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What do nephrologists do/lifestyle of nephro

Discussion in 'Other Subspecialties' started by rs2006, Feb 17, 2007.

  1. rs2006

    rs2006 student
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    Hi everyone

    I hope all is well for everyone-- I just wanted to know if anyone could enlighten me on what private practice nephro docs do-- do they work out of dialysis centers or do they have private clinics? How many hours do they typically work a week/ what is call schedule like-- are there alot of emergencies? In addition, how much of the managed care/insurance issues do they have to deal with-- I have heard that physician payment for dialysis is GUARANTEED by the government. Please help answer these questions. thanks.
     
  2. Punchap

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    I'm also very curious about the above. Any responses?
     
  3. Atlas

    Atlas Senior Member
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    It can vary. I've done two renal months and both were busy. A lot of it depends on where you are, but generally nephrology is a busy specialty. It really does seem like renal gets consulted for every creatinine above 1.2. All kidding aside, there is a lot of office work, consults, dialysis, procedures - enough to keep you busy until 6 pm every night. Most of the docs I know started their day around 7 am and finished up and were home by 7 pm. Where I did my one renal month, the group covered 5 hospitals, so call was killer. In a medium-to-large hospital, there is always someone needing dialyzed. Thankfully you don't have to stay the whole time. However, you will be called in at 2 am to dialyze someone. I also did a month at a major hospital in Cleveland where the fellows took q1-2 call. It was brutal. Nephro is not considered a "lifestyle" specialty. So, to summarize...the weak at heart (cause patients die) and under-achievers need not apply! You wont makes tons in nephro...not like they used to. You used to be able (at one time before 66% of them became coporate-owned) own your dialysis center. Now there is conflicts of interests and STARK laws to contend with. It can be done. The one group I was with owned a dialysis center. It can happen. However, realistically, to make 300K will require a great deal of work. Typically, starting around 160-180 with a comfortable range of 210-225K (seriously) after a few years. Only the ones that really push the limits of the human body will make 350K+! I know... I know..."I saw a job on this site saying $350K yadie-yada" Be careful. I have nephrologists as close friends. The pot ain't THAT sweet. Hope that helps.
     
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  4. Atlas

    Atlas Senior Member
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    Oh yeah...I forgot to add: sure dialysis is covered by the good ol Uncle Sam through medicare, but what people fail to mention is that nephrologists are now losing money to dialyze people now thanks to Uncle Sam's reimbursement cuts. The way the are keeping afloat is through injectable meds like epo, which are not being controlled by who else...good ol Unc' Sam!!! Dialysis is no-longer the pot-o-gold it once was. Sorry to burst your bubble.
     
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  5. Atlas

    Atlas Senior Member
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    Oh yeah...I forgot to add: sure dialysis is covered by the good ol Uncle Sam through medicare, but what people fail to mention is that nephrologists are now losing money to dialyze people now thanks to Uncle Sam's reimbursement cuts. The way the are keeping afloat is through injectable meds like epo, which are now being controlled by who else...good ol Unc' Sam!!! Dialysis is no-longer the pot-o-gold it once was. Sorry to burst your bubble.
     
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  6. salmonella

    salmonella Gram-Negative Rods
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    I fully agree with Atlas' comments above. I used to think nephrology was a chill, cerebral, lifestyle specialty until I did a renal rotation. It was an extremely busy service because they got asked to consult on almost every creatinine elevation, especially by surgeons and ob-gyn who were too busy to tease out the differentials of acute renal failure. The poor fellow took home call every night for the entire consult rotation (usually two consecutive months). Regular day involved coming in around 7am, getting 5-7 consult, with clinic twice a week, leaving around 8-9pm, and ocassionally being called back in the middle of night for emergent dialysis. To make things worse, most renal patients were in the ICU, super complex, with serious medical issues (septic shock, CHF, intubated, tumor lysis syndrome, trauma, multi system organ failure). It takes time to figure out what's going on with those patients. A female renal fellow once told me if you wanted to spend sufficient time with family and have kids, etc, nephrology was certainly not a good choice (instead, do endo, rheum, geriatrics, ID).

    I also heard dialysis was not as lucrative as it used to be. Someone told me they only made a profit of about $5-7 each patient each month, and the financial situation is getting worse everyday. Interventional nephrology is definitely the way to go if you want to make money. Even though they get reimbursed less than radiologists and surgeons who do the same procedures, the pay is still better than running dialysis center or seeing hospital consults.
     
  7. megsMS

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    What kind of procedures do you often do as a nephrologist?
     
  8. tibor75

    tibor75 Member
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    The only good news is that renal consults usually are pretty quick. Especially the ICU ones...can't talk to a patient who is intubated!
     
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  9. Atlas

    Atlas Senior Member
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    True, unless its complicated, which happens often. Also, you better like the ICU because so many of the patients are sick, so you'll find that you spend a lot of time in the unit.
     
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  10. NewYorkDoctors

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    10 years later and it's not getting any better. If anything it's getting worse.

    Everyone should stay away from the trap that is Nephrology. The great bane of this (once-great) specialty is the scourge of ESRD and nonadherent patients as well as ever tightening grip the US Government has on hemodialysis (ostensibly to cut costs).

    If one seriously loves the discipline of nephrology, then you can consider doing the fellowship training to become licensed and board certified as a nephrologist... then promptly work in another primary specialty (whether it is hospitalist, PMD, or another subspecialty if you have the time effort and chance to do another fellowship that complements nephrology).

    Otherwise you will have no lifestyle, no family time, no personal time, barely make more than a hospitalist, no respect (from your peers; maybe from a starry eyed medical resident and medical student), and no pay.

    The sad fact is the supply of renal fellows far outweighs the demand for new nephrologists. Basic laws of economics. Half of the renal fellowship programs should not exist because those are community centers that are not research oriented and the only reason they exist is so the faculty can have cheap labor (i.e. IM board certified PAs whom they can verbally abuse and overuse under the name of "education) and not take the night calls.

    In the underserved rural areas, nephrology is served by locum tenens on a shift work model. Few nephrologists (USAMGs who do renal tend to cluster in academic nephrology in big cities anyway and FMG/USIMGs are either limited by visa restrictions from going to rural areas or do not want to risk being in #45 territory nowadays) want those jobs anyway.

    The fellowship needs to contract to rebalance the supply and demand issues plaguing the workforce.

    All of these "leaders" in the ASN keep writing about how anesthesia in the 90s and GI in the early 2000s were very unpopular and now that they are popular again and that this is a cycle of economic downturn and upturn. Not gonna happen with nephrology. One major reason: FEDERAL GOVERNMENT. Everything the Federal Government touches becomes bureaucratic and inefficient. Not to make this a libertarian philosophical post, but basically ESRD and HD are tightly controlled by CMS and that's never going to be a honey pot ever again. Plus, GI had the benefit of receiving the screening colonoscopy recommendations around the early 2000s. Further. anesthesia contracted in size before becoming what it is now. In addition, the job apocalypse for anesthesia back then was primarily in places like California as well as outpatient pain clinics. It was never that bad to get a standard anesthesia job in a hospital somewhere.

    I don't regret doing nephrology fellowship in the sense that I still like the medicine part of it. But the real life practices are brutal and not worth any educated person's time or effort.

    Outside of academic nephrology (i,e. transplant, GN, CRRT, etc), community nephrology should be best utilized as "value-added" to primary care Internal Medicine. This is the ideal role for a nephrologist who cannot do another subspecialty.
    Work as Internist who also can specialize in hypertension, CKD, electrolyte issues. Once CKD4-5, can also be the quarterback to get them HD education and dialysis access. Once they are on HD, refer to a colleague nephrologist or the medical director nephrologist based at a center who still does dialysis. (for whatever insane reason) You continue as PMD for the patient. Medical director at HD unit does all of the HD and bills for it. Win-win.

    Low back pain and total body pain is NOTHING compared to ESRD management.


    As for the pay:
    - Big city academic center: expect $150K to start as junior attending before RVU bonuses and building an ESRD base. But short of getting research honoraria and doing speakerships and those kind of supplemental income, do not expect to make more than a hospitalist down the line.
    - Private Practice: if joining a practice, you'll probably get the usual offer of about $175K to 200K depending on volume as a junior attending. Get worked nearly as hard as fellowship for 3 years. An outside chance of making partner and making $250K. Ceiling? probably $350K for senior partner. But that's not just sitting in an office. That's running to muliple hospitals a day, rounding on HD patients at their sporadic shifts through a day (four shifts a day...), and seeing clinic patients. And you have no NO LIFESTYLE. Further, the senior partners can always say you were doing great but you weren't hitting .350 for the season and they cant make you partner.
     
    #10 NewYorkDoctors, Jan 11, 2018
    Last edited: Jan 11, 2018
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  11. ANCAdoc

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    I think the above is overly negative.

    I've really enjoyed my time so far in practice. I started in private practice after fellowship and have an excellent lifestyle for a nephrologist. Before I left I had 7 weeks of paid vacation and the next year it would have been 9 weeks (up to max 12 at 4 years service +). I didn't run all over the place, we had a large group that was able to schedule HD visits to our daily schedule without the hassle or stress of trying to see clinic visits or inpatients at the same time. For small groups it would be an issue, for most large groups they run very well with great lifestyle. Clinic weeks were 8:30-4 with 1hr lunch, Inpatient weeks were 7-4. On call about 1 weekend a month, 2-3 weeknights a month. The group evenly split profits at the partner level. Overall, I felt I worked less than most nephrologists. I only left the group (offered partnership) because I had concerns about long term sustainability for private groups and long term dialysis revenue potential. This was VERY hard to do and I lost a lot of sleep over it as I really liked the group. Ultimately, I gave 90 day notice and joined with an academic group (strength in numbers with great benefits) and practice solely at one of their suburban hospitals, giving me the private practice feel. I feel decently compensated. Only on call 1 weekend every 5-6 weeks (at 3 suburban hospitals all in the local area, low-volume really, work maybe 2-3 hours) and weeknight call about once every 4-5 weeks (by the week, rarely get called so I sleep very well). Work 8-4 generally with 1hr lunch on clinic days. Our 3 dialysis units are not spread far apart. I'm never at the hospital past 4PM 95% of the time. I'm happy.
     
  12. NewYorkDoctors

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    I am happy for you and others should take notice. But I have bolded the part that makes your arrangement more desirable that I have alluded to in all of my posts as what may make things more desirable.
     
  13. NewYorkDoctors

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    Burnout in Nephrology

    An article on burn out in nephrology. The leaders of the ASN (the governing body for nephrology) have taken note of a high attrition rate and burn out rates among the practicing nephrology community. The salient highlights are:
    - Also, in a recent Medscape Lifestyle Report, 47% of nephrologists reported burnout symptoms, which ranked the fifth most severe compared to 24 other specialties (4).
    - Many factors contribute to physician burnout: work hours, night/weekend calls, excessive bureaucratic tasks, and moral distress (4,5). Burnout is independently associated with job dissatisfaction, faculty/staff turnover, and reduced productivity.
    - Fellows who would not recommend nephrology to others cited the heavy workload, low compensation, and difficult schedule as important factors among others. When looking for jobs, they ranked as “important or very important” the frequency of weekend duties/overnight calls and length of each workday (7)
    - Although interest and strong mentors have a positive influence on the decision to go into nephrology (6), it is clear that many have concerns about the workload of such a career. Unfortunately, many fellows end up regretting their career choice, and it seems that barriers to work-life integration may play an important role.
    -Nephrology fellowship training is known for being arduous, even among the internal medicine subspecialties. Because we manage critically ill patients, there are many times when a nephrologist is needed urgently to help a patient.
    - Training programs that are biased toward inpatient rotations should review rotation structure and consider increasing the balance between outpatient and inpatient experiences.

    Burnout is rising in prevalence in all medical specialties. The initial thought of many older nephrologists is that the change in market forces, full capitation and bundled payments demanding fee for outcomes and not fee for service, would make nephrologists impervious due the extra demands because chronic HD has been this way for many years now.

    However, HD patients do not fit an ACO model well. You can discharge early but how are you going to prevent readmissions? The primary issue is that patients who are non-adherent to fluid control (there are many good patients who can do it, but there are many who cannot do it) are the ones who end up in the hospital. Not to paint a picture of an incompetent HD unit to non-nephrologists, as nephrologists can ask the patient to do more ultrafiltration per session or even come in for extra sessions (CMS will pay for up to 17 sessions per month and with some patients with justification can be on a base 4x a week and provide reimbursements), but many times the patients cannot help it and end up with decompensated HF.

    The squeeze between the "perfect world" that CMS demands and the dystopia that is ESRD care (not by anyone's fault, it's just the nature of the beast) are highly incompatible outcomes and place extra undue pressure on nephrologists which may contribute to stress in the workplace.

    The mentorship and role model idea is a noble one. But short of becoming an academic nephrologists, maybe doing transplant, and doing research and getting grants and speakership honoraria (what do these all have in common? avoiding ESRD if possible), positive role models cannot do that much because at the end of the day, money talks. I am not saying everyone wants to sell out their patients and do unnecessary procedures on patients for a quick buck. Rather when you work as hard as cardiology (perhaps not as hard as EP or interventional cardiology, but general neprhology and general cardiology have a similar volume and complexity of patients, sans procedures in nephrology) and get paid a fraction and get no respect (e.g. nephrology vs CTICU ... often times nephrology becomes relegated to a dialysis technician who just places an order and CTICU dictates UF, duration, and potassium bath), it's hardly a wonder why community nephrologists are burning out.
     

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