Nephrology

[Jesse white]

Hey all, what does the life of a nephrologist look like after graduating from fellowship? Hoping to hear from recent grads. Here are a couple of questions I have for you'll- Private vs academic? Does it help to get that extra year in transplant neph vs glomerular disease vs interventional when you apply for jobs?

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[Renal_Prometheus]

Hey all, what does the life of a nephrologist look like after graduating from fellowship? Hoping to hear from recent grads. Here are a couple of questions I have for you'll- Private vs academic? Does it help to get that extra year in transplant neph vs glomerular disease vs interventional when you apply for jobs?

Simple word is bad. I find that academics completely misunderstand or are blatantly lying about how bad private practice is. Some grads do ok, most end up badly and at some point will consider jumping back to hospitalist for higher incomes/better lifestyle. But of course you already know that a specialty that can't fill positions, will take anyone with a heartbeat, have consequences to pay down the road.

My take on:
transplant nephrology - does not increase your income, waste of time
Glomerular disease - too rare to be worth doing, again waste of your time.
Interventional - severe cuts in reimbursement, no money, waste of your time


you can read my experience with the specialty:

Why Nephrology Grads Cannot Expect To Earn The Same As Their Partners !

Years ago, I had a colleague who accepted a neph job out of fellowship and he was excited with the prospects. Although starting salaries were low(180K/year), within 3 years he will make partner, and according to what the partners told him, they average around 500K/year. Sounds great right? Fast...

forums.studentdoctor.net

 

[NewYorkDoctors]

Read the nephrology is dead thread . Read my posts in particular . I try to paint the glass half full approach to private practice nephrology (but there’s not much there ) while painting a somewhat rosy picture of academic nephrology .

 

[Chemist0157]

Hey all, what does the life of a nephrologist look like after graduating from fellowship? Hoping to hear from recent grads. Here are a couple of questions I have for you'll- Private vs academic? Does it help to get that extra year in transplant neph vs glomerular disease vs interventional when you apply for jobs?

I have been private practice since 2018.

PP was my strong preference after training so much in academia. Just wanted to get out there and be a doctor.

I would not do any additional training unless you plan to function as a transplant nephrologist or interventional nephrologist. It should not have any bearing on any PP job unless again that would be your role in a practice.

The additional glomerular disease training would be clinically useful but grossly unnecessary. You should have all you need from fellowship and supplement that with your own reading and reviewing available guidelines. Conferences are helpful. UNC does a GN conference for instance. I’d favor that over committing more years.

Thinking back to my faculty, the only ones who had additional formal training were functioning as transplant and interventional nephrologists. Maybe some academic programs are different, but I would generally avoid getting more feathers in your hat unless there is a very clear reason for them.

 

[Jesse white]

I have been private practice since 2018.

PP was my strong preference after training so much in academia. Just wanted to get out there and be a doctor.

I would not do any additional training unless you plan to function as a transplant nephrologist or interventional nephrologist. It should not have any bearing on any PP job unless again that would be your role in a practice.

The additional glomerular disease training would be clinically useful but grossly unnecessary. You should have all you need from fellowship and supplement that with your own reading and reviewing available guidelines. Conferences are helpful. UNC does a GN conference for instance. I’d favor that over committing more years.

Thinking back to my faculty, the only ones who had additional formal training were functioning as transplant and interventional nephrologists. Maybe some academic programs are different, but I would generally avoid getting more feathers in your hat unless there is a very clear reason for them.

Great.. thanks! Yeah, this seems to be the general consensus amongst people I've talked to

Simple word is bad. I find that academics completely misunderstand or are blatantly lying about how bad private practice is. Some grads do ok, most end up badly and at some point will consider jumping back to hospitalist for higher incomes/better lifestyle. But of course you already know that a specialty that can't fill positions, will take anyone with a heartbeat, have consequences to pay down the road.

My take on:
transplant nephrology - does not increase your income, waste of time
Glomerular disease - too rare to be worth doing, again waste of your time.
Interventional - severe cuts in reimbursement, no money, waste of your time


you can read my experience with the specialty:

Why Nephrology Grads Cannot Expect To Earn The Same As Their Partners !

Years ago, I had a colleague who accepted a neph job out of fellowship and he was excited with the prospects. Although starting salaries were low(180K/year), within 3 years he will make partner, and according to what the partners told him, they average around 500K/year. Sounds great right? Fast...

forums.studentdoctor.net

I've read most of your posts. You're on (almost) every post that has to do anything with nephrology! Haha. I appreciate you being honest in your posts and painting a realistic picture. But surely you must have encountered a happy nephrologist however rare that might be? Sure being a hospitalist is better than being a nephrologist from a financial standpoint, but I can't see myself being a hospitalist

I don't know, most fellows and attendings I've met seem really happy with their decision. Of course, I've also met some people who absolutely despise nephrology, but again, these were candidates who couldn't match their first specialty of choice and therefore just scrambled at the last min and applied to nephrology or it was for visa reasons or some other reason except for passion for subject itself. I'm sure your overall experience with the field also depends on where you train.

If you don't mind me asking, are you/were you a nephrologist who then switched to being a hospitalist? Or do you just know a lot of unhappy nephrologists?

 

[Chemist0157]

Great.. thanks! Yeah, this seems to be the general consensus amongst people I've talked to

I've read most of your posts. You're on (almost) every post that has to do anything with nephrology! Haha. I appreciate you being honest in your posts and painting a realistic picture. But surely you must have encountered a happy nephrologist however rare that might be? Sure being a hospitalist is better than being a nephrologist from a financial standpoint, but I can't see myself being a hospitalist

I don't know, most fellows and attendings I've met seem really happy with their decision. Of course, I've also met some people who absolutely despise nephrology, but again, these were candidates who couldn't match their first specialty of choice and therefore just scrambled at the last min and applied to nephrology or it was for visa reasons or some other reason except for passion for subject itself. I'm sure your overall experience with the field also depends on where you train.

If you don't mind me asking, are you/were you a nephrologist who then switched to being a hospitalist? Or do you just know a lot of unhappy nephrologists?

Sure thing. I’m around if you have questions. People DM me from time to time.

 

[Renal_Prometheus]

I've read most of your posts. You're on (almost) every post that has to do anything with nephrology! Haha. I appreciate you being honest in your posts and painting a realistic picture. But surely you must have encountered a happy nephrologist however rare that might be? Sure being a hospitalist is better than being a nephrologist from a financial standpoint, but I can't see myself being a hospitalist

I don't know, most fellows and attendings I've met seem really happy with their decision. Of course, I've also met some people who absolutely despise nephrology, but again, these were candidates who couldn't match their first specialty of choice and therefore just scrambled at the last min and applied to nephrology or it was for visa reasons or some other reason except for passion for subject itself. I'm sure your overall experience with the field also depends on where you train.

If you don't mind me asking, are you/were you a nephrologist who then switched to being a hospitalist? Or do you just know a lot of unhappy nephrologists?

Oh you’ve read most of my posts? I hope I have taught you a few things that your attendings would never tell you. Your perceptions of the field during fellowship is too naive. Once you get out into the real world, it will change drastically. I was in the same boat as you at one point.

 

[Renal_Prometheus]

Great.. thanks! Yeah, this seems to be the general consensus amongst people I've talked to

I've read most of your posts. You're on (almost) every post that has to do anything with nephrology! Haha. I appreciate you being honest in your posts and painting a realistic picture. But surely you must have encountered a happy nephrologist however rare that might be? Sure being a hospitalist is better than being a nephrologist from a financial standpoint, but I can't see myself being a hospitalist

I don't know, most fellows and attendings I've met seem really happy with their decision. Of course, I've also met some people who absolutely despise nephrology, but again, these were candidates who couldn't match their first specialty of choice and therefore just scrambled at the last min and applied to nephrology or it was for visa reasons or some other reason except for passion for subject itself. I'm sure your overall experience with the field also depends on where you train.

If you don't mind me asking, are you/were you a nephrologist who then switched to being a hospitalist? Or do you just know a lot of unhappy nephrologists?

So let me present to you this realistic scenario. So you go into PP, start out at a very low 200k/yr and give your group 3 yrs of hard work. Then you find out they are not offering you partnership, or more commonly, they offer partnership but you don’t share revenue evenly with senior partners, so essentially a worthless partnership. Are you gonna turn around and try another group and give them 3 more yrs to see if they will treat you fairly? You are already 5 yrs in the hole at this point(2 yrs of fellowship plus PP). You don’t think this happens? Why do you think the specialty is non-competitive if fellows and attendings look happy and satisfied with their career choice? Wouldn’t you expect match rate to be higher if this specialty really isn’t that bad? I’m years ahead of your senior fellows who look happy. They don’t know what’s about to hit them. Your comments will age very poorly over time. But it will take you years to figure it out and look back on how foolish they are. PM me if you want to know about pitfalls of the job market and how they trap unsuspecting new grads like you.

 

[NewYorkDoctors]

Also as I have mentioned in my posts , a nephrologist cannot venture out solo the same way a cardiologist or GI. What does a cardiologist who does not get offered partner do? But some echos and stress test machines and open up your own shop .

Neph cannot open up ones own HD center and has no other cpt code to bill other than what an internist bills for .

Hence if you like nephrology , go full academic or don’t bother

 

[Renal_Prometheus]

I find similarities between a new nephrology grad and a newly minted real estate agent. The barriers to entry at this point are low to non-existent. So once they go into the real world, how well they do will vary widely on combination of luck and hustle. A few real estate agents can make millions in commissions, but the average real estate agent don't make that much money. Same thing in nephrology. It's not like in Cards or GI where I know at the very minimum, they will not fall below a certain threshold, and certainly I don't see any cards/GI grad working as a hospitalist. If you believe in the power of the market with it's supply/demand economics, the fact that fellowship spots don't fill is actually market's way of telling you nephrologist are not don't do well in private practice. But some fellows rather believe in what their fellowship programs tell them. You know, the same programs who can't fill spots and have to "sell" nephrology. There's a certain comfort in believing an lie with an optimistic projection, even though deep down you know better.

 

[NewYorkDoctors]

I don’t think any academic nephrologist out there needs to take any personal affront to this thread . We are not bashing the discipline of nephrology or the hard work that the academics provide in education of new fellows or any cutting edge research they might be doing .

We are criticizing the dead end private practice crony capitalism economics of nephrology .

Our dissuading people from applying will not hurt the numbers of the top academic centers . They will always fill up one way or another .

And if their goal is to get more bright researcher young minds to join fellowship , I don’t know why they think getting an entrepreneurial future private resident (who might otherwise be dissuaded from this thread ) will make any difference .

But #nephmadness and other uncool things.

 

[Renal_Prometheus]

It’s an indentured servitude agreement for new grads. There’s no guarantee after all your hard work that your partners will treat you fairly. I still have friends who are partners in their respective groups, not making that much money, and feel “trapped” because they find it embarrassing to go back to hospitalist. Even though financially they would be better off. The sunken cost fallacy plays mind games. But if they could back in time, they would have never done nephrology. So just because someone is doing nephrology doesn’t mean they are happy about their career decisions.

 

[dozitgetchahi]

Great.. thanks! Yeah, this seems to be the general consensus amongst people I've talked to

I've read most of your posts. You're on (almost) every post that has to do anything with nephrology! Haha. I appreciate you being honest in your posts and painting a realistic picture. But surely you must have encountered a happy nephrologist however rare that might be? Sure being a hospitalist is better than being a nephrologist from a financial standpoint, but I can't see myself being a hospitalist

I don't know, most fellows and attendings I've met seem really happy with their decision. Of course, I've also met some people who absolutely despise nephrology, but again, these were candidates who couldn't match their first specialty of choice and therefore just scrambled at the last min and applied to nephrology or it was for visa reasons or some other reason except for passion for subject itself. I'm sure your overall experience with the field also depends on where you train.

If you don't mind me asking, are you/were you a nephrologist who then switched to being a hospitalist? Or do you just know a lot of unhappy nephrologists?

Not nephrology, but one thing I will say is that I wouldn’t trust academic attendings’ view of these things very much. Most academicians have never seen anything outside of academia and have NO idea how the rest of the wide world of medicine works - very few of them will have ever had an actual community doctor job and thus have no real perspective on what it’s like. Also, a lot of academic attendings have bought into this idea that it’s ok to work for trash pay in academia because they’re attracted to the “glory” of working at a big famous institution…there’s a lot of ego stroking and nonsense among academic docs. They either don’t realize or don’t seem to care that they are being taken advantage of by Big Academia. In most specialties these days, academic docs work harder and longer for much less pay while having to deal with much more BS. Any “happiness” you see from them may well be 2/2 Stockholm syndrome.

 

[Renal_Prometheus]

And this is on top of coming from a specialty who struggles to fill spots every year. Academics will say anything to get a warm body now a days. Imagine the conflict of interest. And people actually believe what comes out of their mouth.

 

[Renal_Prometheus]

Outside of last year where there was no application thread, I find conversations in this thread most closely aligned to what we have been talking about. If you scan through the posts, you can re-live the horrors of what many went through. Exactly the same arguments we are making today.
Let me give you a sample of their comments:

Official 2016-2017 Nephrology Fellowship Application Cycle

Here it is. Good luck.

forums.studentdoctor.net

Sample1:
The problem in nephrology is not single domain like job offer or visa candidates etc . the problem in nephrology it is collected all the disadvantage in one speciality . lake of jobs in general . rare jobs in big cities . the amount of driving and multiple places you need to go every day so it is not like working in one hospital and one clinic rather you will be covering 2-3 hospitals 20-30 miles a apart and 3-4 dialysis centers . also the very low starting salary like 170-180 and the very notorious partnership pathway in nephrology as most of the group will abuse the new nephrologist who join the group for 3 years just on hope of giving partnership at the end of the road if any . add to that all the newly graduated nephrologist who will join private groups will be worked like a dog regardless if you are a visa candidates or not , so it is a second visa waiver if you did one before . so I personally think visa is not a big issue here .passion wise . I don't think speciality like nephrology is being loved at the medical student level . that why very few local graduates go for nephrology . add to that the ESRD who keep missing HD and keep coming just to be redialysed again and again it is extremely frustrating and disappointing .most of the peoples went to nephrology are IMG from india , Pakistan Africa and middle east . most of those people debris of other fellowship failed to catch something better . all of them they think that nephrology after graduation like their original country where nephrologist work mainly in one hospital and one clinic . they don't know that they will work in 3-4 dialysis centers , 3-4 hospitals and 2-3 clinics .
The peoples who go for hospitalist represents 35-40% of nephrologist and many of them practiced nephrology for some years and they discovered that they can make 1.6 what they make in nephrology with working only 0.6 of what they used to work in nephrology . moving to hospitalist is not relevant to visa at all .and in general internal medicine you still see less frustrating patient than ESRD in nephrology . that is why hospitalist overcoming nephrology it is not jut the visa or money .
By the end of the day of you love nephrology and you want to compromise with all of your other life for it helped with the hope it may improve some a day no body know when (if any) .just go for it it is waiting for you .

Sample2:
I think the best idea with what happening in nephrology ( the doomed fellowship ) is to shut down the fellowship applications completely for 5 years during that the ASN need to restructure the whole nephrology profession in this country including restructuring the training programs to be academically oriented rather a slavery oriented.
Other ideas is to cancel nephrology as an independent fellowship and create a new pathways like one year fellowship for HOSPITALIST if they want to do some nephrology work beside HOSPITALIST and one year of nephrology for intensivist who want to do some nephrology work beside ICU . In this case nephrology work will be an add on and people will be still making their main income from something more satisfying than just doomed nephrology alone .

Sample3:
nephrology is dead - no question whatsoever about it.
as a hospitalist atleast your work is cut out for you. Nephrology, you have to go around with a begging bowl for your consults/referrals.. This is not going to change, as the old timers hire you, just a recruit for begging. they have no reason to retire as these guys will stay on directors for life for the dialysis unit - all they care is for you to provide bodies to dialyze.
this specialty has been dead for a while.
Program directors need you to be a glorified nurse practitioner(Fellow)- it is cheaper to hire a fellow than an NP . what awaits you on the other end is

A) being a slave to davita/fresenius
B) earn less than a hospitalist
c) begging all the primary care doctors/hospitalists for your consults

this is a dead speciality - DONT SEE IT AS AN ESCAPE from your hospitalist job. There is nothing more demeaning, than begging for consults. You will be slave to some guy who owns a dialysis unit and you work as a body supplier for dialysis.
Being a beggar is what this specialty has cut out for you. don't waste your life - no matter how much you love nephron or physiology - it is hard to beg every day.
Unless you want to be a beggar - don't waste your time
Don't care about what you guys do in the end. Only reason I post , is for you guys to know what it is out in real world.
Program directors know nothing or don't care - as they are not in real world.
Most of the nephrology fellows end up as hospitalists - why waste your time slaving for these programs ?
quit before you make the mistake of applying!!

Sample4:
Academic nephrologists begging candidates at scramble to fill fellowship positions : priceless

Sample5:
Going to nephrology fellowship nowadays remind me with butterflies attraction to fire phenomenon (phototaxis ) . do not worry guys I am sure all the applicants will join top name programs because those programs they do not have anybody to fill their positions . you guys after joining the fellowship be ready to work very very hard day and night for 2 years . after graduation at the end of the road you guys will be a great hospitalists .

Sample6:
Nobody here recruit for hospitalist all of us went to nephrology at some point because we did not like hospitalist and we thought hospitalist is not life long career but later we discovered that we ran away from fire( hospitalist) to volcano (nephrology) . I totally agrees that hospitalist is disappointing but believe it or not nephrology is 100 fold more disappointing than hospitalist and the worst of it when you hate hospitalist and want get ride of it then you go to nephrology full of dreams to become specialist then after 2 years you find your self working as a hospitalist again at that time you will feel how bitter it is .

If you think people here are just recruiting for hospitalist , so why you think we are just recruiting in this forum only ? did you ask your self if we go to other fellowships forums and say the same words do you think it will work or make any sense ? I am sure if you think about it well you will discover where is the problem .

Theoretically speaking if we are in a different world logism should say that being a specialist in nephrology is a lot better than being general internist ,however on ground in this area of the world general internist is more wanted, more earning, less working, less stressed and more happy than nephrologist .unfortunately now nephrology now is on the bottom of all medical specialities including hospitalist, primary care and geriatrics .

If you think hospitalist who works 2 weeks a month does not have time to see the mountain and lake in the advertisement . I am pleased to tell you that as a nephrologist you may not have a chance to see your self in the mirror .

Sample7:
This is probably the most important thing one can say to those who went unmatched in other fields.
Renal has become a joke. Fellowship positions need to be slashed if this speciality is to be saved.

Sample8:
I am currently in my second year of nephrology Fellowship and bit disappointed after my job interviews. Yes, Job situation is better than 2012-2013, but the amount of work to be done with a salary between 180-200 max is ginormous. Most places want 2 weekends to be covered (obviously after a 5 day work M-F). Job description with some employers i interviewed looks like i will have to see 15-20 inpatients and 7-18 outpatients Plus dialysis rounds (dialysis units) in certain days (unsure how many Pts) every day. When i interviewed as hospitalist it felt like a red carpet welcome, but some Neph employers made me feel like they are doing a favor by giving me a job. Most of them will not give a partnership until after year 2 or 3 or even 4. You will be employed for 2-3 years and after that there is no guarantee for partnership. They say if both parties mutually agree they will give partnership, which means that they can say goodbye to you after making you slog for 2-3 years and then again with another job you have to start from scratch. Hospital employed nephrology positions pay better with upto 300K salary but the amount of work is worse than what i have listed above including placing lines in night. Some fellowship programs are starting to train candidates who have no residency in US ( due to shortage of fellows) and some have plans to start fellowship where a week of hospitalist rounding is done so candidates don't suffer financially. With this said, there are going to be more nephrologists (Less demand and more supply is already an big issue). I felt like there are more jobs advertised, but when i call most of them are solo practitioners listing their job and they can't find anybody for years as people have joined and left to become hospitalists. When i went to ASN to interview with some large private employers, i was startled to see 20-30 graduates been interviewed for 2 positions. Joining with a solo practitioner is usually a disaster unless its your own family, so most candidates go for large private groups who have 30-100 physicians in 1-2 states. I don't want to sound kind of pessimistic here but there are certain advantages to do this fellowship. My knowledge of acid/base/ckd and even internal medicine has increased by many folds and am very happy how much i learned. But when it comes to the realities of finding a job am little disappointed. I feel doing academic nephrology is not a bad deal as you are on consult service only 3-6 months of year depending on the location and rest of year is research/CKD clinic which helps with a good lifestyle if you are ok with a paycut ( awesome option for e.g. Physician couples). Do not compare yourself with Hospitalist salaries who work for 6 months of year and base pay is around 250-280K (increased in last 3 years) with most employers+RVU=300-350K and more income if you take extra shifts on week off time. I will keep here everybody updated and i am kind of leaning back to becoming a hospitalist unless i find a reasonable job which i haven't so far. Well there a tons of nephrologists working as hospitalist anyways and i will be one of them. Inspite of all this, i don't regret doing fellowship as am a better physician now. Thanks for reading my post.

Sample9:

In a remote hospital - 4 nephrologists working as hospitalists and all private groups fighting with each other for consults/not have their patients seen by nephrohospitalists. Hospitalist groups dont want to employ anymore nephro trained people, to avoid the politics.

What a situation to be in !!! pathetic and we see absolutely no action from ASN or the programs. do a fellowship and diminish your chances even for a hospitalist job!!!

Sample10:
Nephrology has a terrible attrition rate . In my group of 3 fellows I know 2 are no longer practicing nephrology. Unfortunately because of the drop in quality applicants nephrology programs are resorting to picking up burnt out hospitalists or applicants who couldn't make it into competitive specialities and who then accepted a position without having any interest in nephrology . But then academic attending nephrologists don't want to see patients or get phone calls at night and therefore they keep taking substandard applicants.

I think if there were to drop the number of positions to about half i.e 150/200 the quality of applicants would automatically rise and then with the reduced supply job market prospects would improve , salaries would rise . But that will lead to pain for the training programs in the short run but with long term gain for the speciality. But it's not human nature to usually take short term pain for long term gain.

In conclusion:
So you see guys. Nothing has changed. Same problems over and over and over again. Burnt out burnt out hospitalist choosing nephrology as an escape, only to land back as hospitalist when they find themselves in worst shape. And around and around and around we go. Fellowships programs can always count on a desperate warm body. Problems in nephrology never get fixed. Same complaints every year.

 

[NewYorkDoctors]

An internist can also work super hard in private practice and can mimic the intense hours by doing pcp and still go to hospital and nursing homes and do something like 80-100 hours per week with weekends and that effort can easily translate to 500K + . Some 99213 pcp mills (office only - use hospitalist ) can hit over 1M with enough patient volume .

Why bother to do all that work as a nephrologist ? High ceiling but bottomless pit as well

 

[Renal_Prometheus]

Hey all, what does the life of a nephrologist look like after graduating from fellowship? Hoping to hear from recent grads. Here are a couple of questions I have for you'll- Private vs academic? Does it help to get that extra year in transplant neph vs glomerular disease vs interventional when you apply for jobs?

So do you have a better idea of what nephrologist is like in private practice. I hope I showed you a few things that your fellowship would not dare tell you.

 

[NewYorkDoctors]

While there are a number of successful Nephrology’s who post in this forum , they are the exception and not the rule . Like I said , nephrology has a higher ceiling than hospitalist but also a lower floor . I’m not sure any other IM subspecialty has a lower floor than hospitalist . So make your choice wisely before proceeding.

 

[Renal_Prometheus]

While there are a number of successful Nephrology’s who post in this forum , they are the exception and not the rule . Like I said , nephrology has a higher ceiling than hospitalist but also a lower floor . I’m not sure any other IM subspecialty has a lower floor than hospitalist . So make your choice wisely before proceeding.

I agree with this assessment. I would also add, given my extensive personal experience with this specialty, to take what fellowship programs tell you about the specialty with a grain of salt. Fellowship spots are unfilled for a reason. fellowship programs are desperate for workhorses so it is understandable that they portray portray private practice opportunities in an overly optimistic fashion. In the end, you are the one paying the price if it doesn't work out the way you hoped.

 

[NewYorkDoctors]

While most of these accounts for pro nephrology and con nephrology (private practice that is - academics is fine and dandy and exempt from these forums since they offer job security and fellows to do work ) are anecdotal at best , these anecdotes are worth sifting through . Some academics seem to think these sdn thrrqda are targeting their academic livelihood and they feel their honor threatened ... no ... just no . Academics fulfill a different role in the medical ecosystem and these “nephrology bashing threads” are purely bashing private practice .

Regarding the bottomless floor comment , I will just comment that a private nephrologist who does not have a large hd panel (which is the high ceiling ), they have fewer cpt billing codes than an internist . What does a nephrologist without much hd bill ? The same as the internist or hospitalist minus the annual physical exam code (only for pcps) and those various PCMH incentive cpt codes like for BP and a1c control .moreover, unless you’re seeing a lot of dual Medicare Medicaid or managed triple Medicare Medicaid , seeing a specialist often comes with quite a hefty copay . Good luck collecting - if you do the patients may not follow up often .

I know some neph who give prolia for osteoporosis (not the best move anyway for OTP which has nothing to do with nephrology anyway ) so they can bill the cpt code for subq chemo admin and get an extra $80 . Sad

 

[Splenda88]

@Renal_Prometheus

I am a hospitalist and I dont think hospital medicine is that bad. It's arguably one of most lifestyle friendly jobs in medicine.

We have people in my group that work 7 days straight a month for 165k/yr and call it a day.

 

[dozitgetchahi]

An internist can also work super hard in private practice and can mimic the intense hours by doing pcp and still go to hospital and nursing homes and do something like 80-100 hours per week with weekends and that effort can easily translate to 500K + . Some 99213 pcp mills (office only - use hospitalist ) can hit over 1M with enough patient volume .

Why bother to do all that work as a nephrologist ? High ceiling but bottomless pit as well

I mean, I wouldn’t recommend anyone actually do this (as a rheumatologist I work near a lot of these “PCP mills” and I can attest that their quality of care is atrocious, with me as a specialist picking up the pieces for their neglected patients half the time) but I guess I get the point vs working a huge number of hours for crap pay as a nephrologist.

 

[NewYorkDoctors]

I mean, I wouldn’t recommend anyone actually do this (as a rheumatologist I work near a lot of these “PCP mills” and I can attest that their quality of care is atrocious, with me as a specialist picking up the pieces for their neglected patients half the time) but I guess I get the point vs working a huge number of hours for crap pay as a nephrologist.

The flip side to this is the “crap quality” is equivalent to lobbing a lot of softballs to the consultant for easy money . Consultants who bill private love to get these softballs . Home run derby. Bad quality of care aside , it highlights the disparity . You can work super hard to do all the right care as a nephrologist and not get to bill as many cpt codes as frequently as the pcp mill . You do more work for more effort and get paid less . Wonderful

Needless to say any nephrologist who single handedly has a large HD panel is also running an HD mill and quality probably also suffers

 

[dozitgetchahi]

The flip side to this is the “crap quality” is equivalent to lobbing a lot of softballs to the consultant for easy money . Consultants who bill private love to get these softballs . Home run derby. Bad quality of care aside , it highlights the disparity . You can work super hard to do all the right care as a nephrologist and not get to bill as many cpt codes as frequently as the pcp mill . You do more work for more effort and get paid less . Wonderful

Needless to say any nephrologist who single handedly has a large HD panel is also running an HD mill and quality probably also suffers

Depends on your patient population. I live in semi-rural Alabama, and you wouldn’t believe what I’m seeing…it’s one thing when I worked in a under-resourced inner city clinic as a resident and saw patients who hadn’t been to a doctor in 20 years and had 20 years of unresolved problems…it’s quite another when the pt has been going to a ****ty PCP (and other docs) for 20 years, and still has 20 years of unresolved problems. If the PCP is too dim/rushed/careless/whatever to even spot problems, they won’t even toss out a softball referral to a specialist and the pt will sit with these issues festering for years until they become huge cataclysmic disasters that could have been easily addressed years ago. Good primary care actually matters.

But I digress.

 

[NewYorkDoctors]

I saw a pleuritis pericarditis case today for a pulmonary consult and I spent quite some time going through the ct scan then doing physical exam and going through history items . No apparent joint or other systemic symptoms . Will arrange for blood work .

When I ask if the patient has seen a cardiologist before since I will need pericarditis evaluation , the patient says yes and tells me the cardiologist just wanted her to do a stress test . But no Mention of the pericardial effusion (this Cardiologist had the records ) . He prescribed toprol xl (for BP in office 160/100 and her 105)

She then says she did not take the toprol and asks me if she can hold it. She then asks me about hypertension and if she really has it . Becuase I am nephrology hypertension as well , I humor her and walk through the aha acc definition of hypertension and home and 24 hour criteria . She measured 160/100 at triage this morning but after we talked and calmed her down she was 129/82. Hence I inform she does not yet meet hypertension criteria and may have white coat. Etc..

I ask her if she ever brought this up to her PMD. She said no becuase the pmd has too many patients and doesn’t have time to talk . I said not even the thirty seconds I took to explain the BO criteria ? Really ?

Now I get to judge because I inherited a large primary care panel (for which I provide superimposed renal and pulmonary care - which the patients take for granted ) so I also do primary care . If you are busy , establish more follow ups pcps! If you have managed Medicaid managed Medicare , these patients either have no or very little deductible copay (waive it if you have to ) . See them more often and explain and treat the problem ! You make more money too ! Send this anxious lady for me to provide reassurance took way too much time ... and I did it all with fake smile and fake empathy .

 

[Renal_Prometheus]

I wonder if there’s gonna be a nephrology fellowship application thread this year? I’m sure many of us here are eager to share our experiences with this specialty 🤣

 

[NewYorkDoctors]

Probably there will be but won’t gain much traction. This thread will persist . Everyone loves to slow down on the freeway to watch a dumpster fire multi car train wreck in progress

 

[Renal_Prometheus]

To be complete frank, if the majority of grads of this specialty ended well, there would not be so much animosity from ex-nephrologists towards their own specialty. There is also large discrepancy between what an academic's perception of the nephrology job market vs what's really going on in private practice. Unfortunately, most will end in disappointment. It seems almost common sense that specialties with low match rates are not worth doing financially. But it still comes as a surprise to some neph grads that realities of the private practice are much worse than what their attendings portrayed it as.

 

[Renal_Prometheus]

What’s incredibly harmful to peoples careers are older applicants and IMGs with visa issues. The misinformation propagated by academic nephrologist can cause tremendous career damage when they find out they are better off just taking a hospitalist job. The opportunity cost for older applicants is tremendous because they don’t have that many working years to make up the “mistake”. For people with visa issues, they get the worst jobs in an already bad job market. Sure, there are many nephrology jobs out there, but you end up working harder and making less than a hospitalist. Wasn’t the whole point of doing a subspecialty to be better off than a hospitalist? The whole thing is wrong on so many levels. The most desperate people get screwed the hardest because they have limited options and want to better there current situation. So wrong.

 

[Splenda88]

What’s incredibly harmful to peoples careers are older applicants and IMGs with visa issues. The misinformation propagated by academic nephrologist can cause tremendous career damage when they find out they are better off just taking a hospitalist job. The opportunity cost for older applicants is tremendous because they don’t have that many working years to make up the “mistake”. For people with visa issues, they get the worst jobs in an already bad job market. Sure, there are many nephrology jobs out there, but you end up working harder and making less than a hospitalist. Wasn’t the whole point of doing a subspecialty to be better off than a hospitalist? The whole thing is wrong on so many levels. The most desperate people get screwed the hardest because they have limited options and want to better there current situation. So wrong.

They should restructure these specialties IMO. People that are going into subspecialties should only do 2-yr of IM residency.

 

[void88]

I agree with this assessment. I would also add, given my extensive personal experience with this specialty, to take what fellowship programs tell you about the specialty with a grain of salt. Fellowship spots are unfilled for a reason. fellowship programs are desperate for workhorses so it is understandable that they portray portray private practice opportunities in an overly optimistic fashion. In the end, you are the one paying the price if it doesn't work out the way you hoped.

I'm just curious. Do you still practice Nephrology, or did you take a different route (e.g., Hospitalist)?