Pediatric Nephrology -- Am I crazy??

[Superman DO]

I have always loved the field of nephrology since school, and now that I am doing my rotation in it this month, I have thoroughly enjoyed my time in the specialty. I know the salary isn't great, and you do not financially come out ahead in the long run it seems given the three year fellowship. But, the mix between hospital and clinic medicine as well as the academic subject matter is just fantastic. Any peds neprhologists on here (or anyone with good information) shed some light about the current state of the field and any predictions where it might be headed in the future? How competitive is this fellowship, especially if I do not have any research experience? Is it reasonable to count on the PSLF program to help pay of my enormous debt if I choose a lower paying specialty? I have two great faculty members I'm speaking with, but just looking for different perspectives.

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[MEN2C]

In 2014, there were 61 positions and 37 applicants for pediatric nephrology.

 

[Superman DO]

In 2014, there were 61 positions and 37 applicants for pediatric nephrology.

Well, those are definitely reassuring statistics.

 

[mvenus929]

Is it reasonable to count on the PSLF program to help pay of my enormous debt if I choose a lower paying specialty?

Probably not, given that we don't know if it will exist 11 years from now when you would qualify, if it will exist in its current state (all remaining debt paid off, or if there will be a cap), or if you will be able to find a job that meets the qualifications. Your residency and fellowship would likely count, but a lot of attendings aren't employed by the hospital in wch they work, but are instead paid through a for profit group that contracts out to the hospital.

 

[Stitch]

Sorry for being a little late to the party. If you do nephro, you'll pretty much always have a job somewhere. There's a lot of demand. That also means many are overworked. I think the peds nephro people are generally some of the smartest people out there. The kidney is complex. I don't know what the salary is, but like most peds jobs, it's less than it should be. If you love reading/learning about it and you like the patient population, then you should do it.

 

[Perrotfish]

In 2014, there were 61 positions and 37 applicants for pediatric nephrology.

I'm amazed they found 37 people to do this. Three more years as a trainee, no pay bump, less flexibility with you location, sicker patients, more work, and perpetual home call? It seems like anyone smart enough to be a nephrologist is smart enough not to be a nephrologist.

BTW did anyone catch the AAP update on fellowship training a few months back? Where they 'updated' us that they may one day consider shortening a peds fellowship to less than 3 years, but not anytime soon? The AAP leadership is just catastrophically bad.

 

[oldbearprofessor]

I'm amazed they found 37 people to do this. Three more years as a trainee, no pay bump, less flexibility with you location, sicker patients, more work, and perpetual home call? It seems like anyone smart enough to be a nephrologist is smart enough not to be a nephrologist.

BTW did anyone catch the AAP update on fellowship training a few months back? Where they 'updated' us that they may one day consider shortening a peds fellowship to less than 3 years, but not anytime soon? The AAP leadership is just catastrophically bad.

Perhaps the same type of folks who chose pediatrics despite it having a relatively low financial ROI, make the same decision for the same reason about what fellowship to do. The same issue exists for numerous pedi fellowships, not just nephrology.

Although you're welcome to hate on the leadership of the AAP, I'm not sure this is the issue to do it on. The AAP doesn't decide on what fellowship requirements need to be for board certification, that's the ABP. Did the AAP specifically say that they thought the ABP should reject shortening fellowships? Link?

 

[Perrotfish]

Perhaps the same type of folks who chose pediatrics despite it having a relatively low financial ROI, make the same decision for the same reason about what fellowship to do. The same issue exists for numerous pedi fellowships, not just nephrology.

I guess I just can't imagine subjecting yourself to the abuse of training into your mid 30s, and then taking much more call for ever, for the sake for focusing on an 'interesting' organ system. Taking a pay cut for a better patient population yes: that's just sacrificing your quality of life outside of working for the quality of life in work. In pediatrics I am basically paying 100K a year to not have to deal with adult patients. I don't really see the attraction for the nephrologists.

If they're really going half unfilled I guess most Pediatricians agree with me.

 

[Superman DO]

From a financial standpoint, I know it is not the greatest decision. But thankfully, I try not to base big life decisions on money. At the end of the day, I just want to be able to pay my bills, feed my family and have a little money left over for some fun. Sure, it may make my life more difficult, but I still cling to the idea that we as physicians should always put our patients and humanity before ourselves. I'm not sure how busy other pedi nephrologists are at other medical centers, but my faculty members really do not seem overworked at my institution. Furthermore, multiple times they reiterated how happy they were with their job. While I hate the idea of having to train for three additional years, I would rather sacrifice three years for forty years of happiness than to be unhappy for forty years because I decided to take the easier path and settle for a job that was not fulfilling. Besides, if no one decided to specialize in pediatrics anymore just because it isn't financially worth it, who will care for these patients with complex medical needs?

 

[SB100]

I too will be pursuing nephrology, and there's nothing crazy about wanting to go into a field even if the financial ROI is minimal compared to if you didn't pursue it. Just make sure you enjoy the bread and butter material of whatever specialty you choose as that'll be a large part of your practice. I'm much happier working through complicated fluid, electrolyte, and acid-base problems and working with patients with chronic kidney disease, but also enjoy evaluating new patients with hypertension, proteinuria, etc. which most nephrologists see as new referrals.

 

[mvenus929]

I'm not sure how busy other pedi nephrologists are at other medical centers, but my faculty members really do not seem overworked at my institution. Furthermore, multiple times they reiterated how happy they were with their job.

I will say, the nephrologists at my institution are very willing to take on new mentees. One in particular did fellowship where I went to med school (we overlapped, actually, so he's a fairly new attending) and every time he sees me, he tries to convince me to do nephrology. I do applaud those interested in it, I'm just not.

 

[Perrotfish]

From a financial standpoint, I know it is not the greatest decision. But thankfully, I try not to base big life decisions on money. At the end of the day, I just want to be able to pay my bills, feed my family and have a little money left over for some fun. Sure, it may make my life more difficult, but I still cling to the idea that we as physicians should always put our patients and humanity before ourselves. I'm not sure how busy other pedi nephrologists are at other medical centers, but my faculty members really do not seem overworked at my institution. Furthermore, multiple times they reiterated how happy they were with their job. While I hate the idea of having to train for three additional years, I would rather sacrifice three years for forty years of happiness than to be unhappy for forty years because I decided to take the easier path and settle for a job that was not fulfilling. Besides, if no one decided to specialize in pediatrics anymore just because it isn't financially worth it, who will care for these patients with complex medical needs?

While I fully agree that its reasonable to trade 3 years for 40, I've been putting off today for tomorrow since high school and do you know what I've noticed? Tomorrow never f-ing comes. There's always a next thing, one last thing the powers that be tell you that you have to do to be happy. Some people get strung along by the leeches for life, always striving for the next brass ring until they retire a miserable thrice divorced dean at an academic medical center. Meanwhile, like anyone whose had a moment of clarity in a casino, every once in a while you look up realize that the house is the only one that's winning at this game. There's a reason they call it work: happiness and fulfillment are things that happens outside the office. Be one of the smart ones: get off the merry-go-round of misery. Don't just feed with your family, be with them. Don't let your bosses use your conscience to exploit you. Live your life while you have it.

But what if everyone thought this way, you ask, what then? If no one decided to specialize in pediatrics anymore they would raise the reimbursement rates and go back to the 1 and 2 year fellowships they used to have, and then it would be worth it again. Whenever you sacrifice yourself to medicine you're not helping your patients, you're helping either a rich taxpayer or an insurance company that will titrate their take while leaving your patients the maximum possible amount of screwed.

One last unrelated thought: study after study has shown that Pediatric subspecialist density makes no difference in regionwide patient health, while Pediatric generalist density has a linear relationship with patient health. It turns out that when there are no subspecialists around generalists just do the job. Like real doctors.

 

[oldbearprofessor]

There's a reason they call it work: happiness and fulfillment are things that happens outside the office. Be one of the smart ones: get off the merry-go-round of misery. Don't just feed with your family, be with them. Don't let your bosses use your conscience to exploit you. Live your life while you have it.

I wonder if you are able to see that decades after medical school is over, when the kids are growing and grown and don't need you to be "there" very much and when the spouse is either gone or pretty independent, the work experiences and relationships in the care of sick children are a big part of living life and being happy. I won't argue the younger years here and now, that's an argument best made by younger folks, but I am certain that seen at my age, I am very very grateful for the career I have and have had as a pediatric specialist. There never was and never will be a "merry-go-round of misery" for me and many of us who follow our passion in caring for children as pediatric specialists. As always, YMMV.

 

[Perrotfish]

I wonder if you are able to see that decades after medical school is over, when the kids are growing and grown and don't need you to be "there" very much and when the spouse is either gone or pretty independent, the work experiences and relationships in the care of sick children are a big part of living life and being happy. I won't argue the younger years here and now, that's an argument best made by younger folks, but I am certain that seen at my age, I am very very grateful for the career I have and have had as a pediatric specialist. There never was and never will be a "merry-go-round of misery" for me and many of us who follow our passion in caring for children as pediatric specialists. As always, YMMV.

While I understand that children grow, I'm not sure that my spouse being "gone or pretty independent" is a necessary part of my planning for my old age. Call me sentimental, but I'm hoping my spouse is going to be as close and as comfortably co-dependent as my parents and grandparents were to each other. Anyway while I don't argue that there is some satisfaction to be found in the office, I still think that a lot of us have had the experience that work is work and in general the meaningful part of life happen at home.

Anyway, maybe the pessimistic crowd is right and medicine is just becoming a less satisfying profession over time? Physicians of your generation were part of a transition between the historical baseline of small, middle class, essentially solo physicians who were stressed with small business ownership, and my generation of harried, middle class, employee physicians who are not really in control of their working environment. Most people agree that your generation enjoyed an unprecedented amount of authority, job satisfaction, and pay. I don't think its necessarily wise for us to listen to our elders when we plan our careers. Our experiences are just too different.

 

[michigangirl]

For the original poster-- if peds nephro is what gets you going-- do peds nephro. I am very close to many pedi nephro fellows and attendings. They are all fabulous, happy people who just love and respect the kidney. I need their expertise for many of my patients in the PICU. In the research realm, they are top notch, and our program gets everyone through the MPH or PhD in public health so that they can make meaningful contributions to science. They do great research. They have an impact on a community level (for example, one of my close colleagues just won a grant to study risk factors for hypertension in children in Baltimore city). They don't make a ton of money, but they make ENOUGH. Enough to be happy, have a nice lifestyle, be there for their families-- and guess what, feel good when they go home at the end of the day.

With regards to the other ongoing conversation in this thread-- I'm completely with OBP on this one. I trained for 8 long years. I make a salary below the median for both of my subspecialties. Those who are dissatisfied with medicine are either in the wrong practice model or haven't found what makes them click to make all the other "noise" of new medicine diminish. In the end, you make yourself happy. You find what works. If you're getting bitter find another way or get out. But it doesn't mean everyone is doomed. Working in a HUGE academic center I am definitely not in control of my working environment. But I raise a stink when it's important to me and my patients, and I keep doing what makes me happy within the confines of the instiution, because in the end, the institution offers me many opportunities that wouldn't be possible in another setting. Family will always come first, but it doesn't mean one can't derive immense satisfaction from their "day job". Sure, there are times that its frustrating, but the positives far outweigh the negatives. When that ratio begins to tip, it's time to find a different setting.