Nephrology one of the most intellectual specialties?

[pulmoblast]

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Why did they even do nephrology in the first place? It's not like the financial and job market calculus between nephrology and hospitalist medicine was markedly different 2 years ago when they made the decision to do a fellowship.

They like the speciality. They just couldn't find nephrology jobs that suited them


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[WheezyBaby]

Vampires and werewolves, cats and dogs, nephrologists and cardiologists, rivalries as old as time. Even nature is publishing peacemaking articles (http://www.nature.com/nrneph/journal/v5/n1/full/ncpneph1001.html) to try to put an end to the daily bloodshed when the two run into each other on rounds. Maybe one day they can combine efforts in the name of patient care, work on those beans and the pump synergistically, and optimize the 80 yo obese DM/CHF/ESRDer so they can die peacefully on the vent of overwhelming sepsis

 

[LoudBark]

They like the speciality. They just couldn't find nephrology jobs that suited them


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Nah, not true. Most of them these days don't so much choose nephrology as nephrology chooses them. Lets be honest here boys and girls, the state of nephrology is such that a lot of people who in no way, shape, or form could do do cardiology, heme / onc, pulm, GI........find their way in to nephrology because they want to do a fellowship because for whatever reason they think they are above being a hospitalist and can still feel they are that all important specialist.

 

[jdh71]

Nah, not true. Most of them these days don't so much choose nephrology as nephrology chooses them. Lets be honest here boys and girls, the state of nephrology is such that a lot of people who in no way, shape, or form could do do cardiology, heme / onc, pulm, GI........find their way in to nephrology because they want to do a fellowship because for whatever reason they think they are above being a hospitalist and can still feel they are that all important specialist.

That's kind of a douchey thing to say.

I don't remember any of the nephro folks from residency pining for cards or GI but "settling" on nephro. Though there may be some of people picking a specialty they think they can match to over another. Even then I don't think it's so they can crap on hospitalists. There is something to be said for what is largely becoming a consult only service.

I just don't see a great way to increase reimbursements to these guys with dialysis centers being gobbled up and run largely by corporate outfits now. In many markets I bet the hospitalists make more, but that's a pretty thankless job.

 

[Raryn]

That's kind of a douchey thing to say.

I don't remember any of the nephro folks from residency pining for cards or GI but "settling" on nephro. Though there may be some of people picking a specialty they think they can match to over another. Even then I don't think it's so they can crap on hospitalists. There is something to be said for what is largely becoming a consult only service.

I just don't see a great way to increase reimbursements to these guys with dialysis centers being gobbled up and run largely by corporate outfits now. In many markets I bet the hospitalists make more, but that's a pretty thankless job.

The phrasing is kinda douchey, but it is true:

A lot of nephrology programs are desparately trying to get candidates b/c they're going unmatched and they need fellows to spread the work load. The number of applicants has gone down ~33% over the last 5 years (from ~450 to ~300) while the number of spots has gone up if anything.

This has led to a number of programs being very... flexible with admissions. So many nephrology fellows are people that were convinced to do it because they dislike hospitalist work, or (rationally) decided they couldn't match one of the more lucrative fields.

That said, many also are people that enjoy renal physiology and just like the work.

 

[Crayola227]

I dunno. Nephrology was just so chill. Like, soooooooooooo chill, I figure that's why you do it. That was my impression when I did my nephro rotation.

 

[WheezyBaby]

I dunno. Nephrology was just so chill. Like, soooooooooooo chill, I figure that's why you do it. That was my impression when I did my nephro rotation.

Not mine at all, but it was a consult service, regularly 40-60 patients on the list. Or well, still seemed fairly chill for the staff I guess, but the fellows worked

 

[Crayola227]

Not mine at all, but it was a consult service, regularly 40-60 patients on the list. Or well, still seemed fairly chill for the staff I guess, but the fellows worked

yeah, I don't even mean to say the hours were lighter because they weren't

I don't know if it's the work or the personality type or what, I never got in deep enough to sort out what gave nephro that feel
my rotation was the consult service for a large VA and large tertiary center with transplant
????

 

[LoudBark]

That's kind of a douchey thing to say.

I don't remember any of the nephro folks from residency pining for cards or GI but "settling" on nephro. Though there may be some of people picking a specialty they think they can match to over another. Even then I don't think it's so they can crap on hospitalists. There is something to be said for what is largely becoming a consult only service.

I just don't see a great way to increase reimbursements to these guys with dialysis centers being gobbled up and run largely by corporate outfits now. In many markets I bet the hospitalists make more, but that's a pretty thankless job.

I didn't mean it to come across as a douche bag thing to say, but there is a lot of truth to it. Nephrology today is not your grandfather's nephrology.

I went through the application process and the fellowship and have seen the changes first hand. Nephrology is in a state of crisis right now. Just 10 years ago a decent amount of American graduates went in to it. The number has gone down every year since then. There are more unfilled spots after the match than ever. Programs scramble to find anyone, and yes I mean anyone, as long as you don't have a history of a felony conviction, to fill a spot.

Not to sound all Donald Trump and xenophobic, but lets just be honest here and not ignore the obvious. We practice here in the United States but currently have a specialty where hardly anyone who graduates from American medical schools wants to go in to it anymore. This is not seen in any other specialty. This is not seen in psychiatry, family practice, pediatrics, PM and R and certainly not any other subspecialty in medicine for that matter. Faculty in academic settings are aware of this and are bewildered as to what to do. It is a shame, but it is the truth. It doesn't mean that foreign graduates can't be capable nephrologists, of course they can. It is just a crisis that starts in medical schools in this country that there is a specialty that no American grads want to do. Sure you may be willing to name some American grad you went to residency with who went in to nephrology, but today that is the rare exception.

I trained at a university program that no doubt would be considered a top tier place. It is as if the nephrology program is in a different world inside those hospital walls. While cardiology and GI and whoever else is taking fellows who are also trained at top tier places, the nephrology program out of desperation for going unmatched is interviewing and ranking candidates who are at the bottom of the barrel so to speak.

There is definitely a certain degree of self selection with nephrology, whether people are willing to admit it or not. It may be politically correct and cute to say that everyone who chooses nephrology does so because they love nephrons and tubules and glomeruli. Sure there are some who do. That being said, judging by the quality of applicants that I have seen and people in my program see applying, we know that many of them could not do any specialty other than nephrology. Again, everyone may have some anecdotal story of that friend from residency who was AOA and from a top 10 med school who could have done any specialty and still chose nephrology, but that is again the exception.

 

[Crayola227]

I didn't mean it to come across as a douche bag thing to say, but there is a lot of truth to it. Nephrology today is not your grandfather's nephrology.

I went through the application process and the fellowship and have seen the changes first hand. Nephrology is in a state of crisis right now. Just 10 years ago a decent amount of American graduates went in to it. The number has gone down every year since then. There are more unfilled spots after the match than ever. Programs scramble to find anyone, and yes I mean anyone, as long as you don't have a history of a felony conviction, to fill a spot.

Not to sound all Donald Trump and xenophobic, but lets just be honest here and not ignore the obvious. We practice here in the United States but currently have a specialty where hardly anyone who graduates from American medical schools wants to go in to it anymore. This is not seen in any other specialty. This is not seen in psychiatry, family practice, pediatrics, PM and R and certainly not any other subspecialty in medicine for that matter. Faculty in academic settings are aware of this and are bewildered as to what to do. It is a shame, but it is the truth. It doesn't mean that foreign graduates can't be capable nephrologists, of course they can. It is just a crisis that starts in medical schools in this country that there is a specialty that no American grads want to do. Sure you may be willing to name some American grad you went to residency with who went in to nephrology, but today that is the rare exception.

I trained at a university program that no doubt would be considered a top tier place. It is as if the nephrology program is in a different world inside those hospital walls. While cardiology and GI and whoever else is taking fellows who are also trained at top tier places, the nephrology program out of desperation for going unmatched is interviewing and ranking candidates who are at the bottom of the barrel so to speak.

There is definitely a certain degree of self selection with nephrology, whether people are willing to admit it or not. It may be politically correct and cute to say that everyone who chooses nephrology does so because they love nephrons and tubules and glomeruli. Sure there are some who do. That being said, judging by the quality of applicants that I have seen and people in my program see applying, we know that many of them could not do any specialty other than nephrology. Again, everyone may have some anecdotal story of that friend from residency who was AOA and from a top 10 med school who could have done any specialty and still chose nephrology, but that is again the exception.

maybe they should have a track just for nephro

why do you think this is the case my friend?

 

[jdh71]

I didn't mean it to come across as a douche bag thing to say, but there is a lot of truth to it. Nephrology today is not your grandfather's nephrology.

I went through the application process and the fellowship and have seen the changes first hand. Nephrology is in a state of crisis right now. Just 10 years ago a decent amount of American graduates went in to it. The number has gone down every year since then. There are more unfilled spots after the match than ever. Programs scramble to find anyone, and yes I mean anyone, as long as you don't have a history of a felony conviction, to fill a spot.

Not to sound all Donald Trump and xenophobic, but lets just be honest here and not ignore the obvious. We practice here in the United States but currently have a specialty where hardly anyone who graduates from American medical schools wants to go in to it anymore. This is not seen in any other specialty. This is not seen in psychiatry, family practice, pediatrics, PM and R and certainly not any other subspecialty in medicine for that matter. Faculty in academic settings are aware of this and are bewildered as to what to do. It is a shame, but it is the truth. It doesn't mean that foreign graduates can't be capable nephrologists, of course they can. It is just a crisis that starts in medical schools in this country that there is a specialty that no American grads want to do. Sure you may be willing to name some American grad you went to residency with who went in to nephrology, but today that is the rare exception.

I trained at a university program that no doubt would be considered a top tier place. It is as if the nephrology program is in a different world inside those hospital walls. While cardiology and GI and whoever else is taking fellows who are also trained at top tier places, the nephrology program out of desperation for going unmatched is interviewing and ranking candidates who are at the bottom of the barrel so to speak.

There is definitely a certain degree of self selection with nephrology, whether people are willing to admit it or not. It may be politically correct and cute to say that everyone who chooses nephrology does so because they love nephrons and tubules and glomeruli. Sure there are some who do. That being said, judging by the quality of applicants that I have seen and people in my program see applying, we know that many of them could not do any specialty other than nephrology. Again, everyone may have some anecdotal story of that friend from residency who was AOA and from a top 10 med school who could have done any specialty and still chose nephrology, but that is again the exception.

Fair enough.

 

[Instatewaiter]

Well this rapidly turned into a crap-on-nephrology fest. How about we pick on another specialty...

The lungs suck.

 

[jdh71]

Well this rapidly turned into a crap-on-nephrology fest. How about we pick on another specialty...

The lungs suck.

They do though. None of you should do pulmonary.

Though . . . the fact anyone is in IM in the first place shows a clear track record and pattern of poor life choices.

 

[rokshana]

this is not really that unusual...popularity of a specialty has its ebb and flow...in the mid 90s AMGs didn't want to do anesthesia and then 10 years later it was fairly competitive...5, 6 years ago radiology was crazy competitive, now its trending down, and so on and so on...

correction will eventually happen...the number of fellowships spots will m/l decrease, old nephrologists will finally retire, the baby boomers will need dialysis, etc...who knows?

 

[PlutoBoy]

Do Rheumatology

 

[pulmoblast]

There is some truth in all of the above posts... I think the problem is that many nephrology private practices are unwilling to make new people partners and are cycling through fresh grads paying them poorly. Fat cats sitting at the top skimming whatever is left


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[StrongIslandDoc]

Yeah, and I've seen cardiologists volume deplete their patients, causing contraction alkalosis, hypokalemia, and AKI because they insisted on giving huge doses of Lasix. And I've seen cardiologists pushing for unnecessary dialysis on patients still making urine, which, by the way, could lead to further worsening of renal function. Oh, not to mention cardiologists who push for dialysis on CKD stage 5 patients following cardiac caths, despite the fact that there is no evidence in the literature to show that dialysis following contrast administration is beneficial in those patients. Oh, and I would just love to see one of our cardiology fellows even try to master the mechanisms of ion transport in the renal tubules.

"To be a good cardiologist, you must first know the kidney." - I have carried this sentiment in my back pocket since my junior year physiology course in college. The kidney is indeed complex, it is fascinating - it is humbling. That being said, if you know membrane physiology and fluid dynamics, as a cardiologist does - the renal tubular apparatus is not untouchable in the slightest. If you see an opportunity to teach, teach - share your wisdom so that it may be of benefit to patients who are not under your direct care. Please do not disparage the young physicians who study in your program.

 

[Michel de Montaigne]

Yeah, and I've seen cardiologists volume deplete their patients, causing contraction alkalosis, hypokalemia, and AKI because they insisted on giving huge doses of Lasix. And I've seen cardiologists pushing for unnecessary dialysis on patients still making urine, which, by the way, could lead to further worsening of renal function. Oh, not to mention cardiologists who push for dialysis on CKD stage 5 patients following cardiac caths, despite the fact that there is no evidence in the literature to show that dialysis following contrast administration is beneficial in those patients. Oh, and I would just love to see one of our cardiology fellows even try to master the mechanisms of ion transport in the renal tubules.

Hello Top Gun, I'm currently a medical student in my Nephrology module. To be honest, I'm finding nephrology a rather difficult subject while I'm generally a pretty good student. What you said grabbed my attention as you said that volume depletion causes contraction alkalosis, hypokalemia, and AKI. I understand how volume depletion leads to contraction alkalosis, and AKI also makes sense, however may you be kind enough in explaining the pathophysiology behind hypokalemia. My rational was that an AKI meant hyperkalemia as the kidneys are filtering less and hence excreting less.

 

[Crayola227]

Hello Top Gun, I'm currently a medical student in my Nephrology module. To be honest, I'm finding nephrology a rather difficult subject while I'm generally a pretty good student. What you said grabbed my attention as you said that volume depletion causes contraction alkalosis, hypokalemia, and AKI. I understand how volume depletion leads to contraction alkalosis, and AKI also makes sense, however may you be kind enough in explaining the pathophysiology behind hypokalemia. My rational was that an AKI meant hyperkalemia as the kidneys are filtering less and hence excreting less.

The lasix makes them waste their potassium

 

[Chemist0157]

I got a kick out of reading this thread.

 

[rokshana]

To add to the Nephrology thing... many times the Nephrology gets to be the "Doctor's Doctor" Hypertension that cant be controlled by Medicine, or even Cardiology... goes to Nephrology. Difficult adrenal pathology... Nephrology. Half of ICU patients have Nephrology on board. Even heme-onc.... many of those patents get their beans knocked out, and get a nephrologist

I do take except to the difficult adrenal... if there is a renal etiology then it will be referred to nephrology...otherwise it’s endocrine.

but that being said...I considered nephrology vs endocrine...and picked endocrine...partially because I’m not smart enough to be a nephrologist 🙂

acid-base...so difficult to understand...still have to look things up when I get consults for hyponatremia!

 

[Chemist0157]

I do take except to the difficult adrenal... if there is a renal etiology then it will be referred to nephrology...otherwise it’s endocrine.

but that being said...I considered nephrology vs endocrine...and picked endocrine...partially because I’m not smart enough to be a nephrologist 🙂

acid-base...so difficult to understand...still have to look things up when I get consults for hyponatremia!

I don’t really see that much primary hyperaldosteronism. I think PCPs know how to go looking for that, and when they do, they get sent to endocrinology and/or a surgeon.

I feel like I’m just as likely to see a Liddle syndrome, which I have found, than a clean primary hyperaldo case.

Hyponatremia sucks. All day long.