--there are 50-64 year olds with jobs (or employed spouses) who have COPD/CAD/lung cancer etc etc. My worst private insurance contract is 2.7x CMS rates for E/M, 4x CMS rates for procedures. I could see 5 private insurance patients and make the same as seeing 13 CMS patients, do 2 bronchs on private patients or 8 on CMS patients etc. Allergy has an incredible payor mix, its why they never work more than 4 days a week--they dont need to churn volumes of CMS patients.

Nephrology will almost never get anything other than CMS rates for dialysis/lines/follow ups.

 

[NewYorkDoctors]

Cardiology and pulm both get to see and do procedures on patients who on private insurance though--there are 50-64 year olds with jobs (or employed spouses) who have COPD/CAD/lung cancer etc etc. My worst private insurance contract is 2.7x CMS rates for E/M, 4x CMS rates for procedures. I could see 5 private insurance patients and make the same as seeing 13 CMS patients, do 2 bronchs on private patients or 8 on CMS patients etc. Allergy has an incredible payor mix, its why they never work more than 4 days a week--they dont need to churn volumes of CMS patients.

Nephrology will almost never get anything other than CMS rates for dialysis/lines/follow ups.

i whole heartedly agree.

I primarily serve the Medicaid poor population in NYC . so it's a bunch of managed medicaid or Medi/Medis. ultimately pays nicely though that 2% cut every year for medicare population keeps getting wider and wider as you mention

I have very few commercial insurance patients

but when I do see the occassional Aetna commercial priviate insurance or empire BCBS and this patient is beyond deductible and out of pocket max, the payments for a PFT, CPET, broncho, etc... are higher than what I get


but therein lies the key, will the patient with private insurance pay me if still within their deductible? the answer is unequivocally ... No. I have sent bills before but many of those patients just never show up again daring me to send a collection agency.... which I do not have time for... so i cut my losses, put a note in my EMR patient cannot schedule without paying, then write a letter for PCP.

 

[Renal_Prometheus]

Great discussion. Academic nephrologist act like there’s nothing wrong with this specialty, when in reality everything is wrong, and heading in the wrong direction. Fellows graduate full of hope, and then get there optimism crushed in the first few years in private practice. Me and NYD have both been through the ringer, and know the kind of lies and misrepresentations these programs will say to get a fellow in the door. Ultimately, you just can’t trust what people say when they have trouble filling spots.

 

[NewYorkDoctors]

Private practice nephrology can be very profitable.....


if many things break your way. This includes having an ESRD panel, having a short commute distance, having old nephrologists allow you to buy into an HD center JV to get privileges there, having other doctors rely on you for quick renal consultation and dialysis, etc... too many factors required to make it profitable.

I don't think ANY other IM subspecialty has these "roadblocks" in place from the get go.

For a procedural subspecialty, hang a shingle and start doing procedures and never go to the hospital again unless you wanted to do so.

You are going into the fight with one arm tied behind your back.

 

[Renal_Prometheus]

I love it how people say nephrology has an optics problem. As if that’s the root cause of all its problems. As someone who has ran a nephrology practice for many years, it doesn’t have a optics problem, it has a billing problem.

 

[NewYorkDoctors]

well there is an optics problem in residency

the "cool" renal cases are mostly outpatient in renal clinic or in the transplant floor.

what most IM residents seen inpatient are the missed HDs and ATNs. uncontrolled DM and HTN leading CKD. borriinnnnggggggg

but even if you fix that optics problem, that just attracts af ew more residents to ACADEMIC nephrology


private practice has the billing shortcomings that makes it so a nephrologist cannot have money or lifestyle.

 

[Renal_Prometheus]

Lower barrier to entry = lower barrier to exit

 

[NewYorkDoctors]

this is the EOB of a quick nephrology follow up for a patient with CKD4, HTN, DM, proteinuria noncompliant with meds and diet.

it really does not bill any differently than PCP.
I did not do g2211 on this one as I did not really address anything outside of the CKD/HTN and did not directly address the DM outside of saying follow up PCP and see a dietitian (both not done)

urinalysis dipstick and microscopy (spun it myself to look for some casts - none were found) pays $2.01 lol

 

[Renal_Prometheus]

I recently talked to a few of my buddies who are still in nephrology. They generally regretted their career choices. Some have stated that their retirement plans have changed due to lower than expected income(we were all sold a bag of hopium in fellowship). Very sad situation. These guys who are so enthusiastic in signing up for nephrology right now have a poor understanding of the financial repercussions, to themselves and their families, years down the road. All they hear from academics is 2 years as employee, then big money as partner, which is a bunch of horse**** if you have been reading this thread.

 

[NewYorkDoctors]

It's just like someone saying " do a 'business major' and work for Goldman sachs! the average salary is $600K!"

average indeed..... median far lower.....

the rank and file bankers make like $150,000 and the END of their careers

 

[chessknt]

this is the EOB of a quick nephrology follow up for a patient with CKD4, HTN, DM, proteinuria noncompliant with meds and diet.

it really does not bill any differently than PCP.
I did not do g2211 on this one as I did not really address anything outside of the CKD/HTN and did not directly address the DM outside of saying follow up PCP and see a dietitian (both not done)

urinalysis dipstick and microscopy (spun it myself to look for some casts - none were found) pays $2.01 lol

View attachment 387416

I would argue any chronic complex condition under regular management qualifies for g2211. CKD4 is complex, boom done.

 

[Renal_Prometheus]

I like what NYD said about nephrology in the past. It has a higher peak, but also a lower floor than a hospitalist. We all know of neph grads who are doing hospitalist right now. It’s really career gambling; that’s what it is. But if you are going to gamble, make sure you can afford to lose. It’s just sad seeing 40 year old guys, being the only breadwinner in the family, going into nephrology for the hope of striking it rich. I’ve seen too many failed cases. Just because you are desperate doesn’t excuse you from hurting your family financially.

 

[NewYorkDoctors]

I also say there's nothing wrong with someone wanting to do two years nephrology "in order to become a subspecialist."
There is just NO reason to join the nephrology private practice workforce unless you have visa issues.

Besidse just doing hospitalist, you can also do GIM and advertise yourself as a hypertension specailist or something

 

[Renal_Prometheus]

people go into nephrology because that’s the only specialty they can get into. Is that a good enough reason to do a specialty?

 

[NewYorkDoctors]

people go into nephrology because that’s the only specialty they can get into. Is that a good enough reason to do a specialty?

issue is anyone competitive for nephrology is also competitive for geriatics and infectious diseases.

what makes nephrology "better" than those other two?

the "potential" of procedural revenue.

But as seen in this thread, the senior doctors hoard it all like a ponzi scheme

 

[Renal_Prometheus]

But as seen in this thread, the senior doctors hoard it all like a ponzi scheme

All those smiles during the recruiting process was a trick to lure “fresh meat” into chains of slavery by dangling the hope of partnership. Give me 3 years of cheap labor and we will see if we make you partner. Real enticing offer don’t you think. Just watch those grads faces when they realized got worked to death, was offered partnership(in name only), but don’t share JV with older guys and essentially is still making less than a hospitalist. Given my experience, you have no idea how many suckers fall for this over and over again. A lot of smiles at the fellowship interview too wouldn’t you say? Probably smiling there’s a sucker willing to cover their night calls when they can’t get anyone else to join.

 

[NewYorkDoctors]

Not even an NP or PA is willing to take HD night call . That is telling

 

[Renal_Prometheus]

Not even an NP or PA is willing to take HD night call . That is telling

Residents always have an overly romanticized view of this specialty prior to entering. Reality hit them hard couple of years into to private practice and then they quit to be hospitalists. At least endo and rheum have good lifestyle to back them up if all else fails. What are you gonna do in Neph if your first group you join doesnt work out? Try another one starting at the bottom and see if they will treat you better? People are not thinking with their brains and specialty decisions are more emotional than anything else.

 

[RustBeltOnc]

Do you guys think there is another forum that discusses the pros and cons of working in the American health care / medical education industrial complex as honestly as this one? This is arguably the only forum that deals with hard truths; in other places on SDN/reddit, there is too much "hopium."

 

[NewYorkDoctors]

well Dialysis has been a medicare benefit and thus heavily regulated by the government (i.e. medical industrial complex or "dialysis industrial complex") for the longest time now.

But regardless of that, there is a perverse incentive for nephrologists to get people onto HD and stay there (unless transplant comes along at which time it is no longer moral grey zone but morally reprehensible to deny someone transplant unless too old and frail) as that is how revenue is generated.

This perverse incentive is the primary reason that turns me off to nephrology as a practice.

 

[Renal_Prometheus]

There is perverse incentive for academics to recruit fellows into their program as many positions go unfilled. Unfilled positions means more scut work and night calls for attendings, which defeats the purpose of academic medicine to begin with. I look back at my career on all the lies and manipulation they spewed to get us to sign on to their program, all the lies about how lucrative it is after partnership and how nephrology was in high demand, all lies or half truths, and then they take no responsibility years later as one fellow after another left the specialty because private practice as just that horrible. Some got screwed by partners, others couldn't take the hard lifestyle anymore, some couldn't stand getting payed so little even after partnership. I just can't stand how they get away with this. Notice every time an academic come onto this thread the first thing they spin is how well their fellows have done and how lucrative it "CAN" be. It's dangling a carrot in front of donkey. And they know full well many people who are even considering nephrology are desperate people looking for a ray of hope. It's just unbelievably disgusting what these academics are willing to say when all you have to do is look around and there's literally a neph trained hospitalist in every corner of this country.

 

[NewYorkDoctors]

The top renal fellowships (the ones with in house renal transplant basically) do not have to pull this scam. They know they offer the opportunity for a very good academic career. The academics are powerless themselves to control market forces in the community. It's all these renal felowships that do not have in house transplant, in house onco nephrology , in house glomerular centers etc... that really have no business having a fellowship who have to resort to these cheap tactics

 

[RustBeltOnc]

I think the problem with nephrology work force right sizing is symptomatic of an issue afflicting the entire medical education industrial complex.

There is an unspoken incentive to "build" schools and training programs (the incentive being, it's easier to run these things then actually practice medicine). However, there isn't a check/balance on these things except, long term I suppose market forces.

One thing I find comical is, on other forums a discussion of "grade replacement" to facilitate admission/matriculation to a new / less prestigious medical school. It makes the schools in question look quite desperate for students; one cannot help but wonder - why are they so desperate? At the end of the day, you can build a medical school, but that doesn't mean that there is a commensurate increase in capable students and future careers with cognitively challenging and rewarding work.

 

[Renal_Prometheus]

Is it ethical for fellowship programs to advertise to applicants how well nephrologists are doing by using top 10% of incomes as examples. In reality, the median nephrologist in this country is not doing well at all, and the bottom 1/3 have quit to become hospitalists. They intentionally neglect to mention the bottom and just focus on the top and paint a broad stroke as if it’s representative of the whole job market. But I guess ethics is already out the window when programs rountinely take applicants who couldn’t match residency in order to exploit them for their cheap labor.

 

[CptNemo]

this is the EOB of a quick nephrology follow up for a patient with CKD4, HTN, DM, proteinuria noncompliant with meds and diet.

it really does not bill any differently than PCP.
I did not do g2211 on this one as I did not really address anything outside of the CKD/HTN and did not directly address the DM outside of saying follow up PCP and see a dietitian (both not done)

urinalysis dipstick and microscopy (spun it myself to look for some casts - none were found) pays $2.01 lol

View attachment 387416

IMHO, this would be correctly billed as a 99214 + G2211.

CKD + HTN satisfies 2 chronic illnesses even if stable, so you get moderate complexity.
You get can meet moderate risk very easily - either prescribing or deciding not to prescribe a medication, or you can come up with how social determinants of health are limiting treatment (compliance issues)
Alternatively, you can review a combo of 3 labs/notes to meet data review criteria.

2/3 of the above Elements of MDM at a moderate level gives Moderate Level of MDM = 99214

My understanding is that G2211 is also easy to meet if you are going to be longitudinally managing a patient's CKD.

https://www.asn-online.org/policy/webdocs/UseoftheG2211.pdf

Honestly, we rarely bill 99203/99213 - maybe in a case of a patient who is referred but doesn't really need to see a nephrologist for any reason (i.e., tells an NP PCP that they are having "kidney pain" or is a psych patient who tells NP PCP that they have "kidney problems" and NP PCP refers to nephrology and we fail to screen out the referral). Basically if you review 1 note and 1 lab and you decide no further testing is needed, then that's a 99203/99213

We don't bill for UAs as leadership decided that it is too much of a hassle to maintain CLIA PPM certificates and easier to just run these through the main central lab.

 

[NewYorkDoctors]

speaking of UAs, I dusted off my old USB camera microscope. some company named swift. this is a USB camera on a light microscope that can take pictures on the computer.
this is how i take pictures of urinary sediment

none of this pays money... but it sure is fun to play with microscopes

though from a practical standpoint, I have spund own the urine sediment of lupus nephritis patients (biopsy proven) just to find those RBC casts and urinary acanthocytes.

I see them and think... boy was that a waste of time but it sure is fun to make nice pictures and play with a microscope

I tried to look into how to gram stain sputum and blood but it turns out it is much more involved than I thought...

 

[NewYorkDoctors]

so new patinet comes in as a favor by PCP ... PCP is a PA.... (there is an MD billing but this Internist has 7 PAs and this MD does not see every patient. not that the MD has to by NY law. As long as the MD is available for questions, the PA can be independent...)

PCP PA is uninvolved and patinet has not seen PCP in 6 months.
meds are a mess... pharmacy list has like 40 meds but she is not taking all of them of course.
brings in med bottles but the same med bottle has different pills inside.

no labs from PCP for over one year.

what a beaut to start the morning.
all the patient can talk about is the patient's chronic neck and lower back pain and how "this might be related ot the kidneys."

Addendum: popping NSAIDs nonstop, on ACE + ARB at the same time (from old prescriptions), taking some herbal thing which i googled and found can cause interstitial nephritis.

refuse to get admitted for workup and fluid management.
oh well document, tweak meds, follow up once a week going forward, document unable to pay copay citing she has financial difficulties and alternative is going to emergency room, etc... . luckily my own PAs can serve as the "pseudo primary care" while I just make the executive decisions on the beans. But I am going to end up managing most issues as this patient's own PCP is hands off.

addendum 2: after getting a thorough history and then checking some available records, this patient has seen two other nephrologists before. both told her "lose some weight and take your BP meds. come back in 6 months with labs."
a common thing to say. but it totally loses the point of CKD management.

In the community, there is no incentive to slave away like a resident brute forcing all these issues that cannot be solved in one visit . rather let em burn and get them onto the machine.
This is the other part of community nephrology that irritates me to no end.
It is the "moral hazard" involved when managing CKD/ERSD patients

 

[Renal_Prometheus]

My main gripe with this specialty is that fellowship programs can be a little more upfront with the problems facing new grads and not try to push hopium of making it big. As an example, I recently talk with a neph fellow and he was completely bewildered the older partners were screwing over the young ones to hold onto JV and real estate. Those of us in private practice know its all too common, but it still comes a shock for a neph fellow. I seriously doubt the majority of fellows going into Neph know what they getting into. And as I’ve said before, many of my cofellows have had to revise their retirement plans based on these “uninformed” career decisions made years ago. Ethically, I feel obligated to speak out and inform the uninformed because many choose to stay silent and watch people fall into the hole.

 

[Renal_Prometheus]

With all the problems this specialty is having in recruiting fellows, how “honest” can fellowship programs afford to be? There’s inherent conflict of interest in asking an academic whether it’s a good idea to go into nephrology.

 

[NewYorkDoctors]

all an academic can say is "if you joint academic faculty and have fellows to do your night call, you can have a decent career."

that is the only true statement that can be said. anything else said should be taken with a big grain of salt

 

[Renal_Prometheus]

all an academic can say is "if you joint academic faculty and have fellows to do your night call, you can have a decent career."

If you can get a sucker to take your night calls. Just like we suckered you into taking ours! And now you know practice practice is a big gamble and wish to stay in academics to avoid the exploitation. It’s like a Ponzi scheme where you constantly need new entrants at the bottom to feed the people at the top, otherwise it collapses.

 

[Renal_Prometheus]

I keep hearing comments like if only old guys share ancillary revenue fairly with new partners, it’s not a bad specialty. Well, they won’t share because they can’t afford to!! There’s a cap on how many dialysis pts a geographic location can support. It’s not endless growth. It’s not like cards where you make good money on the procedures you do. If they share fairly, they may have to be looking for the next hospitalist job. So it’s a cycle of exploitation that never stops because financial fundamentals does not support everyone making a lot of money.

 

[Renal_Prometheus]

There seems to something strange going on w/ nephrology.

For instance, the 3 established nephrologists at my shop are doing incredibly well. They are in their late 50s or early 60s.

One of them is a working machine. He had a partner that I was acquainted with and he already left. He told me the guy makes over 1 mil per year easily, but he was making 325-350k with picking up hospitalist shifts in my group.

That acquaintance also told me there was someone before him who left after 2 yrs as well.

Why these dynamics exist in nephrology?

And the average neph applicant applying has no idea this is the true nephrology job market today. All they hear from academics is big money after making partner. They don’t stop to think why this specialty goes unfilled if everyone will make big money post-partner.

 

[NewYorkDoctors]

a very helpful post on this subreddit

academic nephrology is cool and all

but private practice leaves much to be desired.

I am one of those who went back to being a hospitalist after 10+ years private practice. I enjoy nephrology a lot and find it gratifying being a specialist. I do miss it at times but I am very happy working as a hospitalist at this point. I hope to provide you some insight here. These are some of the reasons I changed (in no particular order of importance)

• sometimes we all need a change for the sake of change. We feel like we stop growing. Whether it is a new city, a new job, a new field etc, change is exciting (but also not necessarily easy)
• I was privileged to be in an awesome group. It was a single specialty group practice, but having to manage all the nuances of a practice in this challenging medical economic climate can be very stressful. Sometimes it’s just easier being an employee rather than an owner
• I got sick and tired of having to go to multiple places on any given day. Nice to be at one place
• earlier on in my career I enjoyed the change in scenery from hospital work, dialysis rounding and office. However, since emr has exploded esp through the pandemic, it has become very cumbersome to work in all these silos bc people demand quick responses. I got tired of having to work on my clinic inboxes after busy hospital days. Now this would pertain to any field that does more than one setting (pulmonary, cardiology etc), but we have the added dialysis clinic to the problem
• nursing quality has suffered and many inexperienced nurses will call you for the dumbest things sometimes and wake you up from sleep, such as a k 3.2 at 3 am in the morning. Can easily wait until the morning but now you lie in bed a wake for a while
• no fun driving to a hospital in the middle of the night to see a sick pt
• having to deal with the undocumented dialysis population is emotionally draining
• having to manage dialysis unit staffing (as a medical director) is tiresome
• I am happy to never step foot in a LTAC again. Those places are very depressing
• reimbursement keeps getting cut which can be financially stressful.

There may be more reasons, but these are some of mine that caused me to change. I am not trying to discourage people from pursuing nephrology as I really enjoyed my career but I was ready for a change and looking to simplify my life.

Hope this helps

 

[Renal_Prometheus]

It’s definitely a challenging economic climate for nephrology. The specialty struggles to generate revenue, and to be frank, older partners cannot afford to share ancillary revenue equitably with new partners. You have a situation where new associates are paid a low starting salary, put in 2-4 years of sweat equity, in the hopes of another person honoring their promises. It’s too easy to screw someone over. Not smart to put that much power over you in someone else’s hands.

 

[Renal_Prometheus]

Well I think the thing I was trying to say in that post was it was just surprising that during my 2nd year the "lie game" had to continue. At that point they had already gotten 2 years of scutwork out of me and the discussions about private practice were in complete confidence. But then again unfortunately this is what this specialty has become. It is sad but the new reality.

Why does the lying from academics have to keep going on? Is it because once you have lied, you have to keep lying to cover for the earlier ones?

 

[Renal_Prometheus]

Is there a reason to take these type of applicants other than having a warm body to do scut work?