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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 forward to today and this friend has left that job and is working as a hospitalist. So what happened? From my conversations with him, his partners actually didn’t lie to him, they just didn’t tell him he would make the same as them.
Let me give you 2 other examples of real life people. Names are erased for anonymity. I’ve been privy to their situation because we still communicate with each other to this day.
Friend A: This friend took a job in a large city with one of the dominant groups(20+ nephrologists in the group). Starting around 170k/year with partners making over 400k/year. Partners share in the JV(dialysis unit and access center) and dialysis billing, sounds very equitable on paper right? This group had no history of exploiting new grads and not making them partner. Sounds very fair, on paper. In the first year, he noticed something very wrong with distribution of hospital coverage. While the senior partners were stationed in large hospitals with large patient census, the new guy was given the task of “conquering new territory”. So basically he was driving to 6-7 hospitals/LTAC per day seeing 3-4 patients per place. He could never get a foothold in one place with large patient census. Very quickly, he realized that even if he made partner, his billing would never be at the same level as his partners. And since nephrology reimbursement is based on volume, it was just not worthwhile to keep doing this, so he quit. Since my friend left this group, they have hired couple of new grads and those have quit within 1-2 years as well. But when they recruit new fellows, they can say people quit on their own for “personal/family reasons.” It’s not because the group didn’t make them partner.
Friend B: This friend took a job in a medium sized city with the largest nephrology group in town(12 nephrologists). During recruitment, the senior partner told him that starting salary was 200k/year for 3 years, but that “he” personally took home over 500k/year as partner. Sounds great right? Wrong; my friend assumed that he would make the same once he made partnership and that was completely incorrect. Within couple of years, friend B realized that he was working significantly more and making less than a hospitalist on a per hr basis. What was the issue? About half of the income generated comes from joint venture investments in dialysis units. And while the senior partners kept the profitable units to themselves, they gave him the less profitable dialysis units to invest. So not only did this guy had to take out a huge loan to invest, his return on cash was “so so” at best. He was so sick of it at the end that he quit to take a hospitalist job. He’s currently making over 400k/year, working 22 days out of the month, and is much happier. The devil is in the details and new graduating fellows simply are not equipped to negotiate the complexities of nephrology practice revenue distribution.
I’m saying all this not to dissuade any applicant from applying to nephrology if they are truly interested. The problem I see today is that nobody is telling the applicant the downsides, which can cause severe career damage for those investing this many years to potentially be worse off than a hospitalist. Do you think that fellowship programs, so eager to get bodies for scut work, will tell you this? Or do think recruiting nephrology groups will tell you that joining their group is a “trap”. What’s unfortunate is that an applicant will look at the average nephrology salary online, and think it’s pretty good, and will go into the specialty based on that. What they don’t realize is that it’s average the of the “winners”, while the losers who have left the specialty are not included. There is a survivorship bias in the stats. I think most graduating fellows will give it a go at a nephrology job just based on sunken cost fallacy alone. But just because they joined a nephrology group, doesn’t mean they will remain a nephrologist long term. If you ask me, based on what I see and my personal experience, I would venture to guess that 30-50% of neph grads will leave this specialty within 5 years of graduation. Don’t be fooled when fellowship programs tell you 100% of their grads were successful in getting a neph job; they just won’t tell you what percent are still practicing nephrology. Best of luck to all future nephrologists!
Let me give you 2 other examples of real life people. Names are erased for anonymity. I’ve been privy to their situation because we still communicate with each other to this day.
Friend A: This friend took a job in a large city with one of the dominant groups(20+ nephrologists in the group). Starting around 170k/year with partners making over 400k/year. Partners share in the JV(dialysis unit and access center) and dialysis billing, sounds very equitable on paper right? This group had no history of exploiting new grads and not making them partner. Sounds very fair, on paper. In the first year, he noticed something very wrong with distribution of hospital coverage. While the senior partners were stationed in large hospitals with large patient census, the new guy was given the task of “conquering new territory”. So basically he was driving to 6-7 hospitals/LTAC per day seeing 3-4 patients per place. He could never get a foothold in one place with large patient census. Very quickly, he realized that even if he made partner, his billing would never be at the same level as his partners. And since nephrology reimbursement is based on volume, it was just not worthwhile to keep doing this, so he quit. Since my friend left this group, they have hired couple of new grads and those have quit within 1-2 years as well. But when they recruit new fellows, they can say people quit on their own for “personal/family reasons.” It’s not because the group didn’t make them partner.
Friend B: This friend took a job in a medium sized city with the largest nephrology group in town(12 nephrologists). During recruitment, the senior partner told him that starting salary was 200k/year for 3 years, but that “he” personally took home over 500k/year as partner. Sounds great right? Wrong; my friend assumed that he would make the same once he made partnership and that was completely incorrect. Within couple of years, friend B realized that he was working significantly more and making less than a hospitalist on a per hr basis. What was the issue? About half of the income generated comes from joint venture investments in dialysis units. And while the senior partners kept the profitable units to themselves, they gave him the less profitable dialysis units to invest. So not only did this guy had to take out a huge loan to invest, his return on cash was “so so” at best. He was so sick of it at the end that he quit to take a hospitalist job. He’s currently making over 400k/year, working 22 days out of the month, and is much happier. The devil is in the details and new graduating fellows simply are not equipped to negotiate the complexities of nephrology practice revenue distribution.
I’m saying all this not to dissuade any applicant from applying to nephrology if they are truly interested. The problem I see today is that nobody is telling the applicant the downsides, which can cause severe career damage for those investing this many years to potentially be worse off than a hospitalist. Do you think that fellowship programs, so eager to get bodies for scut work, will tell you this? Or do think recruiting nephrology groups will tell you that joining their group is a “trap”. What’s unfortunate is that an applicant will look at the average nephrology salary online, and think it’s pretty good, and will go into the specialty based on that. What they don’t realize is that it’s average the of the “winners”, while the losers who have left the specialty are not included. There is a survivorship bias in the stats. I think most graduating fellows will give it a go at a nephrology job just based on sunken cost fallacy alone. But just because they joined a nephrology group, doesn’t mean they will remain a nephrologist long term. If you ask me, based on what I see and my personal experience, I would venture to guess that 30-50% of neph grads will leave this specialty within 5 years of graduation. Don’t be fooled when fellowship programs tell you 100% of their grads were successful in getting a neph job; they just won’t tell you what percent are still practicing nephrology. Best of luck to all future nephrologists!