Nephrology is Dead - stay away

[Renal_Prometheus]

since chemist0157 obsessively responds to every one of my posts, lets see if he responds to this one. Test, test. one, two, three

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[rokshana]

Endoscopy is actually a lot of fun, but yes, anything can be tolerable if you get compensated well to do it and have a good lifestyle.

Nephro has 3 strikes, no pay, no lifestyle, and boring.

But others can say the only redeeming aspect of GI is the pay...

My sister tells her kids not to yuck someone else’s yum when they turn their nose up to food...same principle... there are specialities that I would never consider, because it is of no interest to me, but not for me to say it doesn’t have appeal to someone else.

 

[Renal_Prometheus]

Many decades ago, nephrology was a highly lucrative, and competitive specialty. Money changes everything.
Interest in any particular specialty, throughout the decades, varies with compensation. It's a sad reality.

 

[lessismore123]

Many decades ago, nephrology was a highly lucrative, and competitive specialty. Money changes everything.
Interest in any particular specialty, throughout the decades, varies with compensation. It's a sad reality.

As much as we like to get on our high horses, in the end medicine is a job. That competitiveness of specialties varies with compensation, job demand, and working hours only makes sense - I wouldn’t necessarily call that sad.

 

[blue.jay]

Is Nephrology-critical care combination is a lure to attract more applicants these days? Have heard ppl do did Nephro-crit either end up choosing neprology or crit because its almost impossible to find a hybrid job like PulmCCM.

 

[CCM-MD]

Is Nephrology-critical care combination is a lure to attract more applicants these days? Have heard ppl do did Nephro-crit either end up choosing neprology or crit because its almost impossible to find a hybrid job like PulmCCM.

I know a few nephro crit. They all do full time CCM.

 

[blue.jay]

A friend of mine didn't match in GI. He had good research and publications. He was offered a nephrology spot post match in a good University program which didn't fill 3/4 position. They verbally guaranteed one year critical care spot in the same institution when he completes (but still has to formally apply via ERAS). Can we trust these programs will get us one year CCM fellowship in their institution or is it just a bait?

 

[CCM-MD]

A friend of mine didn't match in GI. He had good research and publications. He was offered a nephrology spot post match in a good University program which didn't fill 3/4 position. They verbally guaranteed one year critical care spot in the same institution when he completes (but still has to formally apply via ERAS). Can we trust these programs will get us one year CCM fellowship in their institution or is it just a bait?

I would be careful. Get it in writing if possible. I know someone who didn't get one of these "promised" spots at a program in NC.

 

[Renal_Prometheus]

COVID-19 will impact the nephrology workforce

Nephrology News and Issues | The COVID-19 virus has tested the world’s population and economy, leading to changes in the way we deal with all aspects of life. The idea of months ahead of social distancing, mask wearing, high unemployment, business closures, new rules for eating in restaurants...

www.healio.com

This article pretty much summaries all the problems with the specialty right now. None of it is news for those
who have been paying attention. I quote:

Troubled specialty
Prior to the pandemic, nephrology had already lost much of its glitter as a specialty when compared to other internal medicine subspecialties. The nephrology match program in 2020 was 62%, meaning 38% of the positions remained unfilled or were filled by candidates coming from the supplemental offer and acceptance program.1 The number of candidates filling slots has remained stable but the number of nephrologists going into private practice is continually diminishing (70.3% of fellows in 2011 vs. 51.5% in 2018).2 A significant number of international medical graduates represent 69% of fellows, but they have visa issues that require them to work in underserved areas (J-1 visa) or with an academically affiliated hospital (H1b). There also appears to be more fellows albeit a small number, who have no internal medicine training in the United States. Thus, they are ineligible to take nephrology boards.

Additionally, many nephrology fellows have an eye toward working as hospitalists or as critical care physicians due to better initial compensation, scheduling and lifestyle reasons. According to the Medscape 2020 Physician Salaries Report, nephrology has the lowest percentage of practicing physicians among all specialties (at 44%) who feel they are fairly compensated.

 

[blue.jay]

COVID-19 will impact the nephrology workforce

Nephrology News and Issues | The COVID-19 virus has tested the world’s population and economy, leading to changes in the way we deal with all aspects of life. The idea of months ahead of social distancing, mask wearing, high unemployment, business closures, new rules for eating in restaurants...

www.healio.com

This article pretty much summaries all the problems with the specialty right now. None of it is news for those
who have been paying attention. I quote:

Troubled specialty
Prior to the pandemic, nephrology had already lost much of its glitter as a specialty when compared to other internal medicine subspecialties. The nephrology match program in 2020 was 62%, meaning 38% of the positions remained unfilled or were filled by candidates coming from the supplemental offer and acceptance program.1 The number of candidates filling slots has remained stable but the number of nephrologists going into private practice is continually diminishing (70.3% of fellows in 2011 vs. 51.5% in 2018).2 A significant number of international medical graduates represent 69% of fellows, but they have visa issues that require them to work in underserved areas (J-1 visa) or with an academically affiliated hospital (H1b). There also appears to be more fellows albeit a small number, who have no internal medicine training in the United States. Thus, they are ineligible to take nephrology boards.

Additionally, many nephrology fellows have an eye toward working as hospitalists or as critical care physicians due to better initial compensation, scheduling and lifestyle reasons. According to the Medscape 2020 Physician Salaries Report, nephrology has the lowest percentage of practicing physicians among all specialties (at 44%) who feel they are fairly compensated.

"Office visits and dialysis rounding can be done from a physician’s office or even home, further reducing drive time. With the ability to handle a greater patient load, we might see workforce in practices shrink unless there is a significant increase in the incident patient population"
- this is concerning too. Utilizing NPs to see chronic dialysis pt and using NP/tele services for simple CKD f/u will decrease demand.
I wonder if the number of Nephrology fellows going into critical care will saturate ICU jobs too.

 

[blue.jay]

Even PAs don't find Nephrology appealing

 

[blue.jay]

The rise of PA renal fellowships

 

[Renal_Prometheus]

So my question is if only half the graduates are going into private practice, with many choosing to do hospitalist/CC, that sounds pretty bad for a specialty decision. Do people not do their research before investing years of their life? Believe too much of the positive spin from academics? If you are one of those nephro turned hospitalists, clearly your perception of the specialty pre-fellowship was different than what it is now. Why the disparity between perception and reality?

 

[InternistDO]

I can't speak to nephro specifically, but I can say in medical school and IM residency there's a lot of pressure to specialize. Not necessarily from program faculty, most of whom are general internists, but from classmates, the internet, other specialists. I had a GIM attending M3 year say "yeah. he's to smart to stay as a hospitalist" about another (hospitalist) physician. Here on SDN there's often a lot of buzz about trying to get out of general medicine by way of fellowship. I'm not too surprised that people get on the fellowship train without really thinking about the downsides and then realize the grass isn't always greener once they're there.

 

[DennisReynolds]

I can't speak to nephro specifically, but I can say in medical school and IM residency there's a lot of pressure to specialize. Not necessarily from program faculty, most of whom are general internists, but from classmates, the internet, other specialists. I had a GIM attending M3 year say "yeah. he's to smart to stay as a hospitalist" about another (hospitalist) physician. Here on SDN there's often a lot of buzz about trying to get out of general medicine by way of fellowship. I'm not too surprised that people get on the fellowship train without really thinking about the downsides and then realize the grass isn't always greener once they're there.

yupp. Because they are a buncha nerdsssss.

 

[IM2GI]

But others can say the only redeeming aspect of GI is the pay...

My sister tells her kids not to yuck someone else’s yum when they turn their nose up to food...same principle... there are specialities that I would never consider, because it is of no interest to me, but not for me to say it doesn’t have appeal to someone else.

To be fair, I said that 6 years ago....

 

[Tenesmus83]

Honestly, I rather potential applicants know the positive and negatives of this specialty before going into it. You are always better off being informed.
With many of my nephrology friends who are now hospitalists, I really wondered if listening to the career guidance of their nephrology attendings had tremendous negative consequences on their career.

 

[blue.jay]

Honestly, I rather potential applicants know the positive and negatives of this specialty before going into it. You are always better off being informed.
With many of my nephrology friends who are now hospitalists, I really wondered if listening to the career guidance of their nephrology attendings had tremendous negative consequences on their career.

What % of nephrology graduates in PP are successful in getting ownership in their practicr after 2-3 years?

 

[Renal_Prometheus]

What % of nephrology graduates in PP are successful in getting ownership in their practicr after 2-3 years?

I don't think anyone has hard data on what percentage this is. You should take the fact that fellowship positions
don't fill as a warning, and not as an opportunity. The market is always right.

 

[Renal_Prometheus]

This is an article that was published a few years back. It sheds light on why many go back to hospitalist even after practicing
nephrology for several years.

The Choices We Make Dictate The Life We Lead

Learn about Nephrology Fellowship Programs which offer the nephrologists to meet current and future needs in the United States.

nephrologyusa.com

excerpt from the article:

"They have heard horror stories from their more experienced peers not being offered partnership, or not getting the Medical Directorships promised or not being allowed to participate in joint venture opportunities. As one nephrologist three years out of training put it, “There is greed in nephrology; many of the older physicians do not want to share and ultimately, they do not. There is a lack of stability for fellows going into practices and no guarantees that after all your efforts that you will get a fair shake.”

He believes this concern is another factor as to why residents are not going into the specialty or nephrologists coming out of training choose an employed Hospitalist position. These thoughts or similar have been shared by numerous nephrology fellows interviewed (all of which request anonymity for obvious reasons). There are nephrology practices out there that have a reputation for hiring, working people unfairly and then firing them without offering anything. In other cases, there are limited opportunities to joint venture and many practices in popular locations have the bulk of their units already opened with limited growth available. These are issues the residents and fellows are wrestling with that make the decision to go into nephrology a difficult one. "

 

[NewYorkDoctors]

“There is greed in nephrology; many of the older physicians do not want to share and ultimately, they do not. There is a lack of stability for fellows going into practices and no guarantees that after all your efforts that you will get a fair shake.”

A little update on things -
Finished PCCM fellowship (yes the full 3 years) after Nephro fellowship and IM residency.

Opened and started private practice - was moonlighting as GIM throughout 5 years of fellowship so I have a patient base of GIM patients - slowly to expand.

Affilitations with three local hospitals - Clinical Instructor Title given at one of the hospitals graduated PCCM from as I continue to do part time teaching and rounding for my own patients who get admitted who are admitted under myself (usually the primary pulm or renal patients - too busy to admit all IM patients)

Doing CCM was meh for me. But it was a given in order to be at a tertiary care pulmonary training program.

Things going smoothly. Work in a high volume area. I do not do chronic HD - I give those patients over to the other nephrologists.

When applying for my privileges to get Nephrology privileges also, I had to overcome a lot of territoriality from the existing private nephrology groups and the in house academic group. I merely wanted to be able to do my own HD for any of my own patients who were admitted in the hospital. The concessions I had to give were any chronics go to the other private groups and all CRRT are given to the in house group. I could only really do acute new start HD if the patients were not attached to centers.
The only bright side is I have agreements with the local GU groups to send the recurrent urolithiasis patients my way for Litholink testing and follow up.

Anyway I am busy enough with pulmonary and just overall playing center field for the other private cardiology groups that I dont really mind. But just a sign of the territoriality

 

[Renal_Prometheus]

There is an increasing number of fellowship programs who fill unwanted positions with foreign grads who were not successful
in obtaining an IM residency in the US. This is very worrisome trend for the specialty as these are applicants are taken, let's be honest,
to satisfy a manpower shortage. Most of these graduates remain unable to obtain an IM residency after fellowship. This amounts to exploitation
of a vulnerable population and somethings needs to be done about this.

 

[Scope guy]

There is an increasing number of fellowship programs who fill unwanted positions with foreign grads who were not successful
in obtaining an IM residency in the US. This is very worrisome trend for the specialty as these are applicants are taken, let's be honest,
to satisfy a manpower shortage. Most of these graduates remain unable to obtain an IM residency after fellowship. This amounts to exploitation
of a vulnerable population and somethings needs to be done about this.

some do go back to home country after training. its a win win

 

[TAVR4life]

I know a lot of IMGs who do nephrology (it’s easy to obtain with open spots yearly) only for visa purposes to stay in US until they get enough years here to apply for a green card

 

[Chemist0157]

Is Nephro a bad idea if you can match into a top 3 fellowship?

What about Nephro/CCM combined programs

There would be overlap, but I would be more focused on programs that can easily rattle off where their previous fellows went after graduation and what kind of jobs they have.

The combined programs seem to be getting more and more popular. I am seeing more talk about them at least compared to when I went through fellowship.

 

[Renal_Prometheus]

Is Nephro a bad idea if you can match into a top 3 fellowship?

What about Nephro/CCM combined programs

I would recommend that you read through my posts on this thread with links to articles. My question is that if you decide to go for it and years down the road you find yourself back as a hospitalist, is that a outcome you can stomach?

 

[blue.jay]

@Renal_Prometheus are you a nephrologist?

 

[Tenesmus83]

COVID-19 will impact the nephrology workforce

Nephrology News and Issues | The COVID-19 virus has tested the world’s population and economy, leading to changes in the way we deal with all aspects of life. The idea of months ahead of social distancing, mask wearing, high unemployment, business closures, new rules for eating in restaurants...

www.healio.com

This article pretty much summaries all the problems with the specialty right now. None of it is news for those
who have been paying attention. I quote:

Troubled specialty
Prior to the pandemic, nephrology had already lost much of its glitter as a specialty when compared to other internal medicine subspecialties. The nephrology match program in 2020 was 62%, meaning 38% of the positions remained unfilled or were filled by candidates coming from the supplemental offer and acceptance program.1 The number of candidates filling slots has remained stable but the number of nephrologists going into private practice is continually diminishing (70.3% of fellows in 2011 vs. 51.5% in 2018).2 A significant number of international medical graduates represent 69% of fellows, but they have visa issues that require them to work in underserved areas (J-1 visa) or with an academically affiliated hospital (H1b). There also appears to be more fellows albeit a small number, who have no internal medicine training in the United States. Thus, they are ineligible to take nephrology boards.

Additionally, many nephrology fellows have an eye toward working as hospitalists or as critical care physicians due to better initial compensation, scheduling and lifestyle reasons. According to the Medscape 2020 Physician Salaries Report, nephrology has the lowest percentage of practicing physicians among all specialties (at 44%) who feel they are fairly compensated.

This article doesn't even taken into account the percentage of nephrologists who have practiced for some years and then quite to take hospitalist jobs because it just wasn't worth the effort. Trust me, majority of my neph friends who quite are in this group. My god, people need to stop thinking about his specialty as an escape from their current miserable job.

 

[coreytayloris]

what is the current ranking of nephrology programs in the country? or is there somewhere to find it?

what are Cornell, MGH and Sinai faring like?

 

[PikminOC]

They fill the spots with IMGs
Reason IMGs have a fascination with sub specialization and desire some subspecialty training , if they ever return to their home country.

It's high time IMG's get away from this warped thinking.

Try to get a specialty that is worth the time and effort.

If not stay on as internist or Hospitalist - at least a better pay and lifestyle


Don't delude yourself thinking you made it to a stellar program in nephrology because of your talent. You make it because no American grad wants it and you fool yourself thinking you made it!!


IMGs get IM easily because AMG's choose the better specialities.
Nephrology fellowship is not desired even by most IMG's and you chose it!!

Nephrology is like the scum of the scum of all the specialities as of now

Is it still as easy to get residency when even AMGs don't match?

 

[FutureInternist]

I had family circumstances that forced me to take a “temporary” hospitalist job after Nephrology fellowship.

7 years in and there’s no way I would ever go into it.
4 of my classmates are in private practice, and pretty much hate it.
One is in academics and loves it.... but he was always a weird one .

Some folks talk about lack of respect in hospitalist jobs, but when you work half a year, have no call, no follow ups whatsoever, make 220-250k base, with lots of jobs offering RVUs, and “round and go” so you can be home around 3 pm even on your “on” cycle.... who cares what the specialists say.

Just take the pt, bill, and move on.

 

[Renal_Prometheus]

I had family circumstances that forced me to take a “temporary” hospitalist job after Nephrology fellowship.

7 years in and there’s no way I would ever go into it.
4 of my classmates are in private practice, and pretty much hate it.
One is in academics and loves it.... but he was always a weird one .

Some folks talk about lack of respect in hospitalist jobs, but when you work half a year, have no call, no follow ups whatsoever, make 220-250k base, with lots of jobs offering RVUs, and “round and go” so you can be home around 3 pm even on your “on” cycle.... who cares what the specialists say.

Just take the pt, bill, and move on.

your classmates hate private practice in which way? Not making enough money for the hassle?

 

[FutureInternist]

your classmates hate private practice in which way? Not making enough money for the hassle?

Basically.

The HD rounds are killer, but more and more practices are using NP or PA just for those.
The constant calls for a K of 6, drawn PRE-dialysis, but a critical so have to call.
The constant blood cxs being positive but not knowing if pt got Vanc after HD or not.
The nephrologist being more of a PCP than the actual PCP since pts see them way more often.

 

[Renal_Prometheus]

Basically.

The HD rounds are killer, but more and more practices are using NP or PA just for those.
The constant calls for a K of 6, drawn PRE-dialysis, but a critical so have to call.
The constant blood cxs being positive but not knowing if pt got Vanc after HD or not.
The nephrologist being more of a PCP than the actual PCP since pts see them way more often.

Probably more so because of the poor reimbursement. Anybody can put up with these "hassles"
if they get payed a lot of $$$.

 

[FutureInternist]

Probably more so because of the poor reimbursement. Anybody can put up with these "hassles"
if they get payed a lot of $$$.

Thats personality dependent.
At a certain point, the extra $ is not worth the hassle since it will not impact lifestyle in any way whatsoever.

But.... to each their own.

 

[Renal_Prometheus]

Thats personality dependent.
At a certain point, the extra $ is not worth the hassle since it will not impact lifestyle in any way whatsoever.

But.... to each their own.

I'm surprised your cofellows have not taken the hospitalist route by now. It's such a common outcome with
the newer generation of neph graduates that nobody is suprised anymore.

 

[Renal_Prometheus]

what makes this specialty disappointing is not so much that financially it's not worth doing, although that is an issue for many who leave for hospitalist positions. It's that people who are in positions of power, to actually change the specialty, refuse to acknowledge that there is a problem. As if people don't know that a fellowship who only fills 60% of it's spots have serious problems with it. If you can't acknowledge there's a problem, then there's nothing to fix right? So you end up continuing this cycle of taking IMGs with no US residency, graduates go into private practice to find out they are working harder to make less than a hospitalist and then jump ship, or that senior partners in the group, faced with declining reimbursement, starts taking advantage of junior partners. There's a lot of exploitation at multiple levels. This cycle just continues and there is no hope, because according to the people in power, there's nothing wrong with this specialty.

 

[deleted941485]

what makes this specialty disappointing is not so much that financially it's not worth doing, although that is an issue for many who leave for hospitalist positions. It's that people who are in positions of power, to actually change the specialty, refuse to acknowledge that there is a problem. As if people don't know that a fellowship who only fills 60% of it's spots have serious problems with it. If you can't acknowledge there's a problem, then there's nothing to fix right? So you end up continuing this cycle of taking IMGs with no US residency, graduates go into private practice to find out they are working harder to make less than a hospitalist and then jump ship, or that senior partners in the group, faced with declining reimbursement, starts taking advantage of junior partners. There's a lot of exploitation at multiple levels. This cycle just continues and there is no hope, because according to the people in power, there's nothing wrong with this specialty.

This is the story or rad onc, path, etc as well

 

[Renal_Prometheus]

An underestimated consequence of doing an easy to get into specialty like nephrology is the human suffering it cause. Many who will consider this specialty are applicants who are unable to get into a more competitive specialty, and go into into it as an escape from a dreary hospitalist job. They are going into it on hope of a better outcome. So imagine doing 2 yrs of fellowship, and another 2-3 yrs in private practice getting payed 200k/yr(full time), and finally figure out A) Your not making enough to justify keep doing this or B) your group had no intention of making you partner. It's real and the numbers are not insignificant. People can do real damage to their own careers and the people around you who advocated for this specialty are not going to take a lick of responsibility. It's all on you. It's just a shame that desperate people get screwed the hardest.

 

[Scope guy]

This is the story or rad onc, path, etc as well

didnt know Rad onc and path had similar issues as well

 

[Tenesmus83]

I just want to add on to what you has already said. In my city, I personally know of 6 trained nephrologists who are currently practicing a combination of hospitalist/primary care. The fellowship program here, despite all the bad publicity with the specialty, still manages to get fellows. I just can't imagine the psychology of those who choose to signup. They must know positions are unfilled for a reason. Is the mentality just to get any specialty at any cost and worry about the consequences later?

 

[sloh]

I just want to add on to what you has already said. In my city, I personally know of 6 trained nephrologists who are currently practicing a combination of hospitalist/primary care. The fellowship program here, despite all the bad publicity with the specialty, still manages to get fellows. I just can't imagine the psychology of those who choose to signup. They must know positions are unfilled for a reason. Is the mentality just to get any specialty at any cost and worry about the consequences later?

Seems to be some predilection for thinking more training and more fellowships is always better. I see it in my specialty (PM&R) as well. Many jobs don't require fellowships and jobs that do are in academia that pay poorly.

 

[TAVR4life]

There’s no incentive for hospitals not to over train residents/fellows. We are cheap labor who run the hospitals and their hospital services, provide night coverage, we help offload work from attendings, and every ACGME-approved resident and fellow is subsidized by the government, 2-3x what they pay us. Yes the government uses tax payer money to pay the hospital to “train us.” Now tell me why would Hospital administration and academics worry about the job implications of overtraining cheap highly subsidized labor? If anything the market over time will decrease the salary of new attendings if the supply out paces demand. For those that can’t get jobs there’s always another year of “training” (ie cheap labor). Win-win-win situation for them at the expense of trainees.

 

[blue.jay]

The situation for pediatric nephrologist is even worse. Their job market is the worst and those poor souls are earning as much as a midlevel after 6 yrs of GME and thousands of dollars in debt. Huge sacrifice for their passion.

 

[rokshana]

I just want to add on to what you has already said. In my city, I personally know of 6 trained nephrologists who are currently practicing a combination of hospitalist/primary care. The fellowship program here, despite all the bad publicity with the specialty, still manages to get fellows. I just can't imagine the psychology of those who choose to signup. They must know positions are unfilled for a reason. Is the mentality just to get any specialty at any cost and worry about the consequences later?

Did it cross your mind that they really like nephrology and are happy to do what they like and are not driven by money?

 

[deleted941485]

The situation for pediatric nephrologist is even worse. Their job market is the worst and those poor souls are earning as much as a midlevel after 6 yrs of GME and thousands of dollars in debt. Huge sacrifice for their passion.

BUT BUT THEY ARE PASSIONATE! And that should carry you through and make you ignore everything else.

 

[Scope guy]

whats the consensus of nephro critical care? what does it add, with ref to jobs? 5 or 10 years from now, will it give an edge?

 

[blue.jay]

whats the consensus of nephro critical care? what does it add, with ref to jobs? 5 or 10 years from now, will it give an edge?

Critical care has gotten very competitive lately. Nephrology and ID makes them an attractive applicant and increases the odds of matching. I don't think anyone can practice both nephro and critical care like pulmonary/critical care. As nephrology is mostly a private practice/business based model it's not possible to serve two masters. At least for ID, theoretically one can do ID and critical care locums, though I haven't commonly heard of an employer (other than academics) which allows for 50% critical care time and 50 % clinical ID time.

 

[Tenesmus83]

Did it cross your mind that they really like nephrology and are happy to do what they like and are not driven by money?

The only problem with that argument is that the aforementioned nephrologists were all graduates of the local fellowship program.
So somewhere along the way, expectations didn't meet reality in the real world. And I can only guess who(fellowship program) were feeding those unrealistic expectations.

 

[Renal_Prometheus]

So proud that OP started this thread many yrs ago and it has garnered more responses and views than any nephrology application thread. It's very important for applicants to see the downsides of the specialty before committing years of their lives chasing a dead end specialty. Academic programs are lying through their teeth about how well their graduates are doing, to ensure their own survival. Attrition rates in private practice are very high. Low reimbursement relative to workload, It's common knowledge. And it's a shame not more nephrologists come forward to acknowledge these problems due to embarrassment/stigma. I challenge potential applicants to use their common sense: There's a reason fellowship positions go unfilled and programs have to beg you to join them. It doesn't happen in competitive specialties. There's no need to cover someone else's night calls for 2 yrs so you can figure out you are better off as an hospitalist.