Nephrology is Dead - stay away

[Renal_Prometheus]

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profit margins of dialysis units are dopping dramatically. Notice Fresenius(worlds largest dialysis provider) had 1.9 billion of net income in 2018,
and in 2022 their net income has dropped to 673 million. In 2021, FMC had 16.75% drop in net income(compared to 2020) and in 2022, had alarming 30.53% drop compared to the previous year(due to surge in labor costs). So if you were a nephrology fellow today, what do you think the dialysis industry will be at five years from now? Profit margins have been dropping every year! Hey @CptNemo, are you preparing your fellows for the financial tsunami that's about to him them in the face?

Fresenius Medical Care AG (FMS) Financials - Income Statement

Detailed annual and quarterly income statement for Fresenius Medical Care AG (FMS). See many years of revenue, expenses and profits or losses.

stockanalysis.com

Fresenius Medical Care Income Statement (Annual)​

Financials in millions USD. Fiscal year is January - December.

Year	2022	2021	2020	2019	2018
Revenue	19,398	17,619	17,859	17,477	16,547
Revenue Growth (YoY)	10.10%	-1.35%	2.19%	5.62%	-6.95%
Cost of Revenue	14,088	12,542	12,322	12,081	11,392
Gross Profit	5,310	5,077	5,537	5,396	5,155
Selling, General & Admin	3,785	3,096	3,134	3,032	2,885
Research & Development	228.62	220.78	193.77	168.03	114.07
Other Operating Expenses	-148.2	0	0	0	-809
Operating Expenses	3,865	3,317	3,328	3,200	2,190
Operating Income	1,445	1,760	2,210	2,196	2,964
Interest Expense / Income	360.14	353.6	409.98	491.06	448.47
Other Expense / Income	86.7	84.38	134.98	103.59	22.98
Pretax Income	998.36	1,322	1,665	1,601	2,493
Income Tax	324.95	352.83	500.56	401.61	511.08
Net Income	673.41	969.31	1,164	1,200	1,982
Net Income Growth	-30.53%	-16.75%	-2.94%	-39.47%	54.86%

Oh, and you don't think profit margins of dialysis units won't affect the bottom line of nephrologists? Those of my friends who joint ventured with a dialysis unit, their JV money has dropped in the last 2 years. Other nephrologists with medical directorship agreements have had their fees cut with each re-negotiation. JV & MDA fees are the only thing that's keeping the older/established nephrologists from jumping ship and becoming a hospitalist. If you think nephrology reimbursement is bad now, just wait a few years, there's room for further downside.

 

[NewYorkDoctors]

lol. we are not the same person. but I am glad we have such a wide audience.

We are just telling it like it is.

Academic Nephrology - wonderful career for those who like the discipline.

Private Practice Nephrology - dog eat dog - you might get lucky if you leave the big overpopulated urban areas. If you want to craft a niche somewhere remote and be a pioneer, this is not a bad way to to do it. For everyone else? See this entire thread.


Also the context of the applicant must be taken into account
AMG - top US med school, top US IM residency, really loves nephrology - joins CUMC in NYC and becomes a transplant nephrologist and becomes a bona fide academic star and future leader of the ASN. Great career! Do it !
Can everyone who applies to nephrology go this route? No

Most nephrology fellows end up getting PP jobs that RP has mentioned about. Do these always pan out? Some find niches. Some do not. But most do not join academics. If you do not join academics and do PP, then your job should be to find a good balance between money made , effort spent, and life enjoyed.
This ratio is not found in most PP nephrology jobs unless you are the head honcho. Therefore, what is the point?
Maybe you'll find some cush job like for Kaiser Permanente out in California. But can everyone find such a job? More likely people will be disillusioned and return to hospitalist medicine with the goal of making enough savings to try to open a GIM PP practice while using the nephrology knowledge for better medical care.

I see no reason why nephrology PDs should be mad at this advice. Unless they are concerned that driving off those inevitable future PP junior partner dead end job doctors from joining fellowship might adversely affect their warm body count overnight.... oh wait the top programs do not have to worry about that because the top programs sell themselves! Those middling programs that have no business having a fellowship and can kick some sand.

 

[Renal_Prometheus]

The dialysis industry is in a race to the bottom. Medicare reimbursement doesn't adjust for real inflation. Labor costs only rise with time, shrinking profit margins year after year, with no ability to counteract these trends in a one payer system. And nephrologists are heavily dependent on JV and MDA fees to justify practicing nephrology; because they are underpaid from seeing large volume of pts. It's a toxic mix that anyone with some foresight will give them pause about entering into this specialty. But of course there are always plenty of applicants who think with their hearts and not their brains.

 

[NewYorkDoctors]

The dialysis industry is in a race to the bottom. Medicare reimbursement doesn't adjust for real inflation. Labor costs only rise with time, shrinking profit margins year after year, with no ability to counteract these trends in a one payer system. And nephrologists are heavily dependent on JV and MDA fees to justify practicing nephrology; because they are underpaid from seeing large volume of pts. It's a toxic mix that anyone with some foresight will give them pause about entering into this specialty. But of course there are always plenty of applicants who think with their hearts and not their brains.

Those applicants should enter academic nephrology, participate in NephMadness and the such, enjoy their intellectual stimulation, and never ever gripe about how they don't get paid enough in public as they were warned.

 

[CptNemo]

This number seem ridiculously low for operating expenses per treatment. Something is off about this number. From internal data I've seen(I can't list the source), other large dialysis providers come close to $300/treatment(labor, supplies, building rent) in terms of operating expense, and I'm not talking about individual clinics, but the aggregate whole. As an example, in this article in 2017, DaVita is cited to have an operating expense of $269/treatment compared to the @253.31/treatment you cited for 2022. An this was back in 2017, and we know labor costs have gone up significantly in the last couple of years.

A Comparison of Payments to a For-profit Dialysis Firm From Government and Commercial Insurers - PMC

This study assesses differences in payments from government and commercial insurers to dialysis clinics using data from a single for-profit organization.

www.ncbi.nlm.nih.gov

DaVita Inc Revenue, Expenses, and Operating Income for Dialysis Services, Including per Patient and per Treatment, in Calendar Year 2017

​	Total, $​	Per Patient, $​	Per Treatment, $​
Revenue​	​	​	​
Total net​	9 360 000 000​	47 321​	331​
Government​	6 271 200 000​	35 424​	248​
Commercial​	3 088 800 000​	148 722​	1041​
Total expenses​	7 592 000 000​	38 382​	269​
Operating income​	1 768 000 000​	8938​	63​

I don't know the specific numbers. Here's another analysis that implies that cost is $270.07 per treatment using 2021 data:

Part 3: The financial state of the outpatient dialysis clinic

Ever wondered how much money a dialysis clinic actually makes?

thepostop.substack.com

As you can imagine with financial reports, the numbers can always be fudged a little and costs may be combined or put in a different bucket to make things look better.

Big picture is that you don't make much (if anything) on straight medicare patients. Units rely on private insurance for their profit - the substack article nicely points this out.

 

[Renal_Prometheus]

I don't know the specific numbers. Here's another analysis that implies that cost is $270.07 per treatment using 2021 data:

Part 3: The financial state of the outpatient dialysis clinic

Ever wondered how much money a dialysis clinic actually makes?

thepostop.substack.com

As you can imagine with financial reports, the numbers can always be fudged a little and costs may be combined or put in a different bucket to make things look better.

Big picture is that you don't make much (if anything) on straight medicare patients. Units rely on private insurance for their profit - the substack article nicely points this out.

This data was from 2021, and I’ve got news for for you, labor costs have gone up significantly since then. My internal data show operating cost close to $300/treatment as of now, with projections to continue to rise over time. That’s my point, cost of labor will continue to outpace Medicare adjustment for dialysis, shrinking profit margins year by year until it implodes. That’s why it’s unwise for people to go into nephrology when large percentage of your income depends on JV and MDA fees. That’s the big point!!!

 

[Renal_Prometheus]

I guess the big takeaway from this thread is that going for a non-competitive specialty has real career consequences. Not everyone is aware of the risks, sadly, as many people end up as a hospitalists years down the road due to unfair partnerships. If only their attendings was more honest on market realities in the beginning! You can’t blindly believe what an academic says about this specialty as they are primarily interested in getting warm bodies to take their night calls. There is a severe conflict of interest in program’s advertising these unfilled fellowship spots and what’s best for the individual. I get PMs from applicants this year telling me when they go on interviews, the PD is still selling them on how lucrative nephrology is in private practice. Really? So lucrative that spots go unfilled and you are practically begging people to come.

 

[Renal_Prometheus]

I would be interested to hear some stories of from current applicants who are interviewing. What are some of the things programs have said or promised to you to get you to join. It never ceases to amaze the degree of desperation these programs undergo to get a fellow.

 

[deleted1164820]

During my interviews now, The faculty are aware that Nephrology as a specialty has low to no interest among candidates. Some of the faculty has never been on the private side of the world and possibly only second hand knowledge about PP. Just one are two kept professing and hypothesizing that nephrology PP can get you good money, but even they don't seem to be well informed about the private side. Most of them are interested in teaching and or on the research side of nephrology. They spent so much of their time on their own niches areas and PP is never even on their radar.

I know they want some warm bodies to get some basic work done, but generally programs have made huge steps to lighten the work load of the fellows. So it did not feel all evil during the interviews at least.

Most of the programs have hired their own fellows as faculty as well, which is a good thing.

 

[NewYorkDoctors]

the thesis is this thread is not "Nephrology should die and go away..." That is asinine.

the thesis is "Academic Nephrology is still a great career choice for many and should be seriously be considered but those interested. But stay far far away from private practice nephrology unless you have a very clear plan for your career in place due to the predatory nature of private practice setups due to the 'limited resource' of ESRD patients. "

I do not see why this is controversial?

 

[Renal_Prometheus]

Just one are two kept professing and hypothesizing that nephrology PP can get you good money, but even they don't seem to be well informed about the private side.

So if PP neph can get you good money, why is interest in the specialty so low? That’s the disconnect with reality. The market, as exemplified by interest in the specialty, is an incredibly accurate reflection of how good the money is in pp. It’s a leading indicator. But some some of these academics are either ignorant or don’t want to openly acknowledge nephrology isn’t worth doing any more.

 

[Renal_Prometheus]

You have to realize that academics cannot acknowledge to applicants that there’s no money left in nephrology. They already have a hard enough time recruiting fellows, they cannot acknowledge this openly. They need to feed hope to their fellows so they can use them to run the hospital for 2 years. Their whole mojo is that starting salaries are of course low, but you will make big money post-partner; but wait! How many of the recent grads have managed this? Most will make partner, but the big money like the previous generation is not there any more. The reason I look down on some of these academics is that they will promise the world to the applicant, live off of their cheap labor and ignorance, and take NO responsibility when years down the neph grad begrudgingly returns to hospitalist Medicine because private practice nephrology is so much worse than they were promised. That’s why I preach on SDN that you need to be able to think for yourselves and not take their word for granted.

 

[deleted1164820]

You have to realize that academics cannot acknowledge to applicants that there’s no money left in nephrology. They already have a hard enough time recruiting fellows, they cannot acknowledge this openly. They need to feed hope to their fellows so they can use them to run the hospital for 2 years. Their whole mojo is that starting salaries are of course low, but you will make big money post-partner; but wait! How many of the recent grads have managed this? Most will make partner, but the big money like the previous generation is not there any more. The reason I look down on some of these academics is that they will promise the world to the applicant, live off of their cheap labor and ignorance, and take NO responsibility when years down the neph grad begrudgingly returns to hospitalist Medicine because private practice nephrology is so much worse than they were promised. That’s why I preach on SDN that you need to be able to think for yourselves and not take their word for granted.

@ RP Not to discredit you sir, But honestly the Programs are not promising any big money. The only promise I have been hearing from the faculty is "Nephrology is interesting" and they love to talk about how interesting it is and they are not looking to get back as being a hospitalist even after getting a lower salary. Some genuinely acknowledge that the money is low and they are in academics, just because they didn't know any better options. Unfilled fellowship is definitely unpleasant thing for the division, But the programs have become much smarter now, they have lot of NPs, APPs who can cover the night calls and programs are not necessarily worrying about who to fill the call slots. They got those things figured out and they are improvising and trying to be less dependent on fellows as they may not be able to fill fellowship positions every year.

As you always say, most programs even if they don't fill during the match cycle, they somehow fill the spots with any one having a pulse as an off-cycle candidate.

 

[NewYorkDoctors]

@ RP Not to discredit you sir, But honestly the Programs are not promising any big money. The only promise I have been hearing from the faculty is "Nephrology is interesting" and the love to talk about how interesting it is and they are not looking to get back as being a hospitalist even after getting a lower salary. Some genuinely acknowledge that the money is low and they are in academics, just because they didn't know any better options. Unfilled fellowship is definitely unpleasant thing for the division, But the programs have become much smarter now, they have lot of NPs, APPs who can cover the night calls and programs are not necessarily worrying about who to fill the call slots. They got those things figured out and they are improvising and trying to be less dependent on fellows as they may not be able to fill fellowship positions every year.

As you always say, most programs even if they don't fill during the match cycle, they somehow fill the spots with any one having a pulse as an off-cycle candidate.

Only the top academic programs at top tertiary care centers can afford NPs and APPs like that becuase there is such high volume that they actually generate revenue to justify the NPs . Those programs are top tiered educational and they deserve to fill with fellows .

It’s the vast majority of these other programs that cannot afford NPs that want the warm body fellows .

Plus NPs will never do overnight go into the hospital call

While I agree these academics never outright lie about the money , they do consistently push the idea that “it’s a a great career.” Yes I agree your PD or director of nephrology career is great . But can every renal graduate get those jobs ? It’s simply a numbers game

 

[Renal_Prometheus]

Neph is in a bad place right now, and dialysis unit profit margins are worsening every year. And to think that 30 yrs ago it was one of the most competitive IM specialties; because it was very lucrative. How things have fallen. There is no accountability on why so many Neph grads are not practicing in the field they were trained in. No acknowledgment from academics that people are not coming into nephrology because salaries are low and not worth the time. All these programs do is hype how great their fellows have done without providing specifics(trust me, nobody follows up with their fellows on how much money they are making post-graduation). It’s the greater fool theory and there will always be some sucker who are desperate enough to bite. Then these people graduate to realize they were fooled, so they take an academic job(at least get the lifestyle) and tries to sale the specialty to the next fool.

 

[Renal_Prometheus]

Why are there so many unfair partnerships in nephrology? Could the reason be that nephrology has a hard time generating revenue, and senior partners need to live off of the backs of junior partners in order to justify practicing this specialty? A lot of practices don’t share existing JV/MDA fees from current dialysis units even after you make partner. So your starting salary might be 250k/yr, but after making partner you will make 300k/yr, after paying your share of overhead expenses. They will let you share in JV/MDAs in any new dialysis units that is built, which may be a never as current market is over saturated with dialysis units. New grads are too inexperienced to understand the trap they are walking into. Get worked couple of years, realize they are not making the money relative to high workload, and onto the next job. It’s so predictable yet so sad people keep falling for this.

 

[NewYorkDoctors]

other IM subspecialties have a far easier time generating revenue thanks in in office procedures.

no in office procedures? what's the point? just do GIM.

hence if you're in it for the money, dont do renal

if you love nephrology and dont have money as the first goal, do academic nephrology and be respected by your peers.

simple as that


zero zilch reason to do private practice nephrology unless you are well connnected

 

[Renal_Prometheus]

What nephrology fellowship is today is a form of labor exploitation on non-competitive/desperate applicants, fanning false hope of them escaping a dreary hospitalist job. The people who are encouraging residents to apply are on the dark side of this, knowing full well they will never tell their own children to go into this specialty.

 

[Renal_Prometheus]

If you believe in the Hippocratic oath to “first do no harm”, and you see a high percentage of your neph cofellows end up badly in private practice, then you need to come here and say something. For the interested applicants who read this, it can save a few careers from being ruined. I’m vocal here because I know what I say is true. We cannot allow the problems thats plaguing this specialty to be distorted by academics who obviously benefit from fellows joining their program. Neph fellows need to understand fully the career risks they are taking on.

 

[NewYorkDoctors]

primum no nocere applies to patients not impressionable IM residents or jaded hospitalists lol

 

[Renal_Prometheus]

Note: This may not apply at some programs where they take desperate people such as those without US Internal Medicine residency training in order to exploit them

Although I don’t have exact numbers, my sense from talking to new grads is that the number of these exploitative neph programs are increasing(maybe 25% of neph programs are doing this). If it’s going to come down to attendings taking their own night calls, or taking applicants with no US IM training, I think we all know how those decisions get made. The larger issue for the specialty is:

1) Does competency of Neph grads matter any more? Or is it just a churning machine for desperate people?

2) what message is that sending to applicants and residents? When there’s no barrier to entry. Do they actually expect to end up doing well going into a specialty that stoop to this level of lowness.

3) Does ASN really want nephrology to be know as a specialty people go into because they couldn’t match IM residency? Because the word has spread like wildfire among IMGs that there’s a path to get into US training system through nephrology.

4). exploitation in fellowship is good precursor to more exploitation in private practice? We have outlined plenty of cases of unfair partnerships and screwing junior partners after paying them very little for the first few years. Is exploitation a structural issue in nephrology because the specialty just can’t generate enough revenue to be share equitably among partners?

 

[NewYorkDoctors]

Although I don’t have exact numbers, my sense from talking to new grads is that the number of these exploitative neph programs are increasing(maybe 25% of neph programs are doing this). If it’s going to come down to attendings taking their own night calls, or taking applicants with no US IM training, I think we all know how those decisions get made. The larger issue for the specialty is:

1) Does competency of Neph grads matter any more? Or is it just a churning machine for desperate people?

2) what message is that sending to applicants and residents? When there’s no barrier to entry. Do they actually expect to end up doing well going into a specialty that stoop to this level of lowness.

3) Does ASN really want nephrology to be know as a specialty people go into because they couldn’t match IM residency? Because the word has spread like wildfire among IMGs that there’s a path to get into US training system through nephrology.

4). exploitation in fellowship is good precursor to more exploitation in private practice? We have outlined plenty of cases of unfair partnerships and screwing junior partners after paying them very little for the first few years. Is exploitation a structural issue in nephrology because the specialty just can’t generate enough revenue to be share equitably among partners?

1) i'm sure it matters for the top academic programs because they want to train real doctors and top nephrologists.
but i see so many community renal programs openign fellowships that have ZERO BUSINESS having a fellowship... if a program does not have their own PD, CRRT, or transplant in house and have to refer out to another center then I don't see the point of having a fellowship otherthan cheap labor

2) im sure the top academic centers still send a good positive message. but overall the aggregate message is "if you are a competitive resident and respect yourself, you will not do nephrology but do something else."

3) ASN is powerless to do anything.

4) yep indeed that is the case. unlike other IM subspecialties, nephrology cannot generate much revenue via CPT code use in the office. one has to travel around and pursue the "scarce resource" (pardon i dont mean to dehumanize these ESRD patients who do need our TLC) of ESD patients. if nephrology actually did things in the office like a general cardiologist (renal sono akin to echo, consistently doing ABPM akin to Holter, have some kind of renal stress test lol not the furosemide version) and then give all the HD to a dedicated HD person (like how general cards gives the big procedures to EP or interventional cardiology) then I can see a pathway for a successful outpatient nephrologist who does not need to run around like a headless chicken all day
but there is no structured means to make this happen at the moment


a nephrologist is as busy as a cardiologist or pulm/intensivist.
but a nephrologist does not have the benefit of ICU shift work arrangements or the relatively cush and stable outpatient pulmonary patient population (any unstable pulmonary patients go to hospital and get managed by ICU anyway)
a nephrologist gets no where near the revenue generation of a cardiologist.

hence unless one gets the prestige and honor of being an academic nephrologist, then what is the point? do something non procedural and not much less pay but way better quality of life.

if someone wants to escape hospitalist and do something "brainy" then consider infectious diseases. much better QoL. Can also pick up hospitalist shifts.

if you really love nephrology, do ACADEMICS
stay AWAY from the PP market unless you have a plan to get lots of ESRD patients and plan to be the boss and have a claer blueprint in place.
Do not "wing it" and get abused

 

[Renal_Prometheus]

For all people who plan to apply to nephrology. I ask this question. Assuming you start at 200-220k/yr working full time. Not 7 on/7 off like a hospitalist, but double that amount. After 3 yrs, and for no fault of your own, you get told by your seniors that you didn’t make partner. Is that an ok outcome for you? Are you gonna go back to hospitalist or try another neph group all over again? If your plan to start all over again at another group, maybe you truly love the specialty and should go for it. If you can’t afford to waste another 3 yrs without any guarantees, then maybe nephrology is not for you.

 

[NewYorkDoctors]

i'm managing a 72M long standing DM2, HTN, obesity with nephrotic range proteinuria up to 8g of albumin at one point (but without the nephrotic syndrome. no hypoalbuminemia or edema).
Has DM retinopathy nonproliferative.
A1c at worst 11% at best 7.8%
gobbles down burgers, fries, shakes before labwork..... BMI only 31 or so...

has Managed Medicare but no supplement or Medicaid so many med are quite expensive even after his deductible.

he is CKD 4 with recent eGFR around 15-20.
he has had about a 1-2 eGFR decline every year for the past few years since meeting him
he has ambulatory home BP monitoring and i have him on amlodipine and coreg which is doing the job... (off ACE/ARB for hyperkalemia not because of any Cr number) and keeping average 130/80. ideally it could be better but when i ramped it up it went to 110/70 and would get dizzy and rise in SCr.

he can only use insulin, sulfonylureas, meglitinides, and GLP1 agonists
he was on insulin but he gained a lot of weight that I noticed his proteinuria would increase quite a bit when he gained weight
he was on GLp1 agonist therapy for a period of time which helped his weight and proteinuria and A1c... but now his copay went from $47 a month for ozempic to $500 a month.. he cannot afford it.
he is back on glimepiride and repaglinide....

he won't stop eating junk food (because his leptin / ghrelin and dopamine reward system are all messed up from eating junk food all these years) without GLp1 agonist therapy. he is not a good candidate for phentermine and his out of pocket costs for COntrave are very high.

he declined renal biopsy and quite frankly i did not pursue it as the serological immune workup was negative and he never had overt nephrotic syndrome. likely would have been perhaps diabetic nephropathy and perhaps obesity related FSGS.

ive done the whole talk about how HD work, the AV access vs catheter vs graft, how many patients end up with a catheter in their neck in the hospital and that is NOT ideal for all the reasons... how an AV fistula needs time to mature.... how dialysis is an off off switch. it is a spectrum etc....

i'm telling him i want you to walk your way away from dialysis!

the last hope for this patient is to walk 10,000+ steps a day... forever... shed his weight to a lower BMI and hope that improves his BP, DM, and (likely) obesity FSGS to the point that his renal function stabilizes a bit....

Am I asking for too much? this patient is probably doomed to end up on HD within 1 year or so.... more than likely not.
but rather than be content with letting him enter the dialysis industrial complex, I have become his exercise fitness guru.
I gave him a pedometer and began to discuss and preach to him
I am sending him emails and text messages every few days asking him his progress and sending more video links and motivation articles about how merely walking to 10,000 steps or more per day will help lose weight.
I am working over time to ensure this patient is given every chance NOT to end up on the HD machine for the rest of his life... i mean he has Managed Medicare so more payments from the bundle lol...

why? it's the right thing to do.

but this also shows how the perverse incentive for most HD nephrologists is "nah let him burn. ill put on the machine"

 

[Renal_Prometheus]

I’ve talked to some applicants and they are completely surprised by the dark side of nephrology. They are unaware of how deep the well goes. They are miscalculating how much career risk they are taking on by going thru with this specialty. It’s sad that nobody will tell them the truth because the survival of nephrology depends on academics hoodwinking naïve applicants into believing there is still money to be made in nephrology, when they themselves knows it’s a dying specialty.

 

[NewYorkDoctors]

I will say there IS money to be made in nephrology...... but not as an indentured servant of a senior partner in private practice or in academic nephrology (the usual template jobs).
But my other caveat is that same entrepreneurial effort is better served in other subspecialties.
Though I understand some individuals are not competitive for those subspecialties. So there is a way to make lemonade from lemons.

see my prior posts about how to become a non-HD dual GIM / nephrologist (have someone else who does HD do it for you - im sure he/she will appreciate it) and how to leverage certain in office procedures to your benefit.

 

[Renal_Prometheus]

People are desperate. Nephrology attracts those type of applicants. That’s just the reality.

 

[NewYorkDoctors]

Again those who truly want to do Nephrology should do nephrology

But no one should think "doing nephrology willl make you competitive for critical care."

No that's not how this works. Fellowships are not like applying to med school in which you wanted to stuff the stat sheet ahead of time.

Being IM makes you competitive for two year CCM (because the PD has you for two years) and your IM residency level ICU skills are still fairly fres.
Being Pulmonary 2 year makes you competitive for CCM because you have so much built in MICU experience
Being Cardiology makes you competitive for CCM (some who want to be academic CCU directors also get the CCM training) because of all of the CCU experience.

otherwise none of the other IM fellowships makes you competitive for CCM because the PDs only have you one for one year and most of your IM resident level ICU skills have atrophied in your two years of renal. The renal mindset is way different than the IM mindset. In fact, many of the "leaders of Nephrology" actively want you to "unlearn what you have learned" in Internal medicine.

In an undifferentiated medical ICU in the community you will be seeing respiratory failure due to PNA / neurological crises / etc..., septic shock, cardiogenic shock, stroke, DKA, TTP platelet of 1, some HD requiring AKI, obstructive shock secondary to PE, ARDS, poisonings and toxicities...
being a nephrologist is not helpful for most of these ICU cases. the majority of ICU cases do not consult nephrology unless there is a chance that HD is needed (usually oliguric AKI ... if not oliguric most intensivists will not consult renal)

everyone needs to get it OUT of your head that Neprhology makes you competitive for CCM. It does NOT.

The few combined renal CCM programs are training researchers for CRRT in gigantic academic ICUs.


Addendum: I have had a handful of colleagues from the "top NYC renal programs" who did 2 years renal and made it into CCM for one year. They EXCLUSIVELY practice CCM now. They do not do any chronic HD or have renal clinic. They DO feel the renal knowledge helps them with SOME of the HARDER CCM cases (think ARDS with ATN - ECMO + CRRT in a circuit required). But the common denominator for them is that THEY WERE GOOD ENOUGH TO GET INTO 2 YEAR CCM or 3 YEAR PCCM had they not had geographical limitations.
Usually it's the geographical limitations (family, culture for non-Caucasians who like to live in NYC, etc) that preclude many from doing a competitive subspecialty.

Renal - CCM I will admit is USEFUL combination for those who ONLY WANT TO PRACTICE CCM FOR THE REST OF THEIR LIVES.
One does not need pulmonary fellowship to learn how to manage a vent, do chest tubes, do perc trachs... that's really CCM. (just like how surgeons can do it from their SICU training from general surgery residency)

In fact I know of one professor of medicine from some academic California hospital system who was initially PCCM then he actively went and did 2 year renal fellowship (before he made professor of course) to get HD privileges and he's some super duper bonafide academic intensivist who writes on CRRT now. great stuff.

The only issue is Renal - CCM has no "backup plan." Pulm-CCM has the ability to do less ICU later on and do more clinic (which honestly is quite "easy" in that there are clear diagnostics and clear treatment plans in outpatient pulm compared to outpatient renal. short of GNs with clear cut immunosuppressants, most of outpatient renal is using meds to bide time before the inevitable decline to ESRD)

 

[Renal_Prometheus]

I love it when an academic comes on here and say you should be able to make x amount after partnership. My reaction is have you tried to get a private practice job recently? How many of these groups will share JV/MDA fees equally with a new partner without a large buy in(meaning more loans for you). Most will say something like if a new dialysis unit opens up, you can buy into it, but the seniors keep the existing units. This is why the surveys of practicing nephrologists show a higher median salary than what’s actually achievable for new grads(because they left the field). The same surveys that I’m sure academics reference to an unsophisticated applicant when speaking about earning potential. There is an information disconnect between what the applicant thinks nephrologist make and what’s actually happening in the real world, and programs are living off it.

 

[Renal_Prometheus]

deliberately misleading applicants into a failing a specialty is a shameful business model. Academics who promise an applicant they will definitely make more money than a hospitalist should be called out and shamed. Rampant exploitation of new grads by private practice groups "promising" x and y, need to be brought forth so that applicants can properly assess the risk/reward of entering a specialty.

 

[NewYorkDoctors]

to be fair, the "top tier" academic renal programs probably don't do this. they can sell being an academic faculty doctor and all those nice things

its the mid level or bottom barrel trash eating programs that do this. avoid those malignant programs at all costs.
if the PD tries to tell you "what a great career nephrology is" and "how well graduates are doing" but that program does not have in house transplant, in house CRRT, nephrologist performed renal biopsies (which implies high volume that radiology does not want to do it), in house PD, home HD education, then you know its a trap fellowship who just wants you as a warm body


also if you are older 35+, FMG/IMG, who has no debt, does not seem great prospects for hospitalist or GIM (honestly most FMG/IMG prefer to stay in big cities near their culture. totally get it. but big cities hospitalist jobs are not the high paying ones out there. plus not everyone is able to join a strong IPA to negotiate top insurance rates as PCP) and want to take a chance on nephrology, then do what you have to do. just know you are not obliged to enter a dead end private practice renal job. make a calculated risk but know when to cut your losses.

 

[Renal_Prometheus]

make a calculated risk but know when to cut your losses

It’s not that easy. Many of my friends who are still practicing nephrology have fallen into a career trap. They are partners, but don’t make the same amount as senior partners, and less than a hospitalist on a per hr basis. They are unhappy and want to switch to a higher paying job, but these are the roadblocks:

1). Try another group but start all over again at low salaries and hope the new group treats you fairly? Bet your PD never mentioned this possibility when he was courting you! But it’s real, and unfortunately too common.

2). Go back to hospitalist? But mentally it’s hard to justify spending 5-6 years in nephrology just to go back. Hard to tell friends and family that it was failure.

3). Go into academics? Underpaid but at least have some perceived prestige with the position. And live off the fellows, assuming your program can fill spots.

So they can continue to grind at their miserable jobs getting underpaid because there are no good alternatives. They will comfort themselves that they are a “partner” and a “specialist”.

 

[NewYorkDoctors]

It’s not that easy. Many of my friends who are still practicing nephrology have fallen into a career trap. They are partners, but don’t make the same amount as senior partners, and less than a hospitalist on a per hr basis. They are unhappy and want to switch to a higher paying job, but these are the roadblocks:

1). Try another group but start all over again at low salaries and hope the new group treats you fairly? Bet your PD never mentioned this possibility when he was courting you! But it’s real, and unfortunately too common.

2). Go back to hospitalist? But mentally it’s hard to justify spending 5-6 years in nephrology just to go back. Hard to tell friends and family that it was failure.

3). Go into academics? Underpaid but at least have some perceived prestige with the position. And live off the fellows, assuming your program can fill spots.

So they can continue to grind at their miserable jobs getting underpaid because there are no good alternatives. They will comfort themselves that they are a “partner” and a “specialist”.

true true.

best not to get into that trap in the first place.


bottom line if going into nephrology, go academic or don't bother (unless you are well connected ... which basically means someone is retiring or close to it and is handing you the keys to the kingdom). While some rationalize "if I just work a little harder and be more entrepreneurial, then i can make it," that same effort can yield far more dividends in GIM or another medicine subspecialty. Why? as mentioned in prior posts if you can do more CPT codes one way or another in the comfort of your own office then

But if you really liked nephrology as a discipline, you would do academic faculty job. Academic nephrology is a great career! not the highest paying but you will be happy and satisfied with the medical/intellectual part!

If you really like nephrology as a discipline want want to make a private practice job work (in which you are not the boss and do not control the HD panel), then I really do not know what to say as I am not a glutton for punishment.

 

[Renal_Prometheus]

I think the other issue that applicants fail to consider when applying for neph is how rampant unfair partnerships are and how often new grads get exploited. To some, it’s a complete surprise until the very end. What makes nephrology tricky is starting at a different group means starting at low salaries all over again and it may be too difficult for older people with family to bear. There’s a financial penalty to moving and starting with a new group. If you were in a top 4 IM sub specialty, starting salaries are double what a nephrologist starts out as, and moving to a new job because the old job was unfair is not as much of a hindrance. I’ve see this dynamic play out over and over again with my Neph colleagues and it’s really sad that people didn’t figure it out sooner.

 

[Renal_Prometheus]

At the end of the day, there’s a very good reason why this specialty is non-competitive. You cannot expect to enter this specialty without career consequences down the road. I know, people are desperate to get out of hospitalist and Neph is easy to get; that’s its biggest plus. But I’ve seen more financial harm done to people than those who have benefited from this career change. For applicants, you have to listen to what the market is telling you; not academics who are so desperate to the point of taking anyone with a pulse.

 

[NewYorkDoctors]

its also easy to do ID, geriatrics/hospice too...
yes those do not really make more than hospitalist either but one can get the "honor of being a specialist" and dealing with very "academic" topics.

logically that means that there is still hope and cope that one can make it big in HD... no you cannot unless you are "well connected" and hope to inherit the HD patients. this is very political due to the scarce resource of HD patients. just think of making it big in nephrology analogous to making it big in wall street. if you are well connected, you will make it big. if you are not, then you will never make it anywhere and will end up living pay check to pay check but you have your fancy suit and you share a nice lincoln towncar after work...

 

[CRRT]

I think this thread has run its course. Nephrology was bad 5 to 10 years ago but that is no longer the case. Renal Prometheus now sounds like a broken record.
Yes, you have to be careful when joining a group; look at their past history etc but I think if you plan well, Nephrology is not a “doom and gloom” scenario at present. I was trying to recruit a nephrologist to our hospital. He had graduated in 2013 and was working in a smaller city. He was easily making more than 600 K at present in his current job.

 

[CRRT]

I think we should welcome some fresh perspective in this thread. Some people telling how they found success and fulfillment while practicing Nephrology. We really want to hear from those people too.

 

[Renal_Prometheus]

Nephrology was bad 5 to 10 years ago but that is no longer the case

Oh really? The academics never acknowledged the specialty was bad 5-10 yrs ago, but you are now acknowledging for them retrospectively? It’s no longer the case because you there are anecdotal evidence that some are doing well? How about the ones who aren’t doing well or are working as a hospitalist? Can you give them a Time Machine so they don’t waste all those years chasing nothing?

 

[NewYorkDoctors]

I think this thread has run its course. Nephrology was bad 5 to 10 years ago but that is no longer the case. Renal Prometheus now sounds like a broken record.
Yes, you have to be careful when joining a group; look at their past history etc but I think if you plan well, Nephrology is not a “doom and gloom” scenario at present. I was trying to recruit a nephrologist to our hospital. He had graduated in 2013 and was working in a smaller city. He was easily making more than 600 K at present in his current job.

i make over seven figures NOT doing nephrology lol. your logic is specious at best.

I know you are directing at RP, but I have to add context and say that Nephrology the discipline is wonderful.

But private practice is a crapshoot for nephrology . You get more consistency doing GIM or hospitalist. Again not as a NYC employed physician who gets abused by the adminstrators but as a private practice you own your own GIM practice or just as a suburban/ rural hospitalist.

And if anyone cared to read my posts, I comment how wonderful a career Nephrology is and also how one can make it as a private GIM + nephrology minus chronic HD.


The thesis of this thread is

- academic nephrology is wonderful. If you love nephrology, you should encouraged to do so. It is a wonderful and academically fulfilling career.
- Many renal fellowships have ZERO business being open other than to get "warm bodies" for the (admittedly) underpaid faculty. (in NYC, there is the mecca CUMC, Mt Sinai, weill cornell NYP, montefiore, NYU, Northwell North Shore LIJ main campus that has EVERY facet of academic nephrology and are amazing places to get trained and form a future academic career. Outside of these, the other programs really have no reason to be open other than to give warm bodies to the faculty.
- being a junior attending for a predatory old shark is not a good way to go and that describes many PP renal jobs out there. Prove me wrong.
- if money is one's driving factor in life (it happens. don't judge) then do not do nephrology. Do Nephrology for the right reasons

 

[NewYorkDoctors]

I think we should welcome some fresh perspective in this thread. Some people telling how they found success and fulfillment while practicing Nephrology. We really want to hear from those people too.

I welcome yours. not being argumentative. we do need fresh voices.
I wish for Nephrology to be great again... I am just not optimistic but that is no fault of the ASN or the academic doctors. It is the crony capitalism involved with Medicare/CMS setting rates on HD and how most of the revenue generation in nephrology is tied to that machine.

 

[CRRT]

I know you are directing at RP, but I have to add context and say that Nephrology the discipline is wonderful.

But private practice is a crapshoot for nephrology . You get more consistency doing GIM or hospitalist. Again not as a NYC employed physician who gets abused by the adminstrators but as a private practice you own your own GIM practice or just as a suburban/ rural hospitalist.

And if anyone cared to read my posts, I comment how wonderful a career Nephrology is and also how one can make it as a private GIM + nephrology minus chronic HD.


The thesis of this thread is

- academic nephrology is wonderful. If you love nephrology, you should encouraged to do so. It is a wonderful and academically fulfilling career.
- Many renal fellowships have ZERO business being open other than to get "warm bodies" for the (admittedly) underpaid faculty. (in NYC, there is the mecca CUMC, Mt Sinai, weill cornell NYP, montefiore, NYU, Northwell North Shore LIJ main campus that has EVERY facet of academic nephrology and are amazing places to get trained and form a future academic career. Outside of these, the other programs really have no reason to be open other than to give warm bodies to the faculty.
- being a junior attending for a predatory old shark is not a good way to go and that describes many PP renal jobs out there. Prove me wrong.
- if money is one's driving factor in life (it happens. don't judge) then do not do nephrology. Do Nephrology for the right reasons

Good for you if you make seven figures. Looking at your posts it sounds like you work hard and also bill well. I am Hosp employed and not productivity based so I am too lazy to bill for things like lung ultrasound/renal ultrasound or bio impedance. It seems to me that you make a lot of your seven figures from general internal medicine rather than pulmonary. But to do that you have to be up to date with IM too.
The people who have suffered by doing a nephrology fellowship were those who are lazy residents or hospitalists who really wanted to do G.I or interventional cardiology and didn’t have the credentials to get into these fellowships. They wanted an outlet and got into nephrology wanting to put 2 K, 2.5 Ca , 35 HCO3 orders on everybody. Just look at creatinine and shut their mind to the rest of the patient.
Nephrology is not just creatinine and HD. You have to have a command of rheum, cardiology, ID , pulmonary , Endo , hepatology , geriatrics etc. if you are going into it expecting to behave like a scope/stent monkey definitely going to be disappointed.
My city’s (Southern US) university nephrology program didn’t treat their fellows well as a result a few dropped out and they have had trouble recruiting fellows for years. Now that city hasn’t had new nephrologists for years and has a surplus of nephrology jobs.
PP jobs advertising 2 year partnership tracks , JV opportunities and 600 K salaries. The partners in that group spread themselves out in too many hospitals at the same time and now they are stretched too thin seeing 35 pts in hospitals / 10-15 in clinic and going to multiple dialysis units and working 3 weekends a month. These guys were starting to see hospital pts at 4:30 am and finishing their day at 8:30 pm. They did it for a few years but now they are in their late 50s and want a break. If they wanted me to work for them I wouldn’t start out for less than 450 K with an iron clad contract guaranteeing full partnership with JVs in 2 years.

 

[Renal_Prometheus]

they are stretched too thin seeing 35 pts in hospitals / 10-15 in clinic and going to multiple dialysis units and working 3 weekends a month. These guys were starting to see hospital pts at 4:30 am and finishing their day at 8:30 pm.

This is exactly why you don’t want to go into nephrology. Lifestyle is bad.

 

[NewYorkDoctors]

Good for you if you make seven figures. Looking at your posts it sounds like you work hard and also bill well. I am Hosp employed and not productivity based so I am too lazy to bill for things like lung ultrasound/renal ultrasound or bio impedance. It seems to me that you make a lot of your seven figures from general internal medicine rather than pulmonary. But to do that you have to be up to date with IM too.
The people who have suffered by doing a nephrology fellowship were those who are lazy residents or hospitalists who really wanted to do G.I or interventional cardiology and didn’t have the credentials to get into these fellowships. They wanted an outlet and got into nephrology wanting to put 2 K, 2.5 Ca , 35 HCO3 orders on everybody. Just look at creatinine and shut their mind to the rest of the patient.
Nephrology is not just creatinine and HD. You have to have a command of rheum, cardiology, ID , pulmonary , Endo , hepatology , geriatrics etc. if you are going into it expecting to behave like a scope/stent monkey definitely going to be disappointed.
My city’s (Southern US) university nephrology program didn’t treat their fellows well as a result a few dropped out and they have had trouble recruiting fellows for years. Now that city hasn’t had new nephrologists for years and has a surplus of nephrology jobs.
PP jobs advertising 2 year partnership tracks , JV opportunities and 600 K salaries. The partners in that group spread themselves out in too many hospitals at the same time and noe they are stretched too thin seeing 35 pts in hospitals / 10-15 in clinic and going to multiple dialysis units and working 3 weekends a month. These guys were starting to see hospital pts at 4:30 am and finishing their day at 8:30 pm. They did it for a few years but now they are in their late 50s and want a break. If they wanted me to work for them I wouldn’t start out for less than 450 K with an iron clad contract guaranteeing full partnership with JVs in 2 years.

Yep indeed. That's what I shared how one can be a GIM + nephrology without chronic HD and make things work. my whole "schitck" is renal fellowship graduates need not feel compelled to join a potential dead end job (that is very prevalent in the high density areas that many FMG graduates tend to want to live as it is close to their culture). there are other options that you can use your renal degree with other than be a "dialysis monkey"

I see you are a well read long time lurker on this thread. nice. please keep contributing to this thread. seriously. im not being facetious or anything. we do need the Pro Nephrology voice on this thread. If RP is the 1 star review and I am the 3 star review, then we really need the 5 star review on here to keep things balanced.

nice. that's how supply and demand works. there is just way too much oversupply of nephrologist in my neck of the woods (NYC). but again that's no fault of the ASN. that's just economics.


Edit: I will say if all doctors got paid THE SAME. Then nephrology would indeed be THE BEST subspecialty because that earnings / effort ratio is quite high and it is coupled with all the intellectual stimulation that the field offers. again I know I sound like a mercenary always bringing up money. Rather, it is the ( revenue + lifestyle) / effort ratio that matters the most and many of the commonly available nephrology PP jobs have a very low ratio in that aspect.

 

[NewYorkDoctors]

This is exactly why you don’t want to go into nephrology. Lifestyle is bad.

working that many hours as PP solo practitioner GIM in NYC (again assuming strong IPA negotiated rates) can easily net 7+ figures. there is the added bonus of sitting in your office all day too

 

[CRRT]

I have seen some neph programs get quite creative in trying to attract candidates. One program has 3 tracks a neph track , a neph-cc track and a neph / hospitalist track where you can work as a hospitalist parttime while also doing a nephrology fellowship. Recently though they have always filled their positions so that city is not short of nephrologists.

I can never understand what is the attraction of NYC. Low salary , high malpractice , hostile patients , high COL , lazy nurses. I guess on positive side they have a really good and cheap subway.

 

[NewYorkDoctors]

I have seen some neph programs get quite creative in trying to attract candidates. One program has 3 tracks a neph track , a neph-cc track and a neph / hospitalist track where you can work as a hospitalist parttime while also doing a nephrology fellowship. Recently though they have always filled their positions so that city is not short of nephrologists.

I can never understand what is the attraction of NYC. Low salary , high malpractice , hostile patients , high COL , lazy nurses. I guess on positive side they have a really good and cheap subway.

$2.90 now lol. also its dirty and smelly. the violent crime is not as prevalent as social media makes it out to seem (it's not Joaquin phoenix as the Joker in the subway) but it is still hazardous during rush hour

non-Caucasians tend to want to stay in NYC for their culture. yes that's a generalization. Most FMG tend to be non-Caucasian after all.

I totally agree. a salaried employed physician should stay the heck away from NYC
hospitalist jobs in NYC can start as low as $210 and GIM in NYC (salaried employee not PP) can start as low as $160...

yep those are top quality renal programs that deserve the best candidates and churn out graduates who have the best path to a successful career. too bad the lower tiered programs cannot offer that

 

[CRRT]

I think ASN didn’t cut down slots to keep a hand on the demand/supply. But in many places programs have had difficulty filling spots and many people ended up not practicing Nephrology after fellowship so now the job market has gotten better in some places.

I put my CV on practice link recently and I had five hospital recruiters reach out to me asking if I would consider joining their hospital.

I think if someone wants to practice good medicine/Nephrology and not be in the rat race there are quite a few Hosp employed positions, looking for nephrologists.

Just don’t be location specific.

 

[Renal_Prometheus]

I think the problem with nephrology is that starting salaries are low, the work is very hard, and you are doing this all with the hope that your partners will treat you fairly down the road. It just opens itself to all sorts of exploitation because it’s very profitable to employ these new grads and work them like slaves, and then not offer partnership. Fairness is subjective. When you rely on humans to treat you fairly, you are just asking for disappointment. Not to mention many of these seniors have been seeing revenue declines in their JVs recently and have more incentive to screw the new guy. Ask around, some groups are infamous for doing this stuff repetitively but suckers don’t do their research still for these traps.

 

[Renal_Prometheus]

you can think of nephrology as a career gamble. Maybe you end up better than a hospitalist, maybe you end up worse off, in any case it will take a couple of years of your life to find out. There’s no guarantee that going into nephrology will allow you to make more money or have better lifestyle than a hospitalist. That’s what makes it non-competitive. The only guarantee is if you can make it to a top 4 IM sub-specialty, which is what makes them competitive.