Why is nephrology not competitive?

[wanted101]

I see LEGIT sources like MGMA say that their median salary is 400k. Why is it so uncompetitive?? I'd be okay with doing whatever hard work for 400K a year.

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[chessknt]

I imagine it is a combination of patients are always on the sicker side of the spectrum and almost always have crappy government insurance.

 

[Chemist0157]

I see LEGIT sources like MGMA say that their median salary is 400k. Why is it so uncompetitive?? I'd be okay with doing whatever hard work for 400K a year.

I think nephrology is kind of a middle ground subspecialty. You have the higher paid subspecialties where there is a longer fellowship, more procedures (pro/con depending on the person), more acuity/calls/weekends. You then have the lower paid subspecialties but with less/no procedures, minimal acuity calls/weekends. Nephrology is in the middle where you have a shorter fellowship like endocrinology or rheumatology and not a lot of procedures (occasional vas cath insertion or perm cath removal at most), better pay, but can have busy consults, more acuity, more calls in the middle of the night.

The rise of hospital medicine probably drained out people who were on the fence between a fellowship like nephrology and just getting out and working. Nephrology makes more compared to hospital medicine, but it tends to need time to ramp up, a couple of years to build up patient load and time to grow into partnership in private practice for instance. Some people would rather just get out there and make the money now.

There are other thoughts. Sicker patients. Complex work. Minimal procedures. I personally think medical students and residents get very little early exposure to nephrology which hampers number of applicants later. Nephrology feels more like a black box compared to cardiology. Anecdotally, my home program's director has seen a lot of success continuing to fill my home program and increasing interesting (and applicant) number in nephrology for other programs as well.

There was also a time when the powers that be were doing the math and trying to guess-timate how many nephrologists we would need based on how many CKD patients there were and how many ESRD patients there would be. They overestimated the need. Programs could reduce the number of spots and tighten up the figures, but they just don't do it. Number of spots and number of applicants has remained fairly flat over the past few years.

I feel like I got a deal going into a 2-year fellowship of something I enjoy that was not very competitive and then doing well financially, but not everybody sees it that way.

 

[wanted101]

I think nephrology is kind of a middle ground subspecialty. You have the higher paid subspecialties where there is a longer fellowship, more procedures (pro/con depending on the person), more acuity/calls/weekends. You then have the lower paid subspecialties but with less/no procedures, minimal acuity calls/weekends. Nephrology is in the middle where you have a shorter fellowship like endocrinology or rheumatology and not a lot of procedures (occasional vas cath insertion or perm cath removal at most), better pay, but can have busy consults, more acuity, more calls in the middle of the night.

The rise of hospital medicine probably drained out people who were on the fence between a fellowship like nephrology and just getting out and working. Nephrology makes more compared to hospital medicine, but it tends to need time to ramp up, a couple of years to build up patient load and time to grow into partnership in private practice for instance. Some people would rather just get out there and make the money now.

There are other thoughts. Sicker patients. Complex work. Minimal procedures. I personally think medical students and residents get very little early exposure to nephrology which hampers number of applicants later. Nephrology feels more like a black box compared to cardiology. Anecdotally, my home program's director has seen a lot of success continuing to fill my home program and increasing interesting (and applicant) number in nephrology for other programs as well.

There was also a time when the powers that be were doing the math and trying to guess-timate how many nephrologists we would need based on how many CKD patients there were and how many ESRD patients there would be. They overestimated the need. Programs could reduce the number of spots and tighten up the figures, but they just don't do it. Number of spots and number of applicants has remained fairly flat over the past few years.

I feel like I got a deal going into a 2-year fellowship of something I enjoy that was not very competitive and then doing well financially, but not everybody sees it that way.

Thanks so much for the very informative post. I've read that nephro salaries are often looked down upon because of govt control of dialysis centers which used to be nephro's huge money maker. As a govt employee people assume much lower salaries. But very recent data shows salary is 400K median. You mention private practice. So that is likely how people are making 400K? Whenever I mention wanting to look into nephro as an upcoming i med intern everyone says "oh govt control of dialaysis centers = no money" which contradicts MGMA data.

 

[chessknt]

Thanks so much for the very informative post. I've read that nephro salaries are often looked down upon because of govt control of dialysis centers which used to be nephro's huge money maker. As a govt employee people assume much lower salaries. But very recent data shows salary is 400K median. You mention private practice. So that is likely how people are making 400K? Whenever I mention wanting to look into nephro as an upcoming i med intern everyone says "oh govt control of dialaysis centers = no money" which contradicts MGMA data.

The government doesnt control dialysis centers....

Just focus on what you find interesting and go in to that. Someone will always make more money than you (unless you do interventional cards, EP, or GI).

 

[Chemist0157]

Thanks so much for the very informative post. I've read that nephro salaries are often looked down upon because of govt control of dialysis centers which used to be nephro's huge money maker. As a govt employee people assume much lower salaries. But very recent data shows salary is 400K median. You mention private practice. So that is likely how people are making 400K? Whenever I mention wanting to look into nephro as an upcoming i med intern everyone says "oh govt control of dialaysis centers = no money" which contradicts MGMA data.

Dialysis care is regulated by the government, but they don’t own the centers or provide the care. Nephrologists are not government employees. The typical setup is a dialysis company provides the staff and equipment, likely the building, and a nephrology group serves as doctor and medical director, and sometimes the building.

Most nephrology income comes from dialysis care then hospital work then outpatient clinic work.

Private practice makes more than academics, but that is not specific to nephrology.

Not to pick on you, but this helps show how little students and residents now about the financial side of nephrology. I know I barely knew nothing until I started looking into the field myself. There’s more to it than x number of procedures or x number of patients = y amount of revenue. It’s a unique field In that way.

I think also people think that since Medicare is the pay or of dialysis care, that the compensation is poor, but dialysis has by far the most bang for our buck (time). From a purely financial standpoint, seeing patients in clinic helps capture dialysis patients and cover overhead. There’s not much more money in seeing clinic patients than in how anyone else sees clinic patients. Billing system is the same. Hospital consults and follow ups (and dialysis inpatient) pays much better than regular clinic and is also ultimately there to capture dialysis patients.

 

[wanted101]

Dialysis care is regulated by the government, but they don’t own the centers or provide the care. Nephrologists are not government employees. The typical setup is a dialysis company provides the staff and equipment, likely the building, and a nephrology group serves as doctor and medical director, and sometimes the building.

Most nephrology income comes from dialysis care then hospital work then outpatient clinic work.

Private practice makes more than academics, but that is not specific to nephrology.

Not to pick on you, but this helps show how little students and residents now about the financial side of nephrology. I know I barely knew nothing until I started looking into the field myself. There’s more to it than x number of procedures or x number of patients = y amount of revenue. It’s a unique field In that way.

I think also people think that since Medicare is the pay or of dialysis care, that the compensation is poor, but dialysis has by far the most bang for our buck (time). From a purely financial standpoint, seeing patients in clinic helps capture dialysis patients and cover overhead. There’s not much more money in seeing clinic patients than in how anyone else sees clinic patients. Billing system is the same. Hospital consults and follow ups (and dialysis inpatient) pays much better than regular clinic and is also ultimately there to capture dialysis patients.

wow very insightful, thanks a lot. yes, I agree, none of my classmates have this financial knowledge on the field. But neither do the majority of residents which is why the very large majority repeat the common ideas I mentioned and avoid nephro mainly bc of what they believe to be low pay. I was wondering if you have any insight into why MGMA says the eastern U.S. median salary is 275K while the midwest and southern are 400K? I'm curious as to why there's such variation dependent on region. I could see rural v urban but these are region dependent.

 

[Chemist0157]

wow very insightful, thanks a lot. yes, I agree, none of my classmates have this financial knowledge on the field. But neither do the majority of residents which is why the very large majority repeat the common ideas I mentioned and avoid nephro mainly bc of what they believe to be low pay. I was wondering if you have any insight into why MGMA says the eastern U.S. median salary is 275K while the midwest and southern are 400K? I'm curious as to why there's such variation dependent on region. I could see rural v urban but these are region dependent.

The most straightforward answer is that the dialysis patient-to-nephrologist ratio is higher in the higher paid areas, either because ESRD is more prevalent in those higher areas, or there are fewer nephrologists, or both.

I think California is another saturated market last I looked.

Number of nephrologists *should* be proportional to number of ESRD patients. It is a metric fellows can use to gauge a practice they are considering joining after training.

 

[collegestud2013]

The higher median nephrology salaries are being skewed by more senior partnere who have some practice ownership or even own their dialysis center. The job market tends to be saturated so the newer grads get taken advantage of and will work a lot more for a lot less than what they bring in.

Also the average nephrologist works a lot more hours and with a lot of call than the typical 7 on 7 off hospitalist so their hourly rate is often lower than hospitalist. And even lower once you factor in the 2 additional years of fellowship.


Most fellowship programs don’t want to cut their spots (even if they routinely go unfilled and have to really try to find someone) since they want the fellows as free labor to do all the work, especially the busy overnight call (that attendings have to do in a non-teaching environment or pay out of pocket for a mid level to do).

 

[Renal_Prometheus]

Or you could read all of my posts and you will get a good idea of why nephrology is noncompetitive. People underestimate the number of nephrologists who are doing bad financially and who have quit to take up hospitalist jobs. There are lot of them in private practice. In addition to low starting salary, many groups take advantage of fellows coming out, work them for couple of years for cheap labor and then tell them they didn't make partner. Theses are things academics won't tell you. The quoted MGMA figures are the one who have done well, not the ones are not practicing nephrology. There are real problems with this specialty and you are taking on considerable risk of investing 2 yrs of fellowship plus 3-4 yrs of getting payed a low salary to "maybe" make partner. And even if you do, you are making middle of the pack money for subspecialties. That's why its noncompetitive. From investing standpoint, it's a high risk, low to medium reward investment. Obviously, you much rather go into card/GI if you can get in.

 

[Renal_Prometheus]

I think nephrology is kind of a middle ground subspecialty. You have the higher paid subspecialties where there is a longer fellowship, more procedures (pro/con depending on the person), more acuity/calls/weekends. You then have the lower paid subspecialties but with less/no procedures, minimal acuity calls/weekends. Nephrology is in the middle where you have a shorter fellowship like endocrinology or rheumatology and not a lot of procedures (occasional vas cath insertion or perm cath removal at most), better pay, but can have busy consults, more acuity, more calls in the middle of the night.

The rise of hospital medicine probably drained out people who were on the fence between a fellowship like nephrology and just getting out and working. Nephrology makes more compared to hospital medicine, but it tends to need time to ramp up, a couple of years to build up patient load and time to grow into partnership in private practice for instance. Some people would rather just get out there and make the money now.

There are other thoughts. Sicker patients. Complex work. Minimal procedures. I personally think medical students and residents get very little early exposure to nephrology which hampers number of applicants later. Nephrology feels more like a black box compared to cardiology. Anecdotally, my home program's director has seen a lot of success continuing to fill my home program and increasing interesting (and applicant) number in nephrology for other programs as well.

There was also a time when the powers that be were doing the math and trying to guess-timate how many nephrologists we would need based on how many CKD patients there were and how many ESRD patients there would be. They overestimated the need. Programs could reduce the number of spots and tighten up the figures, but they just don't do it. Number of spots and number of applicants has remained fairly flat over the past few years.

I feel like I got a deal going into a 2-year fellowship of something I enjoy that was not very competitive and then doing well financially, but not everybody sees

Hows it going man. I've always wondered if you learned anything new about this specialty through your interactions with me.

 

[wanted101]

Hows it going man. I've always wondered if you learned anything new about this specialty through your interactions with me.

yes i definitely see what you're saying and appreciate the input.