Nephrology fellowship after 17 years of hospitalist work ?

[Docmel52]

I have been a hospitalist ( nocturnist) for 17 years ( nocturnist for last 9)
My pay hasn’t increased in about 7 years. I work 10 nights in a month. 14 hour night shift each, so essentially one night is equal to one and half days !

I do get to spend a lot of time at home with my kids, something I greatly cherish .

Now I have been thinking of applying . There are some positions unfilled in the area. First I am not sure if they will take me being so old. Second, not sure if it’s financially right idea. I will lose 2 years of income . Not sure what the pay structure for nephrologists is in Chicagoland .

I will certainly feel good about having done a fellowship , and probably gain more respect in my field than “dumping grounds” aka hospitalists.

I also feel I can’t continue hospitalist in old age. 10-20 years from now. But having a private practice with nephrology , could continue .

Please share your thoughts.

I have heard how dead it is, pay is low just like hospitalists, but I see nephrologists who are very rich. My sister is in Texas and she makes more than me. She isn’t even in private practice.

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[chessknt]

No.

Nephrology is Dead - stay away

I did my fellowship with great interest in Nephrology - Acid base/electrolyte/Acute dialysis stuff. Joined a private practice - get around 170 K. my day starts at 6 and ends at 5. run around 4 hospitals and 3 dialysis units. Real life of nephrology - Oversupply - tremendous oversupply - so...

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[Nocturnist]

I have been a hospitalist ( nocturnist) for 17 years ( nocturnist for last 9)
My pay hasn’t increased in about 7 years. I work 10 nights in a month. 14 hour night shift each, so essentially one night is equal to one and half days !

I do get to spend a lot of time at home with my kids, something I greatly cherish .

Now I have been thinking of applying . There are some positions unfilled in the area. First I am not sure if they will take me being so old. Second, not sure if it’s financially right idea. I will lose 2 years of income . Not sure what the pay structure for nephrologists is in Chicagoland .

I will certainly feel good about having done a fellowship , and probably gain more respect in my field than “dumping grounds” aka hospitalists.

I also feel I can’t continue hospitalist in old age. 10-20 years from now. But having a private practice with nephrology , could continue .

Please share your thoughts.

I have heard how dead it is, pay is low just like hospitalists, but I see nephrologists who are very rich. My sister is in Texas and she makes more than me. She isn’t even in private practice.

Mind sharing how much you make?
I also haven't gotten a substantial raise in 7 years. My group finally promised to get us a raise this year. I'll believe it when I see it. That said, our bonus structure has been restructured in our favor so I've seen higher bonuses each year. My base for 10 twelve hour shifts plus bonuses would be somewhere in the low-mid 300s, but it hasn't been difficult to moonlight my way to the mid-high 500s each year.

I call the nephrologist our honorary nocturnist because he's always here dictating consults sometimes past midnight. He's at the hospital every single night. He finally found someone to cover for him a weekend or two a month. He has to work in multiple practices and hop between several hospitals on a daily basis to pull a living together.

When I was in training 8-10 years ago, you literally couldn't give nephrology fellowship spots away. I dont think the field's attractiveness has changed much since.

Especially since you're older and looking at a 2 year opportunity cost in a field that generally doesn't pay better than nocturnist, it's likely to be a terrible financial decision. I don't think you're lifestyle or hours will be any better either based on my observation of nephrologists I've come across. Much more sustainable to go to days or cut your shift commitment.

 

[NewYorkDoctors]

I knew someone who was a hospitalist for 20 years. did a scramble fellowship (easier than just going interview...) into a renal fellowship
why? he had lotsa nephrology friends who would arrange for him to buy into a JV at a local center.
that is the key piece. if you have that connection then sure go for it.
he is doing mixed GIM + nephrology + has a small HD panel within walking distance / driving distance of his office and stopped doing hospitalist.
he seems to be happy.

but this example is one of the three examples I provide that nephrology is a good idea from the Neph is Dead thread
1) you love nephrology the discipline and are perfectly fine doing academic nephrology for your whole career
2) you have friends/connections to get JVs into HD center and your friends/family will treat you equitably
3) go private independently and do GIM + renal minus chronic HD (find a colleague who has the HD privileges to take over once the patient has an AV fistula created and needs to start)

if you do not fit these, then you're gambling with your career. sure you might find some nice job in California for a large employer like Kaiser. Have a decent workload and a lower salary than hospitalist but you might be happy with call q8 or something.
you might find a terrible predatory job.
one is gambling in this case

 

[Calizboosted76]

Mind sharing how much you make?
I also haven't gotten a substantial raise in 7 years. My group finally promised to get us a raise this year. I'll believe it when I see it. That said, our bonus structure has been restructured in our favor so I've seen higher bonuses each year. My base for 10 twelve hour shifts plus bonuses would be somewhere in the low-mid 300s, but it hasn't been difficult to moonlight my way to the mid-high 500s each year.

I call the nephrologist our honorary nocturnist because he's always here dictating consults sometimes past midnight. He's at the hospital every single night. He finally found someone to cover for him a weekend or two a month. He has to work in multiple practices and hop between several hospitals on a daily basis to pull a living together.

When I was in training 8-10 years ago, you literally couldn't give nephrology fellowship spots away. I dont think the field's attractiveness has changed much since.

Especially since you're older and looking at a 2 year opportunity cost in a field that generally doesn't pay better than nocturnist, it's likely to be a terrible financial decision. I don't think you're lifestyle or hours will be any better either based on my observation of nephrologists I've come across. Much more sustainable to go to days or cut your shift commitment.

How much are you working to get to that mid 500? Also what location?

 

[Nocturnist]

How much are you working to get to that mid 500? Also what location?

Northeast.

Previously, 18-20 shifts a month.
Since having kids, 12-14 shifts a month plus a combination of bonuses, remote shifts, and short admitting shifts after kids go to bed. Average probably 45-50 hours a week.

 

[Calizboosted76]

Northeast.

Previously, 18-20 shifts a month.
Since having kids, 12-14 shifts a month plus a combination of bonuses, remote shifts, and short admitting shifts after kids go to bed. Average probably 45-50 hours a week.

How late do you short admitting shifts go for? Also how do the remote shifts work? This would be ideal. I am weary about hospitalist med due to the low earning potential everyone talks about.

 

[Nocturnist]

How late do you short admitting shifts go for? Also how do the remote shifts work? This would be ideal. I am weary about hospitalist med due to the low earning potential everyone talks about.

Short admitting shifts= I go in whenever I want and get paid by the admission. Pretty much a blank check. I sign them out and leave as soon as I'm done. Because I get paid per admission and I'm pretty efficient, it's fantastic money per hour. Generally in a couple hours of work I'll make $1000 or 4 hours for 2k. It's nice to be able to put my kids to bed, spend a couple hours with my SO, go make a grand or two and still be back home before midnight.

Remote shifts generally mean remote cross coverage, but I can also do results that need followed up on or even remote admitting. Remote work is generally evening and overnight hours, pretty much whatever hours I say I can work.

Not sure what you've heard or what the earning potential youre wary of exactly, but no day hospitalist in my group makes less than 300k and no nocturnist makes less than 400k. Also keep in mind the opportunity cost of further training.

 

[Calizboosted76]

Short admitting shifts= I go in whenever I want and get paid by the admission. Pretty much a blank check. I sign them out and leave as soon as I'm done. Because I get paid per admission and I'm pretty efficient, it's fantastic money per hour. Generally in a couple hours of work I'll make $1000 or 4 hours for 2k. It's nice to be able to put my kids to bed, spend a couple hours with my SO, go make a grand or two and still be back home before midnight.

Remote shifts generally mean remote cross coverage, but I can also do results that need followed up on or even remote admitting. Remote work is generally evening and overnight hours, pretty much whatever hours I say I can work.

Not sure what you've heard or what the earning potential youre wary of exactly, but no day hospitalist in my group makes less than 300k and no nocturnist makes less than 400k. Also keep in mind the opportunity cost of further training.

How common are job set up like this?

Also from the people I have spoke to in the SE are lucky to be making $300k doing 7/7. I thought before that HM was a hidden gem but some people have got me a little worried.

How is the schedule with family life?

 

[TaroBubbleTea]

Maybe you just need to find a new job

 

[InternistDO]

How common are job set up like this?

Also from the people I have spoke to in the SE are lucky to be making $300k doing 7/7. I thought before that HM was a hidden gem but some people have got me a little worried.

How is the schedule with family life?

There are more than 44,000 hospitalists in the US, I think it's well past hidden gem territory

 

[dozitgetchahi]

Maybe you just need to find a new job

That was my first thought too?

Lotsa hospitalist jobs out there in lotsa places. You could almost certainly find something better than this, even in the Chicagoland area?

Going from hospitalist work to nephrology is like diving out of the oven into the nuclear meltdown. Pay is likely to be worse, lifestyle worse, and oddly enough you may still find yourself doing a lot of hospitalist work to make ends meet anyway.

If I wanted to do an easy, straightforward fellowship to get out of hospital medicine…palliative care is only a year iirc, and the lifestyle is good. Or even sleep medicine. But not nephrology, dear god.

 

[LoudBark]

I will certainly feel good about having done a fellowship , and probably gain more respect in my field than “dumping grounds” aka hospitalists.

You may be disappointed when you find you are not feeling good on the inside from doing a nephrology fellowship.......and no one is bowing down to you with immense respect once you become a nephrologist. Those quite honestly do not seem like legitimate reasons to do a nephrology fellowship and seem more like lack of self esteem being a hospitalist and how you feel others perceive you.

 

[Test Boy]

You may be disappointed when you find you are not feeling good on the inside from doing a nephrology fellowship.......and no one is bowing down to you with immense respect once you become a nephrologist. Those quite honestly do not seem like legitimate reasons to do a nephrology fellowship and seem more like lack of self esteem being a hospitalist and how you feel others perceive you.

The increase in respect will be minimal, if any. You should post this in the nephrology subgroup but I’m sure they will say you’re out of your mind to even consider this.

 

[NewYorkDoctors]

to the OP, you can do the fellowship and get more knowledge and feel "smarter" on the inside.

but the best way to get respect from your patients is to open your own private practice and treat them well
the best way to get self esteem is to open your own private practice , treat your patients well, be the boss/administrator, and make some bank.

this is easier to open as GIM than nephrology

just remember a "standard nephrologist" who works as employed physician is the b***h for the dialysis industrial complex and hospital administrators.

as an academic you have the respect of residents, students, fellows, and internists.

but outside of that, there is no reason to do private practice nephrology unless you have connections to get you JV into a dialysis center and be treated equitably by family/friend nephrologist.

Addendum: if you peruse one of my posts in the neph is dead thread from november 2023, I was detailing how "i put my brain to work" for an outpatient office AKI case. took me over an hour not ot mention all the talking and reassurance and doing things myself.... I mentioned which billing codes I used which pales in comparison to what GIM could have churned out in a 99213 mill with.
again it's not all the money. but the revenue / effort ratio.

 

[Splenda88]

All I am going to say is that: Lol

I am a hospitalist and our PD is a nephrologist that practiced nephrology for > 20 yrs. Always says in every monthly meeting how much he LOVES being a hospitalist.

 

[Splenda88]

How common are job set up like this?

Also from the people I have spoke to in the SE are lucky to be making $300k doing 7/7. I thought before that HM was a hidden gem but some people have got me a little worried.

How is the schedule with family life?

It's not a hidden gem anymore since everyone knows it. Even FM graduating residents are doing HM these days.

There are ~ 4 hospitalists at my shop that think hospital medicine is the best job there is

We have long and short calls (3 short and 4 long). No admissions when you are on short calls. One particular hospitalist usually leaves by 12:30 pm during short calls.

When she is on long calls (she has to admit) she would still go home ~1pm. She will place the admissions orders at home when she got admits (usually 2) and returns to the hospital around 6pm to see them and go back home.

I was talking to her the other day and asked her how many hours she thinks she work every other week and her reply was 50-55 hrs.

Hospital medicine can be a good job for people who don't mind to break the rules.

I am in the SE and I made 405k in 2022 and 401k last year. That's arguably one the best physician gigs for family according to my spouse who is a SAHM. I am home between 1:30-3pm on short call days and ~6:20 pm on long call. I have 7 days off in a row if I don't want to work extra.

A few at my shop would go to their kids activities for ~2 hours while on the clock. I am not aware of that many physician jobs that one can do that.

 

[NewYorkDoctors]

All I am going to say is that: Lol

I am a hospitalist and our PD is a nephrologist that practiced nephrology for > 20 yrs. Always says in every monthly meeting how much he LOVES being a hospitalist.

Nephrology the subspecialty, the medical discipline, the physiology, the pathology, the innovation, all that fluff... is great!

The business aspect of nephrology if you are pay-walled against having your own HD panel and JVs into an HD center is absolutely disastrous for a young physician. No other subspecialty (or specialty) has the same kind of onerous barriers or "buy in requirements" as being a 'traditional' nephrologist has.

back in the Mercedes 80s when HD units were money printing machines and before the 2011 bundled payments, this form of "serfdom" was tolerable because you bought in to be part of something great

why are there such onerous barriers to being a successful doctor in place for such a low paying and hard working piece of junk?

PCPs who run 99213 mills make more than "traditional nephrologists" and without the burden of seeing such complex and difficult patients. plus they dont have to travel from center to center.


doing non-academic nephrology these days is "paying more and getting less."

don't know why anyone would want to do that.

as in the Neph is Dead thread, anyone can do a renal fellowship to get the knowledeg and be a better doctor. jsut don't actually do private practice nephrology. Go full academic, do the fellowship then mix it with GIM, or stay away it's dead.

 

[glorifiedresident]

I think I might have one of the best hospitalist gigs out there--
Average of 10 patients rounding a day, no admissions on rounding shifts. I usually leave by 1:30 (cover cross cover issues until 4PM)
no mandatory nights
It is not unusual for us to have a single digit census when rounding due to good staffing.
I have been doing hospitalist for almost 20 years, it was a great decision and I'm glad I chose it.
The only thing is that there are a wide variety of hospitalist jobs, and many of them just sound awful.
I make mid 300's with very generous benefits.
I think if you find a good hospitalist job it's hard to beat.
The best part of being a hospitalist is the freedom to structure my day the way I see fit. If I had to go to the clinic, I would retire.

 

[Splenda88]

The best part of being a hospitalist is the freedom to structure my day the way I see fit. If I had to go to the clinic, I would retire.

I could not put it any better.

 

[dozitgetchahi]

Nephrology the subspecialty, the medical discipline, the physiology, the pathology, the innovation, all that fluff... is great!

The business aspect of nephrology if you are pay-walled against having your own HD panel and JVs into an HD center is absolutely disastrous for a young physician. No other subspecialty (or specialty) has the same kind of onerous barriers or "buy in requirements" as being a 'traditional' nephrologist has.

back in the Mercedes 80s when HD units were money printing machines and before the 2011 bundled payments, this form of "serfdom" was tolerable because you bought in to be part of something great

why are there such onerous barriers to being a successful doctor in place for such a low paying and hard working piece of junk?

PCPs who run 99213 mills make more than "traditional nephrologists" and without the burden of seeing such complex and difficult patients. plus they dont have to travel from center to center.


doing non-academic nephrology these days is "paying more and getting less."

don't know why anyone would want to do that.

as in the Neph is Dead thread, anyone can do a renal fellowship to get the knowledeg and be a better doctor. jsut don't actually do private practice nephrology. Go full academic, do the fellowship then mix it with GIM, or stay away it's dead.

I don’t even know that I’d say the actual “specialty of nephrology” is that exciting.

- With regards to the technology - my impression from renal rotations as a resident (someone correct me if I’m wrong) is that the specialty is basically stagnating. Most of the “innovation” in dialysis seems to have happened in the mid to late 20th century at best…I didn’t hear anything about some great new dialysis options on the horizon, or some tremendous new way to treat typical CKD from HTN and diabetes, etc etc. Renal transplantation is great and all, but there are way fewer kidneys out there than people who need them.

- It’s monotonous. Rounding on 30 patients in the hospital, many of which the hospitalist consulted you for an SCr of 1.5, just felt like a waste of time and brainpower.

- A lot of nephrologists are just…pedantic. I’ve shared here before how during one of my renal rotations, I witnessed a fellow and an attending argue passionately for 15 min about whether to use 1/4 NS or 1/2 NS in a specific patient…even for someone who became a rheumatologist (a specialty often known for its mental masturbation), that just struck me as a ridiculous waste of time. And there is a lot of that sort of pedantic tomfoolery in renal. Give fluids, subtract fluids. How much Lasix should I give? Take off 1250cc of fluid on his dialysis, not 1000! Blah.

- The dialysis ward is frankly one of the most depressing and unpleasant places to be in the hospital…rounding on a bunch of miserable grocked out people hooked up to dialysis machines was probably the least appealing aspect of residency, aside from overnight call.

Mix all of this in with the lousy lifestyle, declining pay, and fact that young renal docs are getting exploited by the rich boomer nephrologists that came before them (what else is new), and I think it’s a miracle they match anyone to the specialty whatsoever.

 

[sloh]

I think I might have one of the best hospitalist gigs out there--
Average of 10 patients rounding a day, no admissions on rounding shifts. I usually leave by 1:30 (cover cross cover issues until 4PM)
no mandatory nights
It is not unusual for us to have a single digit census when rounding due to good staffing.
I have been doing hospitalist for almost 20 years, it was a great decision and I'm glad I chose it.
The only thing is that there are a wide variety of hospitalist jobs, and many of them just sound awful.
I make mid 300's with very generous benefits.
I think if you find a good hospitalist job it's hard to beat.
The best part of being a hospitalist is the freedom to structure my day the way I see fit. If I had to go to the clinic, I would retire.

Where do you live?

 

[Splenda88]

@sloh

That poster has a unicorn job in term of patient's load and salary for that kind of patient's load,.

In term of structuring your day the way you want, many (or even most) hospitalist jobs give you that kind of control.

For instance, one of my co-workers today saw another co-worker who was supposed to be at work getting her nails done at a beauty salon.

 

[glorifiedresident]

Nor cal.

 

[AlbinoHawk DO]

I wouldn't do tit for nephrology. Most fellowships are extremely busy and the life after simply sucks. Yes, you might not be able to do the hospitalist gig in 20 years, but you certainly can do outpatient PCP work. If you'd still like a fellowship, I'd look into sleep medicine or another 1 year fellowship to get done and move on

 

[NewYorkDoctors]

if anyone wants the "honor" of having a second specialty, consider doing the CME course pathway for the Obesity Medicine
money sink? yes.
but it will give one the "honor" of having another specialty at far lower opportunity cost than doing nephrology

 

[chessknt]

if anyone wants the "honor" of having a second specialty, consider doing the CME course pathway for the Obesity Medicine
money sink? yes.
but it will give one the "honor" of having another specialty at far lower opportunity cost than doing nephrology

And you can introduce yourself as a fat people doctor.

 

[Prehealth1011]

Nor cal.

Is mid 300s “enough” in Northern California? To buy a decent house etc.

 

[NewYorkDoctors]

And you can introduce yourself as a fat people doctor.

I did it so I can get some more insight into treating obesity hypoventilation, obesity restrictive lung disease, OSA..

the local PCPs are not worth a penny or more regarding obesity management.
CPET proven deconditioning and restrictive lung disease due to obesity
no evidence of PH on CPET or TTE
Cardiologist also confirmed no cardiac dyspnea present

follow up PCP for weight management

the PCP keeps sending the patients back to me for "dyspnea."
if I turn them away, they end up getting antibiotics, prednisone, mulitple overlapping inhalers causing polypharmacy (which the pharmacy gleefully bills for them all.... shady mom and pop pharmacies) and other "things" by the PCP... and CTPAs and multiple nuclear stress tests ..... so i figure nah ill take care of it.

if they are diabetic I recommend PCP put them on SGLT2 and GLP1. if PCP does not do this, I end up doing it.... I over see a primary care practice as well (led by an Internist and PAs) so i'm totally at ease doing primary care.

but the biggest thing is I get the patient to start exercising.
I tell them about eating protein first, then fats, then carbs (there is data on this)
i give them pedometers and then get them onto a step challenge. I inform them stay at home and walk in place in your home in circles while watching TV or hold your sofa while standing and walk in place. get those steps up!
i dont push a specific macronutrient diet unless the patient wants it

whenever a patient asks about some fad diet or "herbal therapies to increase metabolism" I ask them how many people who have taken these things that you know of work? best way to increase metabolism and "get good genetics" is to get moving. i know it's hard with your obesity , restrictive lung disease, and OSA but I have demonstrated it is safe todo so. you gotta get over that hump!

"motivational interviewing" like they say in the academic primary care practices (aka hand holding make excuses for patients practices)

i don't do anything crazy like leptin infusions (some data exists for those with leptin deficiency but does not seem to work in leptin resistance)... i would have no idea how to even get that unless they are part of a clinical research trial at Rockefeller or something.


for those patients who "get with my basic step count program" some of them have lost 10% BW and their CPAP treatment reports does show improvement in residual AHI and they just get better with their restrictive lung disease.

if tried for 6 months and not better, I refer to the local baritriac at tertiary care center. most patients balk at this actually

 

[thumbz]

I couldn't fathom doing a fellowship after working as a hospitalist. To go back into the grind to become a nephrologist sounds like the absolute worst life to me. I told Splenda I would try to post more in these threads to people know there are baller HM docs out there, that the sky isn't falling, and that you don't need to kill yourself in HM. However, you do need to be picky. If you signed a contract to work 184 12's for $285k in Denver that's on you and it's the sacrifice you need to make to get to live in Denver.

Now I will admit that in 2018, inflation adjusted, I made $20k/yr more than I make now. That part does suck, but my hospital went from being flush with cash to running net revenue negative since 2021 so that did significantly hurt our negotiations. I am LCOL midwest.

My primary job is teaching - I make $355k/yr for working 150 12's. I'm usually in house 8-5pm, but the residents do everything. It's the best job on the planet.

I moonlight internally with the nonteaching group. I just finished a stretch, average list was 14, by day 4 I was done at 1030 AM with rounding/notes, I was done with everything by 1230 and could have left. (My longest day took until 230pm). But! This group hasn't set themself up in any favorable way, so you can't round and go. "Expectation" is you stay til 5, no one knows where the expectation came from. And because of it they can't keep docs to save their lives. Hence the internal moonlighting. It pays $2k/shift. My group is trying to change that culture - they have 2 swings who come in at 2pm, there's no reason you shouldn't be able to go when they come in. Oh - and closed ICU, no procedures (in my teaching gig we do the procedures). So as Splenda said, find a group where you can "break the rules" by covering for eachother.

That said, I don't mind not being able to go home. I wander around the hospital and shoot the **** with people and really treat it like a social hour. I have a great work life balance, and in 2024 I'll gross somewhere between $450k and $475k. My hospital also tosses $30k into our 401k, so my goal for 2024 is to break $500k in "total comp". For any med students reading this, my take home pay is 56% of my gross. Taxes suck. Deductions suck. I've posted a breakdown before because I was that med student who didn't understand taxes and thought a $400k income would make me $30k take home/month.

To everyone reading this - I didn't go into HM thinking I would EVER make money like this. I wasn't a baller doc, and never intended to work myself to death to make money. But right now I literally look forward to going into work, so I figure make hay while the sun in shining. The take away is I'm not busting my balls to make this kind of money. Our nephrologists work WAYYYY more than I do to make less money. Shoot I work fewer hours than our non-interventional cards and almost make what they make (I count their overnight calls as hours given they average 1-2 pages/hour).

 

[Splenda88]

@NewYorkDoctors

I don't like criticizing PCPs because I think they have a difficult job and most of the patients don't listen to them anyway. However, when it comes to obesity, I think they have failed a lot of their patients.

A few of them in town that I am friend with, I usually call them to let them know they should try to help these obese patients when I am taking care of such patients in the hospital.

Another thing that drives me crazy is the 75-85 y/o with A1C of 6-7 on metformin and sulfonylureas coming to the hospital with hypoglycemia.

 

[NewYorkDoctors]

I couldn't fathom doing a fellowship after working as a hospitalist. To go back into the grind to become a nephrologist sounds like the absolute worst life to me. I told Splenda I would try to post more in these threads to people know there are baller HM docs out there, that the sky isn't falling, and that you don't need to kill yourself in HM. However, you do need to be picky. If you signed a contract to work 184 12's for $285k in Denver that's on you and it's the sacrifice you need to make to get to live in Denver.

Now I will admit that in 2018, inflation adjusted, I made $20k/yr more than I make now. That part does suck, but my hospital went from being flush with cash to running net revenue negative since 2021 so that did significantly hurt our negotiations. I am LCOL midwest.

My primary job is teaching - I make $355k/yr for working 150 12's. I'm usually in house 8-5pm, but the residents do everything. It's the best job on the planet.

I moonlight internally with the nonteaching group. I just finished a stretch, average list was 14, by day 4 I was done at 1030 AM with rounding/notes, I was done with everything by 1230 and could have left. (My longest day took until 230pm). But! This group hasn't set themself up in any favorable way, so you can't round and go. "Expectation" is you stay til 5, no one knows where the expectation came from. And because of it they can't keep docs to save their lives. Hence the internal moonlighting. It pays $2k/shift. My group is trying to change that culture - they have 2 swings who come in at 2pm, there's no reason you shouldn't be able to go when they come in. Oh - and closed ICU, no procedures (in my teaching gig we do the procedures). So as Splenda said, find a group where you can "break the rules" by covering for eachother.

That said, I don't mind not being able to go home. I wander around the hospital and shoot the **** with people and really treat it like a social hour. I have a great work life balance, and in 2024 I'll gross somewhere between $450k and $475k. My hospital also tosses $30k into our 401k, so my goal for 2024 is to break $500k in "total comp". For any med students reading this, my take home pay is 56% of my gross. Taxes suck. Deductions suck. I've posted a breakdown before because I was that med student who didn't understand taxes and thought a $400k income would make me $30k take home/month.

To everyone reading this - I didn't go into HM thinking I would EVER make money like this. I wasn't a baller doc, and never intended to work myself to death to make money. But right now I literally look forward to going into work, so I figure make hay while the sun in shining. The take away is I'm not busting my balls to make this kind of money. Our nephrologists work WAYYYY more than I do to make less money. Shoot I work fewer hours than our non-interventional cards and almost make what they make (I count their overnight calls as hours given they average 1-2 pages/hour).

QFT

honestly the ceiling to make those 7 figures in IM subspecialties is really dependent on a few factors that not every doctor can achieve
A) very high referral volume - usually only possible in a large urban area
+
B) negotiating top rates with the insurance companies which usually requires being part of a large independent practice association to negotiate the best rates
+
C) being very entrepreneurial and putting up a lot of up front costs to run a business
+
D) working close to 80 hours a week (not patient face to face but also business and admin stuff)

short of doing that, HM really is a great mix of lifestyle and revenue/effort.
though if someone wants to live in NYC, HM does not have those things. but if you are willing to move elsewhere, life can be great.

 

[NewYorkDoctors]

@NewYorkDoctors

I don't like criticizing PCPs because I think they have a difficult job and most of the patients don't listen to them anyway. However, when it comes to obesity, I think they have failed a lot of their patients.

A few of them in town that I am friend with, I usually call them to let them know they should try to help these obese patients when I am taking care of such patients in the hospital.

Another thing that drives me crazy is the 75-85 y/o with A1C of 6-7 on metformin and sulfonylureas coming to the hospital with hypoglycemia.

I hear you

I am not saying all PCPs are bad. some really are bad... the older ones who run a mill and don't do any management besides refer out and not send me labs / imaging / reports etc.... send a patient with a blank slate to me. the ones who give benzos and ambien like candy. the ones who give zpaks like candy. the ones who prescribe polypharmacy and never reconcile a med list or cancel prior meds not needed....

the younger ones who actually read MKSAP and actually did training in residency for primary care actually are very good and set proper expectations for patients. I never expect PCPs to fix all problems. they are too busy for that. I expect them not to gaslight patients ahead of referring them to me. i usually just take full ownership of several of the issues I am managing and inform patient do not bother your PCP about this... come to me.

i dont know how it is in other parts of the country. but in NYC for medicare and medicaid (and managed variants), there is no reason to be using sulfonylureas anymore as its very easy to get SLGT 2 inihibits and GLP1 agonists as second line therapy

 

[Calizboosted76]

I couldn't fathom doing a fellowship after working as a hospitalist. To go back into the grind to become a nephrologist sounds like the absolute worst life to me. I told Splenda I would try to post more in these threads to people know there are baller HM docs out there, that the sky isn't falling, and that you don't need to kill yourself in HM. However, you do need to be picky. If you signed a contract to work 184 12's for $285k in Denver that's on you and it's the sacrifice you need to make to get to live in Denver.

Now I will admit that in 2018, inflation adjusted, I made $20k/yr more than I make now. That part does suck, but my hospital went from being flush with cash to running net revenue negative since 2021 so that did significantly hurt our negotiations. I am LCOL midwest.

My primary job is teaching - I make $355k/yr for working 150 12's. I'm usually in house 8-5pm, but the residents do everything. It's the best job on the planet.

I moonlight internally with the nonteaching group. I just finished a stretch, average list was 14, by day 4 I was done at 1030 AM with rounding/notes, I was done with everything by 1230 and could have left. (My longest day took until 230pm). But! This group hasn't set themself up in any favorable way, so you can't round and go. "Expectation" is you stay til 5, no one knows where the expectation came from. And because of it they can't keep docs to save their lives. Hence the internal moonlighting. It pays $2k/shift. My group is trying to change that culture - they have 2 swings who come in at 2pm, there's no reason you shouldn't be able to go when they come in. Oh - and closed ICU, no procedures (in my teaching gig we do the procedures). So as Splenda said, find a group where you can "break the rules" by covering for eachother.

That said, I don't mind not being able to go home. I wander around the hospital and shoot the **** with people and really treat it like a social hour. I have a great work life balance, and in 2024 I'll gross somewhere between $450k and $475k. My hospital also tosses $30k into our 401k, so my goal for 2024 is to break $500k in "total comp". For any med students reading this, my take home pay is 56% of my gross. Taxes suck. Deductions suck. I've posted a breakdown before because I was that med student who didn't understand taxes and thought a $400k income would make me $30k take home/month.

To everyone reading this - I didn't go into HM thinking I would EVER make money like this. I wasn't a baller doc, and never intended to work myself to death to make money. But right now I literally look forward to going into work, so I figure make hay while the sun in shining. The take away is I'm not busting my balls to make this kind of money. Our nephrologists work WAYYYY more than I do to make less money. Shoot I work fewer hours than our non-interventional cards and almost make what they make (I count their overnight calls as hours given they average 1-2 pages/hour).

This makes me sick.

Now question. Is take home excluding 401k and otehr retirement investments? Or do you have to do that out of your ~ $260k?

 

[NewYorkDoctors]

anyway to go back to the OP's question

read the entire Neph is Dead thread.

the only potential reasons why it would make any sense (not just monetary but lifestyle wise) for you to do a Nephrology fellowship would be
A) you want to get into academics
B) you have family / friend connections to get you a JV into an HD center. if you can get this revenue stream going then yes it is worth it as your ceiling has just potentially risen above HM.
C) you plan to open GIM practice and you wish to piggy back some nephrology +/- HD onto it to expand patient base early on

If you do not have B or C, it's not clear how your ceiling can rise above H/M. you want total income as well as the revenue / effort ratio both to go in your favor

if you wanted to go into it and try your luck in the private practice market without ensuring the cards are in your favor and want to "try your luck"... you will waste years of your life.

the biggest issue with nephorlogy is no CPT billing codes one can use independently like a cardiologist (biling echos nucs stress in office), GI (billing scopes in office), pulmoanry (billing PFTs/CPETs/CPAPs etc... in office), heme onc (billing infusion in office), rheum (billing MSK U/S, injections, arthocentesis, infusions in office), etc...

nephrology's extra billing comes from HD and there are a lot of barriers to getting that going. see entire Neph is dead thread.

 

[thumbz]

This makes me sick.

Now question. Is take home excluding 401k and otehr retirement investments? Or do you have to do that out of your ~ $260k?

Thankfully the $260k is the "this is what lands in my bank account and gets spent on shiny ****" - The 401k/HSA is lumped into that 44% that also includes taxes, FICA, Medicare, health insurance, employer disability, etc.

 

[Splenda88]

@thumbz

I was set in doing an ID fellowship, but an ID physician suggested to do HM first and if I dont like it, I can go back doing ID since it's not competitive

My first 3 months on the job as hospitalist, I said to myself I must be missing something because people in SDN said HM is bad, why is my gig ok. Then I talked to former co-residents and only 1 did not like her job.

Things have not changed after 2+ yrs and that co-resident who did not like her job now is working at another place and she loves it because she is usually out between 1-3pm she told me.

 

[Nocturnist]

This makes me sick.

Now question. Is take home excluding 401k and otehr retirement investments? Or do you have to do that out of your ~ $260k?

Deductions include all pretax retirement contributions. In my case I max out a 403 and a 457 for a total of 46k per year. I dont look it that as lost money, only as very illiquid net worth that comes back to me without getting taxed yet.

anyway to go back to the OP's question

The OP abandoned their own thread. Has been MIA for over a week. Why do we owe them any more answers/why can't we take it whichever direction we want to?

 

[NewYorkDoctors]

Deductions include all pretax retirement contributions. In my case I max out a 403 and a 457 for a total of 46k per year. I dont look it that as lost money, only as very illiquid net worth that comes back to me without getting taxed yet.

The OP abandoned their own thread. Has been MIA for over a week. Why do we owe them any more answers/why can't we take it whichever direction we want to?

i just wanted to get in some nephrology digs.

 

[Calizboosted76]

Deductions include all pretax retirement contributions. In my case I max out a 403 and a 457 for a total of 46k per year. I dont look it that as lost money, only as very illiquid net worth that comes back to me without getting taxed yet.

The OP abandoned their own thread. Has been MIA for over a week. Why do we owe them any more answers/why can't we take it whichever direction we want to?

Is your take home comparable? I know money shouldnt matter but I really like 2 specialties similarly and the pay is really the only aspect keeping me from going all in on HM. I see horror stories about some Hospitalists grossing under 300k and it freaks me out lol.

 

[Nocturnist]

Is your take home comparable? I know money shouldnt matter but I really like 2 specialties similarly and the pay is really the only aspect keeping me from going all in on HM. I see horror stories about some Hospitalists grossing under 300k and it freaks me out lol.

Your gross pay has nothing to do with your specialty. It's a function of your pretax deductions, state/ federal taxes, and social security/medicaid. Depending on your state taxes, your take home can vary by upto 13%.
My net pay in January is 51% of my gross. By the time I max out my ssdi and retirement later in the year my take home is around 61%. I'd have to look at my paystubs and do some math but 56% average sounds about right.

Again it has nothing to do with specialty and nobody talks about net pay because it's so individual.

 

[Meerkatology]

is there any reason why nephro is so dead?

if it was that bad wouldnt they just revert to working as a hospitalist since they are licensed for it anyway.
i cant imagine doing fellowship to be paid less + having to maintain 2 certifications

 

[sloh]

is there any reason why nephro is so dead?

if it was that bad wouldnt they just revert to working as a hospitalist since they are licensed for it anyway.
i cant imagine doing fellowship to be paid less + having to maintain 2 certifications

Sunk cost fallacy is real

 

[rokshana]

is there any reason why nephro is so dead?

if it was that bad wouldnt they just revert to working as a hospitalist since they are licensed for it anyway.
i cant imagine doing fellowship to be paid less + having to maintain 2 certifications

Money… and the amount of work to make it…
More established nephros made their money owning dialysis centers… now that doesn’t happen.
Decreased reimbursement for HD pts…

Eh… depends… endocrine is lower paying in the IM specialties, but I like the topic and couldn’t see myself doing outpt PCP work… maybe would have stayed as a hospitalist if I had not matched for endocrine… but now, I think hospitalist work would have been exhausting as a long term job.