Nephrology is Dead - stay away

[Renal_Prometheus]

These are basically people who couldn't match a residency, and hoping to get through the back door. Programs are not afraid of scaring away traditional applicants? I guess there's no need to worry about reputation when there's already none to begin with.

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[NewYorkDoctors]

this doctor will not have any real shot of getting a US IM residency barring some kind of very close relationship between all parties involved and the IM program in house. If that happens, then that n=1 is a decent life move. But again, this is what it is... an n = 1.

This doctor is going to feel miserable not being able to actually do any cardiology but relegated to "cardiology clean-up duties" for the cardiorenal cases.

Forget about "is this a marriage worth getting into." This is going to be "you can look but you can't touch."

 

[MD46]

However if this doctor is from a third world country, after getting fellowship training and credentials from US once they go back they do tend to make more money based on my discussion with some South Asian friends. Likely 3-5 x more in most cases.

 

[NewYorkDoctors]

However if this doctor is from a third world country, after getting fellowship training and credentials from US once they go back they do tend to make more money based on my discussion with some South Asian friends. Likely 3-5 x more in most cases.

there is truth to this statement. though that is usually someone who is already renal trained and wants to go to a top academic US institution and then return with the big credential. That is a valid plan for someone to do US renal fellowship without IM residency.


More often than not, one is trying to "backdoor" into a US IM residency and then try to get cards or GI. lol. that is not going to turn out the way many think

 

[MD46]

there is truth to this statement. though that is usually someone who is already renal trained and wants to go to a top academic US institution and then return with the big credential. That is a valid plan for someone to do US renal fellowship without IM residency.


More often than not, one is trying to "backdoor" into a US IM residency and then try to get cards or GI. lol. that is not going to turn out the way many think

Yep agreed

 

[Renal_Prometheus]

Nephrology is quickly gaining notoriety among IMGs as one of those specialties to go into if you can't match anything. There are many of these discussions going on in IMG subreddits. Just imagine those faculty who went into this specialty 30 yrs ago, where you had to be cream of the crop to get in, and now resort to taking these type of applicants just to get some uninterrupted sleep at night. I don't know if I should feel sorry for them, or feel upset that they are ruining the honor of this specialty for the rest of us by going so low.

 

[Renal_Prometheus]

Last I checked, there are still plenty of academics bragging to applicants that nephrologists can make big money in private practice. While technically not untrue, practically very unlikely with a lot of asterisks and fine print that people don't bother to research. It's almost insulting to someone's intelligence to suggest to them that going into a field with 1/3 of fellowship spots unfilled, and have to take applicants with no residency, will allow them make big bucks in private practice. But suckers still fall for it, which is the amazing part.

 

[NewYorkDoctors]

 

[Renal_Prometheus]

When someone is that desperate to get a fellow, it’s a huge red flag for applicants. There’s something seriously wrong with this specialty. People need to think deeper about the inner workings of why it’s this way rather rely on some academic professing that the specialty is misunderstood and ready for takeoff.

 

[Renal_Prometheus]

The other thing I've noticed is that I sometimes hear new neph grads say, often in front of residents, that they all did well and all their co-fellows joined good groups. In my experience, this is very premature to say. Using myself as a example, all of my cofellows thought they were joining good groups out of fellowship. Within couple of years, half have quit nephrology and the other half are onto their 2nd or 3rd neph groups. It usually takes 3-4 years in group before you figure out all the unfairness in distribution of JV and MDA money, and how partnership contracts favor the people who wrote them. So catching a new grad right out of fellowship and asking him for his opinions on the job market is not the most accurate depiction of realities, in my humble opinion.

 

[NewYorkDoctors]

the director of nephrology at my fellowship is an elderly nephrologist. big time researcher in his heyday in the 60s and onwards
made a killing selling his HD unit in the 80s and stayed on as medical director of his own units.


he would use to say "let's make nephrology great again!" (A pun on #45... dont need to get into politics too much)

But he would just talked about the gold old days and mention what great career nephrology is and would point to his own career path

out of respect, we would all smile and nod.

but internally we would think.... is this guy serious? does he think his n=1 terrific career path is generalizable to EVEYRONE?


While I would LIKE to think that the academics simply are lying to get fellows for their night call... it is entirely possible the older generation that refuses to move on are so myopic and self centered that they simply are delusional about the current state of nephrology

 

[Splenda88]

We just had an FMG that interviewed for a job in my hospitalist group. She did a nephrology fellowship first and now is an IM PGY3.

 

[NewYorkDoctors]

We just had an FMG that interviewed for a job in my hospitalist group. She did a nephrology fellowship first and now is an IM PGY3.

lol. another former renal graduate who is now a hospitalist . this is a self fufilling prophecy no matter which direction you go

It's like the Ouroboros only it does not matter if go clockwise or counterclockwise lol


the merriam webster definition is quite apt

1. : a circular symbol that depicts a snake or dragon devouring its own tail and that is used especially to represent the eternal cycle of destruction and rebirth. 2. usually ouroboros or less commonly uroboros : something (such as a never-ending cycle) that is likened to or suggestive of the Ouroboros symbol.May 15, 2024

Ouroboros Definition & Meaning - Merriam-Webster​

Merriam-Webster
https://www.merriam-webster.com › dictionary › Ourob...

 

[Renal_Prometheus]

There’s too much unpredictability in joining a Neph group. You don’t know if your partners are going to screw you over at the end. Plus lifestyle is much worse than a hospitalist with too much driving to different hosptials every day. There’s not that many neph group worth joining to begin with. My advice to applicants who are interested in this specialty is don’t gamble if you can’t afford to lose.

 

[NewYorkDoctors]

and mine is in those GIFs above

you may think you have nothing to lose like Jack.. but remember what happens to him.... has the time of his life with Rose for a few days (fellowship) then reality hits when the ship sinks

Mythbusters proved jack and rose could have survived on that door... but that takes a lot of effort... just like taking a lot of effort and good luck to make private practice nephrology work.

 

[Renal_Prometheus]

I think the biggest benefit to those who read SDN is that it’s a combined accumulation of everyone’s experiences. For those who want to listen, they can avoid many of the career mistakes that previous generations have made because of lack of knowledge or people unwilling to speaking the truth. It’s an investment in years of earning potential and you certainly want to know what you are getting at the end of the rainbow(or lack thereof).

 

[NewYorkDoctors]

the other thing is much of the criticism direct to this thread comes either from:
1) academics who have a vested interest in having fellows for night calls.
2) those who "only read the headlines" or read the latest page. If those actually bother to read this entire trainwreck, one would realize that we heap tons of praise on academic nephrology. we just blame market forces for ruining private practice nephrology for anyone who is not a senior partner and owns all of the HD patient panels. we are warning those who do not plan to enter academic nephrology (totally decent career) to create a plan before entering renal fellowship.

 

[Renal_Prometheus]

I thought academics said all neph grads make over 500K after partnership? No way they would lie would they?

 

[Renal_Prometheus]

Don’t gamble if you can’t afford to lose. I often see these 2 groups get screwed the hardest and they have no idea they are walking into a trap among the smiles and optimistic projections coming from academics

1). Older IMG hospitalist(>40 yo) who are sole breadwinners in their family. They waste 5 years to find out they were better off just picking up more hospitalist shifts rather than running around town making the senior guys rich. It’s a lesson that, unfortunately, have to taught the hard way. Now they are closing in on 50 and have no way to recoup the lost working years. Remember, you won’t know if you joined an exploitative group until 3-4 years with them. If everyone can discern the good vs bad groups, you won’t have this many nephrologists quitting to be hospitalists.

2). Neph grads needing J1 waivers. Need I say more. Prime targets to screw over and not make Partner as they are attached to the employer and can’t leave. Exploitative partners are actively seeking these applicants to add to their rotating slave pool. You can arguably make a point that J1s can be screwed in any specialty, but there’s more to gain in nephrology because starting salaries are low.

If anything I say is a surprise to you, you are not ready yet to enter the field of nephrology.

 

[CptNemo]

I thought academics said all neph grads make over 500K after partnership? No way they would lie would they?

To chime in about the academics side: it is definitely not as good of a deal as it used to be.

A lot of people who trained >10 or >15 years ago remember a different time, where fellows ran the show and the researcher attending would make some cameo appearances while mostly focusing on their lab. Those times are long gone.

Fellows are much more protected now, especially in the legit programs. There are caps on services. There are growing attending only services (including night coverage). Dialysis rounding and clinic responsibilities for fellows are much much less than before. Fellows also get more than half of their weekends off now - guess who covers that. To add to this, at some places, fellows are unionized, so they are making about ~90K or more base salary with free benefits/meals/various stipends on top of that.

You can compare that to a junior attending who has 75% of his/her effort funded by a K grant, which pays ~100K plus then gets some additional money for clinical work and ends up making high 100s to mid 200s, but gets no free benefits/meals. Plus the junior attending has to pick up the slack for the work that the fellows are protected from... They still get paid at a lower rate due to very high academic/university overhead. The more clinical work you do, the more money you make, but the more clinical work you do, the more your research suffers. When you are on service (even with a fellow), there is now very little free time to do much else that week. It is definitely hard to establish oneself as a researcher now while making enough money to do basic things like - find a place to live, raise a famliy, etc. To make a research career work, it is almost like you need to either 1) be independently wealthy, 2) love research, don't care about money, and don't mind living in a small apartment all your life (in some parts of the US), 3) have a very wealthy spouse/family, or 4) you are desperate for just getting some sort of job.

 

[NewYorkDoctors]

To chime in about the academics side: it is definitely not as good of a deal as it used to be.

A lot of people who trained >10 or >15 years ago remember a different time, where fellows ran the show and the researcher attending would make some cameo appearances while mostly focusing on their lab. Those times are long gone.

Fellows are much more protected now, especially in the legit programs. There are caps on services. There are growing attending only services (including night coverage). Dialysis rounding and clinic responsibilities for fellows are much much less than before. Fellows also get more than half of their weekends off now - guess who covers that. To add to this, at some places, fellows are unionized, so they are making about ~90K or more base salary with free benefits/meals/various stipends on top of that.

You can compare that to a junior attending who has 75% of his/her effort funded by a K grant, which pays ~100K plus then gets some additional money for clinical work and ends up making high 100s to mid 200s, but gets no free benefits/meals. Plus the junior attending has to pick up the slack for the work that the fellows are protected from... They still get paid at a lower rate due to very high academic/university overhead. The more clinical work you do, the more money you make, but the more clinical work you do, the more your research suffers. When you are on service (even with a fellow), there is now very little free time to do much else that week. It is definitely hard to establish oneself as a researcher now while making enough money to do basic things like - find a place to live, raise a famliy, etc. To make a research career work, it is almost like you need to either 1) be independently wealthy, 2) love research, don't care about money, and don't mind living in a small apartment all your life (in some parts of the US), 3) have a very wealthy spouse/family, or 4) you are desperate for just getting some sort of job.

great points all around

regarding 1) independently wealthy

I knew a nephrologist. very intelligent doctor. went to top IM residency in NYC. did Nephrology at a top NYC renal fellowship
then went to U Chicago for HTN subspecialist training and is also an AHA Hypertension specialist

very good doctor, good educator, and highly active in the nephrology social media sphere

he got married and his wife matched into residency in michigan
he has moved out to michigan and is now one of those exploited junior attendings in a private practice


this doctor came from a wealthy family so was under no pressure to be a GI or cardiologist.

things were so promising alas. i hope this doctor is happy so many years out now

 

[Renal_Prometheus]

The most frustrating thing to explain to a Neph applicant is convincing them it’s a bad idea and they are going to be used for cheap labor. They think they know something, but they don’t. They have heard some do well in private practice, but it’s not the majority. They have been told by attendings that it’s a great opportunity now, but it’s a lie. They have not experienced the exploitation in private practice, the excessive driving, the horrible night calls, and the low salaries. Once you have experienced those, it then makes perfect sense why the specialty goes unfilled. It really is just gambling, and most applicants are better off doing more years of research to try to get something more competitive. It’s just that many people are desperate, and when you offer them a shiny object and a story of hope, they will bite to escape the treacherous path of hospitalist medicine.

 

[Cipher9422]

It seems like a lot of hate is coming from predatory PP groups. What are your guy's thoughts on hospital employed positions?

 

[Renal_Prometheus]

It seems like a lot of hate is coming from predatory PP groups. What are your guy's thoughts on hospital employed positions?

They offer higher starting salaries(300-350k/yr), with some RVU on top, but that’s pretty much where you peak out. You will never make crazy money, but the upside is you don’t have a senior partners screwing you over at the end. Probably would be my recommendation for someone needing a J1 waiver or older grads who can’t afford to give a group 3 years of their lives and be told they didn’t make partner at the end.

 

[Cipher9422]

They offer higher starting salaries(300-350k/yr), with some RVU on top, but that’s pretty much where you peak out. You will never make crazy money, but the upside is you don’t have a senior partners screwing you over at the end. Probably would be my recommendation for someone needing a J1 waiver or older grads who can’t afford to give a group 3 years of their lives and be told they didn’t make partner at the end.

oh that's cool then. This seems like the way

 

[Renal_Prometheus]

oh that's cool then. This seems like the way

Before you get too excited, know this. The only hospitals who will hire a nephrologist are places that are rural who don’t have neph coverage. You will have to sacrifice location. Hospitals don’t like hiring nephrologist because it’s a money losing specialty(for the hospital), unlike cards and GI. And if we are talking about rural areas, I can’t imagine any hospitalists willing to take less than 300k/yr working half the year! So are you really better off?

 

[Renal_Prometheus]

From my personal experience, one of my friends works as a hospital employed nephrologist in a small town. While the work is not super hard, he complains to me a lot that he’s only making 330k/yr, working full year, while the hospitalists in the same system makes 350k/yr working 7 on/7 off. Sometimes he hears jokes coming from the hospitalists for how low he gets paid for the amount of work he does. The hospitalists are also picking up extra shifts and most are comfortably pulling in over 500k/yr. This friend of mine has thought about jumping ship(to hospitalist) many times but inertia and respect for the specialty has prevented him from doing so. Now he says he can’t live in a small town anymore as he is an IMG and his family wants to live in a bigger city. I’ve warned him many times about the horrors of big city nephrology practices and how they will make the new guy run around the peripheral hospitals while the senior guy is stationed at the central hospital. Trying to avoid getting screwed in this specialty is almost unavoidable if you want live in a half decent place. I would only trust the senior partner if he’s also your father.

 

[Cipher9422]

From my personal experience, one of my friends works as a hospital employed nephrologist in a small town. While the work is not super hard, he complains to me a lot that he’s only making 330k/yr, working full year, while the hospitalists in the same system makes 350k/yr working 7 on/7 off. Sometimes he hears jokes coming from the hospitalists for how low he gets paid for the amount of work he does. The hospitalists are also picking up extra shifts and most are comfortably pulling in over 500k/yr. This friend of mine has thought about jumping ship(to hospitalist) many times but inertia and respect for the specialty has prevented him from doing so. Now he says he can’t live in a small town anymore as he is an IMG and his family wants to live in a bigger city. I’ve warned him many times about the horrors of big city nephrology practices and how they will make the new guy run around the peripheral hospitals while the senior guy is stationed at the central hospital. Trying to avoid getting screwed in this specialty is almost unavoidable if you want live in a half decent place. I would only trust the senior partner if he’s also your father.

I won't discount what you are saying. You and NewYorkDoctors continue to make good points. I'm only in my 30s and sort of ran through college, med school, and residency and now completely debt free. I spent a few years as a hospitalist and the money/job is easy. Honestly, anyone who has ever seriously worked hospital medicine knows how easy this job can be but it really leaves you having a small sense of unfulfillment. I like Nephrology, to the point that I wanted to apply my third year of Residency but did not pull the trigger.

I'll make a decision on this in 2 years as I have some things I need to attend to first in my personal life that will take time, but still what you've told me has given me hope so I thank you for that.

 

[Cipher9422]

They offer higher starting salaries(300-350k/yr), with some RVU on top, but that’s pretty much where you peak out. You will never make crazy money, but the upside is you don’t have a senior partners screwing you over at the end. Probably would be my recommendation for someone needing a J1 waiver or older grads who can’t afford to give a group 3 years of their lives and be told they didn’t make partner at the end.

Also, from what I see online you are about spot on. The population of these towns and cities are on the smaller end too, 15k-200k.

 

[sloh]

Before you get too excited, know this. The only hospitals who will hire a nephrologist are places that are rural who don’t have neph coverage. You will have to sacrifice location. Hospitals don’t like hiring nephrologist because it’s a money losing specialty(for the hospital), unlike cards and GI. And if we are talking about rural areas, I can’t imagine any hospitalists willing to take less than 300k/yr working half the year! So are you really better off?

True that. Just searched SoCal Kaiser. 1 opening only.

 

[passiveobserver1979]

I got an offer for a neph / cc job for 450K 7 on / 7 off. Not all doom and gloom. There is gonna be a big shortage of nephrologists by 2036.

 

[passiveobserver1979]

Obviously any projected shortage is tempered by the fact that there are many nephrologists who went on to not practice nephrology and could come back to it anytime the market gets better.

 

[Renal_Prometheus]

Obviously any projected shortage is tempered by the fact that there are many nephrologists who went on to not practice nephrology and could come back to it anytime the market gets better.

Another fact that fellowships will not tell applicants when they make these projections on future workforce shortages.

 

[Renal_Prometheus]

Also, from what I see online you are about spot on. The population of these towns and cities are on the smaller end too, 15k-200k.

I’m tempted to start my own renal career consulting service. I feel like applicants can benefit from my experience before making a big career decision like going for nephrology. You simply can’t rely on academics to give you an unbiased assessment of market realities when they are so desperate to get fellows for scut work.

 

[Renal_Prometheus]

I got an offer for a neph / cc job for 450K 7 on / 7 off. Not all doom and gloom. There is gonna be a big shortage of nephrologists by 2036.

7 on/7 off sounds like a straight cc job. Are they offering to let you do some CKD clinic during your on time?

 

[passiveobserver1979]

7 on/7 off sounds like a straight cc job. Are they offering to let you do some CKD clinic during your on time?

Actually I cover both CC and inpt nephrology on my on weeks. Very limited nephrology clinic during time off.

 

[Renal_Prometheus]

I'll make a decision on this in 2 years as I have some things I need to attend to first in my personal life that will take time, but still what you've told me has given me hope so I thank you for that.

Please don’t take what I have said as hope in this specialty. Many of my friends have traveled this path only to dig themselves into a bigger hole. I’m here to warn others from harming themselves.

 

[Renal_Prometheus]

what is a market? a market is a very efficient way of gathering disperse information from buyers(applicants) and sellers(fellowship programs) and coming up with an accurate metric to gauge where a specialty is right now, and whether it's worth going into. So what is the market telling you when 1/3 of fellowship spots go unfilled? The sellers have no skin in the game and don't have to tell you the truth. They have pure upside, and no downside risk if they can get a fellow to be used scut work. The buyers have skin in the game, and can potentially invest many years into this specialty to come out worse off than a hospitalist. So I ask you again, what is the market telling you about this specialty and who can you believe?

 

[Renal_Prometheus]

Fellowship First, Residency Next: The Untold Story of Exceptionally Qualified Candidates in Nephrology​

Fellowship First, Residency Next: The Untold Story of Exceptionally Qualified Candidates in Nephrology

"Common reasons for the declining interest include the challenging patient population (6), perceived difficulty of the subject, declining competitive compensation rate, and lack of work-life balance (7). However, the recent decline in nephrology interest among IMGs, who may share some of the same reasons as US graduates, needs to be further studied"

There's nothing to study. It's a horrible specialty to go into into financially speaking and people with options would rather do something else. So these fellowship programs, then go prey on desperate applicants who couldn't get a residency to cover their night calls.

"According to the annual ASN Nephrology Fellow Survey data from 2019 to 2022, the percentage of IMGs who entered fellowship training without prior US internal medical training has increased from 1.5% to 7% (Figure 2). However, the survey respondents only included a fraction of the total nephrology fellows in training (~20%)"

I would venture to guess that percentage of neph fellows currently without US residency right now is over 10%, and climbing every year. Programs have no shame in exploiting people for cheap labor and mask their actions under the guise of "helping" IMGs get into the US medical system. If these are truly "exceptionally qualified candidates", why can't they match a US IM residency?

A hypothetical case of an IMG​

Dr. X is an IMG who completed medical school in Country XYZ and studied hard to join an internal medicine residency in Country XYZ. However, she always dreamed of working in the United States as a physician and thus completed all the required United States Medical Licensing Examination program exams to apply for an ACGME-accredited nephrology fellowship in the United States as an exceptionally qualified IMG. She came to the United States with hopes of getting an unrestricted license after 2 years of nephrology training and working as a nephrologist in the United States, as the demand for physicians is huge and felt everywhere. As she navigated her fellowship training as a busy nephrology fellow, she realized that her options were far more difficult and uncertain than she had anticipated.

Many states do not allow her to obtain a permanent or unrestricted license because as mentioned above, they require 3 years of training in 26 of the 50 states (some requiring ACGME accreditation for all 3 years) or completion of a US internal medicine residency. Unfortunately, nephrology fellowships are accredited by the ACGME for 2 years, not 3 years; thus, she will not meet this requirement. She was also told by many that the ideal situation is to re-do internal medicine residency in the United States, but obtaining residency has gotten tougher year by year for IMGs.

Although doing a fellowship in the United States is one of the most challenging phases of a physician's career, having limited options and the potential of having to leave the United States permanently can take their toll on anyone. Under current circumstances, fellowship training in the United States without Nephrology ABIM certification does not carry much value, which means a waste of time and effort. The situation is not ideal for the health care community either, as there is a growing need for physicians, which makes it a lose–lose situation.

 

[Renal_Prometheus]

why sign up to be exploited in fellowship, then get exploited some more in private practice by predatory partners. Unless you absolutely have no other career options, like some of those unfortunate IMG applicants described above, why anyone with common sense would go for this? Unless you were too naïve to realize it's a career trap and got swindled by the welcoming smiles on your interview trail.

 

[GoSpursGo]

Renal_Prometheus was warned repeatedly not to spread the doom and gloom across every single nephrology related thread on SDN. Unfortunately he persisted in de-railing other threads to grind his axe, and thus he has been banned.

 

[NewYorkDoctors]

Sad. I will carry on the torch in this thread.

I am the human 3 star review (while RP was the human 1 star review)

For current nephrologists, there is a medicare G code for CKD education G0420
this can be billed in addition to 9921X with the -25 modifier

for Medicare patients (with supplement, medicaid whatever)... this has paid me an extra $100 on top of the 9921X.

This is for those prolonged conversations about the AV access, what to expect in HD/PD, transplant talk, nutrition whatever yo want.

I've gotten this to pay me successfully. it's still not really an " office procedure" of sorts but its something.

for anyone who is wondering, I do not see renal consults anymore. but I also run that side primary care practice with a second internist and midlevels. any patients with CKD4/5 there I will see and manage. i have a handful (enough to count with my two hands) who are transitioning to HD - at which time I refer to my colleague who is more than happy to add someone to his HD panel without having to do too much talking.

 

[passiveobserver1979]

Renal_Prometheus was warned repeatedly not to spread the doom and gloom across every single nephrology related thread on SDN. Unfortunately he persisted in de-railing other threads to grind his axe, and thus he has been banned.

Renal_Prometheus had it coming for a long, long time. He was reposting the same garbage over and over again. I was getting very tired of the Nephrology is Dead thread.

He had been banned from posting in the 2023-24 Fellowship thread and still posted his monotonous negativity in the 2024-25 Fellowship thread.

 

[passiveobserver1979]

Anyway on a different note I went to attend the ASN board review course this year and chatted with a few people.
Seemed like while market is still tight it’s very hard to find nephrologists at present. I met a desi guy who was a solo practitioner in a decent size midwestern town. The guy was super busy ; went to 3 hospitals saw 80 pts a day and got home after midnight every day.
Must be making a ton of money. He told me he was looking for a nephrologist. Starting salary 250 K probably see about 40 pts a day. Sorry not my cup of tea at this age. I am good enough in CC with a little dabbling in nephrology to keep skills up.
Met another guy who completed a nephrology fellowship but went back to hospitalist. He was renewing his nephrology boards. That left me worried ; if the nephrology market continues to slowly get better then all these board certified nephrologists working as hospitalists will come back too.

 

[kacelius]

I got an offer in a major hospital system in El paso, TX for 310K for nephrology hospital coverage for on call days(call days in a month split between 3 other existing guys) and establish the clinic attached to the hospital which I have to start from scratch. I eat what I kill model and I can have more volume if I wanted as the other 3 nephrologists are not employed by the hospital system. They asked me to hit 5000 -7000 RVU/year. Not all doom and gloom. Just posting here that its not terrible as others may think. The salary for the hospitalist is around 285K in the same hospital, low volume though. The deal felt that money wise it was still better than hospitalist at the same facility.

If you are looking to get stuck in Major cities like LA, Dallas or NJ-NY areas, nephrology is still worse. But there are better pastures out there.

 

[NewYorkDoctors]

Renal_Prometheus had it coming for a long, long time. He was reposting the same garbage over and over again. I was getting very tired of the Nephrology is Dead thread.

He had been banned from posting in the 2023-24 Fellowship thread and still posted his monotonous negativity in the 2024-25 Fellowship thread.

yeah i DM'd him not to go into the fellowship thread. I said let the on the fence candidates come to you. leave the dedicated future academic nephrologists to their own devices. I said the posters who post there are probably those who want to do academic nephrology so let them be. i said just post in parallel. besides, my target audience are the cardiology and PCCM applicants who failed to match and who get cold calls from renal programs. I tend to be more active around the scramble / SOAP season.

but hey non-nephrologists love this thread. who doesn't love to slow and and watch a good highway pile up?

 

[NewYorkDoctors]

Anyway on a different note I went to attend the ASN board review course this year and chatted with a few people.
Seemed like while market is still tight it’s very hard to find nephrologists at present. I met a desi guy who was a solo practitioner in a decent size midwestern town. The guy was super busy ; went to 3 hospitals saw 80 pts a day and got home after midnight every day.
Must be making a ton of money. He told me he was looking for a nephrologist. Starting salary 250 K probably see about 40 pts a day. Sorry not my cup of tea at this age. I am good enough in CC with a little dabbling in nephrology to keep skills up.
Met another guy who completed a nephrology fellowship but went back to hospitalist. He was renewing his nephrology boards. That left me worried ; if the nephrology market continues to slowly get better then all these board certified nephrologists working as hospitalists will come back too.

yeah... no....

let's do napkin math

40 99213s as a primary care doctor sitting in an office all day long theoretically gets about 40 x $100 = $4000 a day.

doing pure napkin match 300 days a year x $4,000 = $1,200,000.

while going full private practice can reach this amount, I am not saying everyone can easily hit $1,200,000

rather, 250K is really woefully bad.

I pay my DNP + PA combined $250K right now to see / call / telehealth about 35 patients a day for me. i get to reap the profits. but MDs should strive for better than that.


the ongoing fallacy amongst the nephrology hopefuls is that the "market will bounce back." Nephrology is a perfect microcosm of Keynsian economics. The government sets the prices (i.e. dialysis payments). Dialysis is not governed like a free market. If there is no free market , then one should not expect "a bounce back like what happened in anesthesia and GI." This is the ongoing narrative set by some in academic nephrology.

now if the nephrologist had actual office procedures like the cardiologist, then it becomes easier to generate revenue without having to travel everywhere all the time. while travel is good for exercise, it really cramps the time that could be spent on actually seeing patients in an office.


that being said, I have always been a proponent of GIM + nephrology until you build up your renal panel if one starts solo.

If one wanted to "specialize to avoid doing primary care," then one can do academic nephrology.


but being a junior attending "aka glorified midlevel" for a senior partner hoping to use your for a few years really is not something an MDDO should want to himherself long term.

 

[sloh]

Dialysis May Prolong Life for Older Patients. But Not by Much.

In one recent study, the challenging regimen added 77 days of life after three years. Often, kidney disease can be managed in other ways.

www.nytimes.com

Ms. Outlaw was mistaken on one point — dialysis can prolong the lives of patients with kidney failure. But a new study published in the journal Annals of Internal Medicine analyzed data from a simulated trial involving records from more than 20,000 older patients (average age: about 78) in the Veterans Health Administration system. It found that their survival gains were “modest.”

How modest? Over three years, older patients with kidney failure who started dialysis right away lived for an average of 770 days — just 77 days longer than those who never started it.

“I think people would find that surprising,” said Dr. Manjula Tamura, a nephrologist and researcher at Stanford and a senior author of the study. “They would have expected a greater difference.”

Moreover, those patients spent less time at home; they were in a hospital, a nursing home or a rehab center for about 15 more days than those who never started dialysis.

Another group didn’t begin dialysis early but continued with “medical management” (which could help alleviate symptoms if needed), though half of them started dialysis at some later point. They lived for about the same amount of time as those who started dialysis right away.

 

[NewYorkDoctors]

this was already somewhat known already anecdotally and based on the early versus late start (based on EGFR) trials about a decade ago.

the 80+ year old nephrologists would tell stories about how about before HD became a Mediacre benefit, very few could go onto HD. some patients would sit around with creatinines of 10+ and feel lousy but would still be okay with their furosemide, kayexalate, sodium bicarbonate, and reserpine / alpha-methyldopa / clonidine (lol)

of course the American Diet was not so heavily processed, full of sodium / potassium / phosphorus, and full of addictive chemicals as it was back then so probably it was easier for the CKD5 patient to avoid getting hypertensive and fluid overloaded. with the heavily processed diet these days, CKD5 patients don't stand a chance before getting an absolute indication to start HD.

but by that corollary I have some CKD5 patients with AV fistula ready but whose uremia dimnishes appetite so much, that these patients have never developed fluid overload, hyperkalemia issues, or acidosis because they just don't eat anything.
as I do not do HD myself ( i have a full time nephrologist colleague who happily takes the patients i get a fistula into), I have no perverse incentive to gaslight a patient into starting HD. as long as the fistula is in (and not causing high output heart failure) then i try to stretch out the time they need to go onto the machine as long as possible using mediacl management.