Nephrology is Dead - stay away

[deleted1164820]

Have you guys noticed Internal medicine specialists for overseas, without residency training in the US getting the unfilled renal spots ? I heard a few people do that in ID and Endocrine not sure about nephro.

There must be unfilled spots even now for anyone to grab. But you need all the USMLE steps cleared first.

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[Renal_Prometheus]

You can make 300k/yr as hospitalist right out of residency without picking up extra shifts. people who go into nephrology are giving up the opportunity cost of 2 yrs of fellowship plus 3 years of indentured servitude, to ultimately work harder and make less money(per hr) than a hospitalist as a partner. And academics are actually surprised that nobody wants to go into this specialty? And for all those who say it’s not the money and people are choosing it for passion. Then tell me why there are so many Neph trained people working as hospitalist years later? Where’s the passion when you get tired of driving like a maniac around town for consults at 4 hospitals and round at 3 dialysis units on the same day, and still take night calls for a K of 7. Any reasonable size town you will have more than 1 Neph group competing with you for consults. You don’t just show up and accumulate ESRD population and make the money that fellowship programs sold you on. Welcome to the real world.

 

[NewYorkDoctors]

those who "love nephrology the discipline" exist and they can try to find a nice academic faculty job in which you can play Dr House and have the fellows do the night calls.

 

[Renal_Prometheus]

I’ve learned from my interactions with Neph fellows and attendings that the truth is uncomfortable and people will actively avoid it. People go along to get along, but the truth seekers are always ostracized. It’s unfortunate because as a specialty, when your senior leaders don’t want to face up to the reality of why people avoid nephrology, you cannot have a honest discussion of how to fix things. People are happier to live in a lie then confront the brutal reality of issues plaguing this specialty.

 

[georgestone]

After preparing for Nephro boards , I realized that 80 % of Nephrology faculty was garbage and lived in silos at best , didactics were very poor and fellows were scut monkeys to write more than 20 notes on service /day. I came from one of the best programs ( Allegedly ) but tis unfortunate that fellows weren't taught they way it should be .
Unfortunately this dearth of candidates has been going on for a decade and now lying , cheating and fabricating facts is now a integral part of DNA of Nephro fellowship programs & this is has been going on with out real consequence , now they have steady stream of IMG wo residency so even better so the current practices aren't gonna change

 

[NewYorkDoctors]

when the division of nephrology has to grind every consultation to maximize revenue to make ends meet, you cant/ expect fellows to be anything but scut monkeys who see every creatinine and follow up evvery day and are never allowed to sign off

 

[The kitchen sink]

There’s a lot of manipulation and gaslighting of fellows to get them to take horrible night calls. Fundamentally it’s a bad specialty, that’s why it goes unfilled. So programs need to spin the truth to fill spots. And the type of people who will bite are desperate people looking for hope. The reality is the most vulnerable also gets screw the hardest in the end.

Is it really a ‘fundamentally’ bad specialty?

Or did CMS just gut reimbursement and bundle dialysis so the income potential dropped drastically?

 

[Renal_Prometheus]

Is it really a ‘fundamentally’ bad specialty?

Or did CMS just gut reimbursement and bundle dialysis so the income potential dropped drastically?

It’s a bad lifestyle specialty, requiring a lot driving, hitting multiple hospitals every day, and night calls are brutal. So if the lifestyle is not there, and the money isn’t there, then what are you in it for?

 

[Renal_Prometheus]

Unfortunately this dearth of candidates has been going on for a decade and now lying , cheating and fabricating facts is now a integral part of DNA of Nephro fellowship programs

You and I who have gone through fellowship knows these programs are lying through their teeth and private practice is nothing like what they are claiming. But the fellows don’t know and they are still surprised, even in 2024!, that academics are so blatant in their lies. Like what did you expect was going to happen when you go into a specialty where 1/3 of spots go unfilled? Did you really expect to be going to a lucrative special where this JV, medical directorship fees, and access center money was just going to flow from the senior partners into your pocket just by making partner?

 

[georgestone]

You and I who have gone through fellowship knows these programs are lying through their teeth and private practice is nothing like what they are claiming. But the fellows don’t know and they are still surprised, even in 2024!, that academics are so blatant in their lies. Like what did you expect was going to happen when you go into a specialty where 1/3 of spots go unfilled? Did you really expect to be going to a lucrative special where this JV, medical directorship fees, and access center money was just going to flow from the senior partners into your pocket just by making partner?

I wish I had visited this Forum before I burned 2 years of my life , the purpose of this harsh reality check is not to smear Nephrology but to give a perspective to current & Future fellows whts really out there , 50 % of Nephro grads stop practicing Nephrology after 5 years , thats an alarming number , yet there is no action from ASN even to consider reducing Fellowship spots and now they have IMG's wo residency taking these spots , I hope there is some kind of review by ACGME or Feds

 

[deleted1164820]

I wish I had visited this Forum before I burned 2 years of my life , the purpose of this harsh reality check is not to smear Nephrology but to give a perspective to current & Future fellows whts really out there , 50 % of Nephro grads stop practicing Nephrology after 5 years , thats an alarming number , yet there is no action from ASN even to consider reducing Fellowship spots and now they have IMG's wo residency taking these spots , I hope there is some kind of review by ACGME or Feds

I know few people who don't practice Nephrology anymore. If that number is 50% and they went back to being Internists that's still good for overall market for the rest of us, right?. There is less competition for the existing people. The Practicing Market adjusts based on Necessity. I am not a fan of reducing the spots, as doing so will artificially inflate the demand for fellowship positions temporarily but it does not serve the purpose. Many fellowship PDs told me during my interview that they are not in control and I felt really good. I hate the Ivory tower talk from the faculties and PDs even from the middle of nowhere IM residency programs in the country. I have been a victim of abusive PD who take residents for granted.

Anyways many programs spots are unfilled regardless and the IMGs who has not done residency cannot come into the market as they can not practice without residency in general. They will go back to their own country to practice Nephrology, where they are welcomed with red carpet.

 

[NewYorkDoctors]

I know few people who don't practice Nephrology anymore. If that number is 50% and they went back to being Internists that's still good for overall market for the rest of us, right?. There is less competition for the existing people. The Practicing Market adjusts based on Necessity. I am not a fan of reducing the spots, as doing so will artificially inflate the demand for fellowship positions temporarily but it does not serve the purpose. Many fellowship PDs told me during my interview that they are not in control and I felt really good. I hate the Ivory tower talk from the faculties and PDs even from the middle of nowhere IM residency programs in the country. I have been a victim of abusive PD who take residents for granted.

Anyways many programs spots are unfilled regardless and the IMGs who has not done residency cannot come into the market as they can not practice without residency in general. They will go back to their own country to practice Nephrology, where are welcomed with red carpet.

the one thing that the "novice economist physician" has to understand is that Nephrology is the most heavily regulated medical subspecialty/specialty due to dialysis. I cannot think of any other field that has its payments directly dictated by the government. As a result, the "free market principles" do not apply. Heck the "medical industrial complex" as a whole is full of lobbyists for Big Food and big Pharma anyway and corrupt politicians hoping to line their own pockets. Maybe the next medical law can simultaneously fund some war somewhere also.

Therefore, Nephrology is "not a free market economy." The fallacy of "hey look anesthesia went down and went up" does not apply. It's apples and oranges.


AS mentioned in my posts above, the way a physician makes money is through billing a variety of CPT codes.

The nephrologist's CPT codes are renal replacement therapy primarily . This requires an ESRD patient or at the very least a steady stream of AKi requiring RRT patients.

These patients are not abundant "resources" (sorry I dont mean to put down these patients. but from a business standpoint, that is what these ESRD patients or AKI patients are)

As RP has mentioned many times if the payments for dialysis are stagnant but inflation and costs of running an HD center are going up.
the existing senior nephrologists are not going to give up their bronze goose (I am not calling it a golden goose) to the new generation without a fight or at least with a lot of strings attached.

 

[Renal_Prometheus]

I know few people who don't practice Nephrology anymore. If that number is 50% and they went back to being Internists that's still good for overall market for the rest of us, right?.

I don’t know if it’s 50% or 30%, nobody has true data on this and ASN is not going to take a poll. Anecdotally, about half of my neph friends have quit this specialty to pursue more lucrative career choices. Irregardless, it’s a significant percentage and make you question whether they really knew what they were getting into beforehand. It’s a defeated mentality to think that people quiting this specialty will make the job market marginally better for the rest. It’s a bad specialty and let’s just leave it at that.

 

[Renal_Prometheus]

Anyways many programs spots are unfilled regardless and the IMGs who has not done residency cannot come into the market as they can not practice without residency in general.

There’s legislative push from multiple states to allow foreign docs to practice without doing a residency in the US. Things are changing. If the hospital lobbyists get their way, they will overflood the system with foreign docs who are willing to be abused and make1/3 of what you make. Things are changing and nothing is given.

 

[deleted1164820]

There’s legislative push from multiple states to allow foreign docs to practice without doing a residency in the US. Things are changing. If the hospital lobbyists get their way, they will overflood the system with foreign docs who are willing to be abused and make1/3 of what you make. Things are changing and nothing is given.

I agree, things are changing and nothing is given as you said.

The reason why they are trying to do that is there is Physician shortage. Supply vs demand. The reason Physician salary is higher than 100K in the US is because of shortage. The reason there are mid-levels in this country is because of Physician shortage. People who lived all their life in the USA health system has inflated sense of Physician-salaries/worthiness compared to physician from other countries. Most countries have physicians who make less than 100K USD.

If those hell gates are open to let people in without residency, the salary of all specialties will go down, not just Nephrology. All those foreign trained interventional cardiology physicians will work at resident salaries without any complaining. If I were a politician/hospital admin, I would fight to make it happen. Obviously I would not want that to happen on a economic perspective as a Physician.

So overall having less spots for training doesn't help anyone. So there is no point to beg ASN or ACGME to close down some programs as it doesn't serve anything.

 

[Renal_Prometheus]

I still don't understand how a supply : demand mismatch is not working well for nephrology.

Supply and demand mismatch does not equate to higher salaries for nephrologist. There’s a severe shortage for endo, do they make a lot of money? You can see pts like crazy in nephrology and still don’t make a lot money. The money only goes up when you start accumulating more ESRD pts, which is a limited resource hoarded by the senior partners. That’s why you work, and they get paid, and hope they share down the road.

Is there a real need for more nephrologists? If I need more workers in an area, I can always hire more midlevels to fill any shortage gap. They are cheaper, they can do 80% of what you do, and I don’t have to worry about making them partners and sharing my ancillary revenue with them.

So is there really a supply and demand mismatch? You seem to keep falling for the marketing gimmicks that fellowship programs are selling to fill their unwanted spots.

 

[deleted1164820]

Mid levels are definitely cheaper. But, They are not definitely doing 80% of what a Physician can do. They are at the best 40-50% of what a physician can do. The more you employ mid levels it will slowly erode the business as patients are not that happy to see mid levels 2/3 of the time. I have a lot patients who moved to me from a Physician who employs more NPs. Patients change their physicians at some point as mid levels are bound to miss things and patients end up in the hospital which some times could have been potentially avoided. In this business loyalty goes a long way.

 

[NewYorkDoctors]

mid levels have their role for "acute urgent walk in i must see you asap or else wah wah wah worreid well nothingburger goingo n" as well as doing mundane things like "oh yeah your results are totally normal cool. no don't read the internet like that."

if a physician had to see every single visit like that, that would lead to rapid burn out.

mid levels as part of the team with the physician overseeing all major executive medical decisions can work our efficiently and effectively

mid level s totally independent.. uh oh. be prepared for pan consultation



regarding nephrology, I do not see how a midlevel helps in nephrology

Help round on HD? then the nephrologist has to share that income. this might help if a nephrologist is really making it big and cnanot make it to the HD rounds due to 200 + patients and the nephrologist is always getting CRRT and acute HD consults in the hospital. RARE. This is Final Boss level of nephrology success.

Help with hospital consults? I have seen large renal private groups send a PA into the hospital lduring the day to take all their consults. Prelim reccs are given over the phone by MD to PA to primary team then after office / cliniic / HD center roudning, the scheduled hospital nephrologist of the day/week goes to meet the PA and finish the consult in person together.

Help see the low level pointless referrals for like "trace protein" in a U/A dipstick withotu a high specific gravity or "oxalate crystals on U/A?"
sure PA can see those consults get things ready then MD meets for a moment and talks a bit and reassures then patient gets mad anyway beacuse "patients are gonna patient."


see overnight HD? nope midlevels not doing that unless they get paid like a doctor which defeats th epurpose

 

[Renal_Prometheus]

Mid levels are definitely cheaper. But, They are not definitely doing 80% of what a Physician can do. They are at the best 40-50% of what a physician can do.

I think I’m more qualified to speak on this than someone who hasn’t even started neph fellowship yet. There’s no difference in care with an experienced Midlevel doing chronic dialysis rounds and CKD clinic. I only need a physician for hospital consults.

 

[NewYorkDoctors]

chronic HD units are already being done by NPs in some places

how hard is it?

is dry weight being achieved? if not why? is there still edema? is BP still high? try to challenge dry weight or adjust BP medications.
talk to patient about dry weight challenge and get all kinds of resistance about it
are monthly and quarterly labs being achieved? why not? the patient is eating buger king and coke and fries while on HD? guess that's why.
how is the AV access? how are the venous outflow pressures? not good? send to IR for fistulogram.
listen to the inevitable primary care complains during on HD rounds about some unrelated issue

hoard up all the topical lidocaine, the IV antibiotics, the IV hecterols, try to cut Aranesp dosages left and right... do whatever it takes to save costs from the bundle.
reject all requests for labwork because it cuts into the bundle

 

[georgestone]

I know few people who don't practice Nephrology anymore. If that number is 50% and they went back to being Internists that's still good for overall market for the rest of us, right?. There is less competition for the existing people. The Practicing Market adjusts based on Necessity. I am not a fan of reducing the spots, as doing so will artificially inflate the demand for fellowship positions temporarily but it does not serve the purpose. Many fellowship PDs told me during my interview that they are not in control and I felt really good. I hate the Ivory tower talk from the faculties and PDs even from the middle of nowhere IM residency programs in the country. I have been a victim of abusive PD who take residents for granted.

Anyways many programs spots are unfilled regardless and the IMGs who has not done residency cannot come into the market as they can not practice without residency in general. They will go back to their own country to practice Nephrology, where they are welcomed with red carpet.

This drop out rate isnt New , it has been going on for years , has that made Nephrology Job market/compensation any better ? it has only gotten worse .

It has been discussed previously that ESRD /HD patients are the largest revenue source but its a deprecating pool , even patients with private insurances last 2 years on HD and after that Medicare takes over and we already know their compensations sucks and is heavily regulated .

Also, as per USRDS , mortality is 40-50% with in 5 years of initiating HD , so a practicing Nephrologist must have a constant stream of such patients even to keep ESRD/HD patients at a steady number in their practice , its a uphill battle which only a few win.

I dont have the number /statistics of IMG's and their current practice who have done residencies after doing Nephro fellowship, it will be interesting to see if after using Nephro as a stepping stone they are still pursuing it as a career or Not .

I know a few programs at east coast who were heavily recruiting IMG's wo residency in Nephro fellowship and many candidates after their residencies didn't pursue Nephrology.

Its really unfortunate though bc those IMG's get abused , do scut work and didactics remain poor and they tend to remain silent bc of job security since for many losing that spot means deportation ( because of Visa ) , unfortunately .

I still believe reducing number of fellowship spots might help this field and recruitment crisis , this is what we called adjustment to Market Conditions but seems Nephro programs are getting away by hiring IMG's wo residency so this trend is unlikely to change .


In Pure Monetary terms , this filed is unattractive , given wide work to income ratio , if some one wants to pursue purely for passion then go for it , otherwise when it comes to paying bills /college education for kids , its really bitter to see Nephrologists trying to switch to being a PCP or Hospitalist after burning precious years .

I will encourage many silent members of this Forum who left Nephro and are practicing in other fields to share their experience .

 

[NewYorkDoctors]

Its really unfortunate though bc those IMG's get abused , do scut work and didactics remain poor and they tend to remain silent bc of job security since for many losing that spot means deportation ( because of Visa ) , unfortunately

what if they cross the southern border en route to their fellowships?

anyway politics aside, I still think it would be ideal if there remains the "dialysis doctor" who primarily manages all HD inpatient and outpatient kind of like how the interventional cardiologist does the invasive procedures for a large number of general cardiologists.

of course this cannot happen easily due to losing revenue streams for the "non dialysis doctor"

if general nephrology had office / non invasive procedures like general cardiology, then such a dichotomy would be more palatable. but no such thing exists sadly

 

[Renal_Prometheus]

Its really unfortunate though bc those IMG's get abused , do scut work and didactics remain poor and they tend to remain silent bc of job security since for many losing that spot means deportation ( because of Visa ) , unfortunately .

Residency is getting harder to match for IMGs. Neph programs now have potentially and endless supply of warm bodies to exploit for cheap labor, and these fellows will be quiet and work hard in the hopes of getting a residency afterwards. These people have no interest in doing nephrology and are just doing it as a stepping stone to practice medicine in the US. Since when did we condone exploitation and human suffering? But it’s in so in your face and prevalent that it’s an accepted part of nephrology.

 

[Renal_Prometheus]

Can this specialty go one day without exploiting the desperate. It can’t exist without living off the warm bodies of the desperate. Feed some hopium to some burnt out hospitalist who can’t get anything else. Promise an IMG w/o residency a chance at getting one if you come and take my night call. No shame at all. How about feeding some hopium to a resident that they will make big money after partnership, but fail to mention half the grads have left the specialty because they can’t take the exploitation from senior partners anymore. I’ve heard all the explanations and all the excuses for why it’s non-competitive, and how it’s “misunderstood” by everyone. Can academics go one day without selling this unwanted specialty to a resident and look at the mirror and acknowledge what an awful product they are selling.

 

[NewYorkDoctors]

it's not misunderstood at all, it is what it is

if we take a look at nephrology the discipline (not tkaing into accoutn financial factors) it is pretty cool

a lot of thinking like the classic internist
can do hands on procedures (operative word *can*) - temporary HD cathethers, diagnostic renal ultrasoud, urine microscopy
has a variety of extracorporeal therapies that no other specialty can really lay claim to other them hemeonc with plasmaphersis (which renal can do also) and ECMO from PCCM/cardiology (which is purely critical care setting)
has a very commonly transaplanted organ
has home HD and home PD
has a "fairly easy" biopsy to do compared to other organs and diverse pathology



only thing is if you dont get paid well for all of this interesting (but extra) work then what is the point of doing anything OUTSIDE of academic nephrology? none.

academic nephrology - cool

but there are only so many academic nephrology jobs

 

[georgestone]

it's not misunderstood at all, it is what it is

if we take a look at nephrology the discipline (not tkaing into accoutn financial factors) it is pretty cool

a lot of thinking like the classic internist
can do hands on procedures (operative word *can*) - temporary HD cathethers, diagnostic renal ultrasoud, urine microscopy
has a variety of extracorporeal therapies that no other specialty can really lay claim to other them hemeonc with plasmaphersis (which renal can do also) and ECMO from PCCM/cardiology (which is purely critical care setting)
has a very commonly transaplanted organ
has home HD and home PD
has a "fairly easy" biopsy to do compared to other organs and diverse pathology



only thing is if you dont get paid well for all of this interesting (but extra) work then what is the point of doing anything OUTSIDE of academic nephrology? none.

academic nephrology - cool

but there are only so many academic nephrology jobs

You think they will let some nephrologist run ECMO circuit , Never !!

Temp HD catheters are poorly reimbursed that's why even majority of Academic Nephrologist dont do them ( private guys stopped doing them long time ago )
Can you please give us few examples of Renal TXP jobs which pay well ?? they are hardly any !! and they get reimbursed less than Hospitalist or even General Nephrology and alot of renal txp docs have been forced to do HD rounding to generate more RVU's , its a sad reality.

so some one wants to do a low paying Academic Nephrology Job then go for it and let those IMG's wo residency or gullible candidates who were fooled by false promise of amazing future of Nephrology ,esp Kidney X !! work their Tails off and run after a Mirage !!

Nephrology and its science is very cerebral but the practice doesn't reflect that cerebral Nature unfortunately .

 

[NewYorkDoctors]

I would not trust most nephrologists with volume status assessment

volume is easy in ESRD. they are ALWAYS overloaded. If they are dry then cannot get more UF off the patient usually.
that's so easy even a med student can figure that out.

 

[Renal_Prometheus]

I don’t why it is this way, but I find there’s a severe information disconnect among applicants. I still remember a surreal moment in the past when one of my cofellows broke down over the phone. He had just been screwed over by 2 private practice groups and now he was facing the possibility of giving a 3rd try at neph job or go back to hospitalist. He was a hospitalist for many years before going into neph. I remember him saying at least with hosptialist job, you know the hrs, you know your pay. Nothing like neph where you are asked to give them 3 years of cheap labor and we will see if we give you partnership. And trust me, there are a bunch of killers out there. Some of these neph fellows get severely brainwashed in fellowship and is unprepared for what real world offers. It’s almost like sheep walking into wolf’s den and the sheep has no idea what’s about to happen. Anyways, my friend ended up taking an academic position to avoid the exploitation. Funny thing is, last time I talked him he was actively recruiting residents to join his program and discover the “wonders of nephrology.”

 

[Renal_Prometheus]

If someone comes along and promises you big money if you go into this specialty. It happens be easy to get into because the market has mispriced it. Your red flags should be way up. The market does not misprice these things. Details get swept up under the rug when academics face the possibility of taking their own night calls.

 

[Renal_Prometheus]

Would you ask a realtor whether it’s good time to buy a house? Do you believe them, when they profit from this transactions? Why would you ask an academic nephrologist whether it’s a good idea to go into nephrology? They profit from your cheap labor when it’s obvious they can’t find fellows to do their scut work. Do people not recognize the conflict of interest here?

 

[NewYorkDoctors]

one of my cofellows did nephrology and had a good time in nephrology fellowship learning
was offered a job being the "Director of Nephrology" her her previous hospital where she did IM.
(lol red flags already)
it was a tireless, thankless job that did not get any extra pay for being a "director."
Was doing free admin work basically while seeing a full panel of patients, hospital consults, HD rounds, clinic etc...
luckily the HD center was across the street so no mutliple walking around
but if one did that amount of heavy work as private practice one would be making 500K plus no doubt.
but only made a paltry 220K as a "diretor of nephrology"
no fellows to help , no midlevels.
lukcily that hospital had lot of private practice nephrologists rounding so she did not really have to see too many urgent crash HDs or whatever.

naturally too much stress and too little pay and she is now a hospitalist working half the year for pretty decent pay in new jersey and having a great time raising her kids.

 

[Renal_Prometheus]

naturally too much stress and too little pay and she is now a hospitalist working half the year for pretty decent pay in new jersey and having a great time raising her kids.

This happens way too often in nephrology. Not a surprise to anyone except neph applicants. ASN turns a blind eye to this and fellowship programs act ignorant that it’s going on at all. The whole establishment is trying to convince more neph applicants to go into nephrology when the fundamentals does not support a viable career path. To them, it really does not matter how these neph grads end up as long as you get a sucker to take my night calls.

 

[NewYorkDoctors]

yep pretty much

only the top academic programs who will churn out top quality neprhologists to become future faculty practice doctors deserve to have fellows

too many new programs are opening that have ZERO business have a fellowship other than to get someone to do the night calls for them

 

[Test Boy]

yep pretty much

only the top academic programs who will churn out top quality neprhologists to become future faculty practice doctors deserve to have fellows

too many new programs are opening that have ZERO business have a fellowship other than to get someone to do the night calls for them

Wait, there are new nephrology fellowships still opening up in this climate when half (or more) of all fellowships should be shut down?

 

[Renal_Prometheus]

Wait, there are new nephrology fellowships still opening up in this climate when half (or more) of all fellowships should be shut down?

Yes, more nephrology programs are opening up. They fill them with IMGs w/o residency who are desperate to get into US medical system. They are afraid to raise their voices about the workplace abuse due to their precarious situation and are ideal candidates to to bring into a busy program to handle the scut work. You can exploit them all you want and not fear retaliation. Traditional neph fellows may leave if you push them too hard, but these other guys are prime meat for the grilling!

 

[Renal_Prometheus]

And if neph fellows complain there’s too much exploitation in fellowship, don’t worry, they are only preparing you for what’s to come in private practice

 

[georgestone]

I wonder whats the tipping point going to be given on going exploitation and human suffering and scamming ?

 

[Renal_Prometheus]

I wonder whats the tipping point going to be given on going exploitation and human suffering and scamming ?

The exploitation stops when applicants educate themselves(like reading this thread) on what they are getting into and stop acting desperate.

 

[NewYorkDoctors]

what are ways to make "nephrology a lifestyle specialty?"

get rid of chronic HD and managing the emergencies.
get rid of traveling around to multiple HD centers
work 9-5 without any overnight call or weekends

if you did that you would just have the office without any real office procedures... sounds like primary care... hmmm

 

[Renal_Prometheus]

Nephrology will never be a lifestyle specialty simply because there are too many acute emergencies. The only question is whether you are making enough money to put up with this crap. And looking at how many Neph grads who have cut their losses and went back to hospitalist, the reimbursement is not worth the headache. You are only making the senior partners rich by feeding their dialysis units. Good luck finding someone willing to share that revenue with you.

 

[NewYorkDoctors]

https://onlinelibrary.wiley.com/doi/10.1111/hdi.13137?af=R

Rest in Peace Dr Todd Ing who was a pioneer in renal and dialysis

Dr Daiguirdas called him a "triple threat (like in basketball) - good at acadamics, good at research, and good at clinical care."

What a wonderful doctor who will be missed....














but could any academic professor of nephrology have been all these things without fellows, younger attendings, others "below him/her" doing the "grunt work" of nephrology?

While this is true in all academia, at least other subspecialties of IM (particularly the procedural ones) the "assistant, associate professors, and fellows" below have a well compensated career to look forward to (whether slightly better payment in academia or going to private practice)

That pot of "gold" does not exist and there is no rainbow leading to anything like that

 

[Renal_Prometheus]

At this point, everyone is seeing the crap that fellowship programs pull to get cheap labor through the door. Nephrologist turned hospitalist is so common these days that even residents seen them routinely in the hospital. People are not dumb. It’s all influencing fellowship decisions where quality of neph applicants gets lower and lower. There maybe a day where the majority of neph fellows are IMGs w/o residency. Already big name academic programs are taking them now. Just wait a few years.

 

[Renal_Prometheus]

I once had a neph friend explain to me that neph itself is not poorly reimbursed, but it’s just that senior partners are greedy and unwilling to share JV/MDA money with new partners. I would say maybe they are greedy because they can’t afford to share. The specialty has hard time generating revenue. JV/MDA money is a limited resource that doesn’t expand proportional to new people they hire. In fact ESRD population is declining in this country and I don’t know how a new grad thinks they will have the same opportunities a generation ago.

 

[NewYorkDoctors]

I once had a neph friend explain to me that neph itself is not poorly reimbursed, but it’s just that senior partners are greedy and unwilling to share JV/MDA money with new partners. I would say maybe they are greedy because they can’t afford to share. The specialty has hard time generating revenue. JV/MDA money is a limited resource that doesn’t expand proportional to new people they hire. In fact ESRD population is declining in this country and I don’t know how a new grad thinks they will have the same opportunities a generation ago.

that's because the CPT codes for dialysis requires an ESRD patient (or AKI requiring HD)
Those patients do not grow on trees

Cardiologists do echo, stress test on everyone who walks in the door
GI does colonoscopy EGD on everyone who walks in the door
onc does chemo on everyone (in theory)
pulm does PFTs and others on everyone
rheum doesn't do too much but could inject, aspirate, and infuse quite a few patients


nephrology cannot dialyze everyone that walks in the door
the senior partners want to hoard that precious resource and not share.
it's as simple as that. limited resources. simple economics. tremendous oversupply (like the very post said in this thread) and flat demand or declining demand.

 

[Renal_Prometheus]

Another common phrase I keep hearing from neph fellows, even back when I was a fellow, was the idea that the “speciality will turn it around.” And when you ask why, they can’t give a logical reason why. It seems more of a psychological ploy to take comfort in one’s own bad decision. If anybody knows anything about regulatory problems with dialysis reimbursement, the logical conclusion is that the specialty has more to fall. Unfortunately, from what Ive observed over the years, brain will always make up excuses for bad decisions and will avoid at all costs to admit going into nephrology was a mistake.

 

[NewYorkDoctors]

Another common phrase I keep hearing from neph fellows, even back when I was a fellow, was the idea that the “speciality will turn it around.” And when you ask why, they can’t give a logical reason why. It seems more of a psychological ploy to take comfort in one’s own bad decision. If anybody knows anything about regulatory problems with dialysis reimbursement, the logical conclusion is that the specialty has more to fall. Unfortunately, from what Ive observed over the years, brain will always make up excuses for bad decisions and will avoid at all costs to admit going into nephrology was a mistake.

because doctors are not economists. doctors know platitudes and cite "how anesthesia and GI turned it around."

GI turned it around due to screening colonoscopies being part of guidelines
before then, not everyone patient would go in for "procedures for everyone."

If some breakthrough happened that would allow Nephrology to "do some office procedure on every patient that walks in for a consult" then you betcha nephrology will rebound and become popular


end of the day it's all about what office procedures can be done to make money as quick and easily as possible that dictates the popularity of a subspecialty of IM

 

[Renal_Prometheus]

The other commonly cited excuse to continue to do a poorly paid neph job among friends is the claim that hospitalist jobs is getting saturated and neph is the 2nd worst option. It’s a funny reason, but you can really tell the brain is playing tricks on itself to avoid admitting a mistake. I have many Neph friends, who are partners in their groups, but not making enough money to justify the workload. Some pick up locum hospitalist shifts to supplement their main income. Others keep jumping onto the next neph job, hoping the next one will be the jackpot, but getting disappointed each time. It’s almost sad, but understandable in some respects because they have invested this many years into a specialty and it’s not working out. Perhaps they believed too much of the hopium that was sold in fellowship? So they keep doing neph, even though they despise the work and the pay. The psychology underneath is fascinating and is worth a study onto its own.

But back to mind games. I find many of neph friends justify continuing their current jobs by belittling hospitalist. They say things like hospitalist make less in my area. Or hospitalist jobs are getting saturated and I don’t want to deal with administration BS. Never mind all the BS calls from dialysis nurses throughout the day for clotted lines or high K. Or the fact that neph jobs are already saturated and you need to go rural to find anything worthwhile. They acknowledge both neph and hospitalist are on the bottom rung, but they put Neph one rung higher in order to justify all those years spent chasing the specialist dream.

I’m here to report that sunken cost fallacy is for real. And it’s deadly and costly. If I don’t pull them off the train early, some people will keep digging themselves into a deeper and deeper hole.

 

[NewYorkDoctors]

in the hemeonc thread now there is a thraed "i think I am being bullied."


lol that is every private practice nephrology job for young attendings that do not have family/friend connections out there. join the club haha

 

[Renal_Prometheus]

Do people really want to be screwed over by their partners, pick another group, and get screwed over again. This is common practice in nephrology. I don’t understand why people don’t do their research before going into a specialty.

 

[NewYorkDoctors]

to be fair, those whose feelings are most hurt by this thread are the academic nephrologists I'd bet

I do not see why this is the case?

we PRAISE what a good career academic nephrology... it may not pay the best but if you are in a tertiary care center and have a full complement of fellows every year you have a great job! the cream of the crop nephrology fellows SHOULD do academics and carry on the nephrology torch



but the fact of the matter remains NOT EVERYONE who graduates renal fellowship can get an academic job. there are only so many academic jobs out there.

therefore anyone who goes into Nephrology needs to have clear career plan whether it is
1) go to top academic renal program and join academic faculty somewhere and continue to teach fellows
2) go back to your home country with your top renal degree
3) leverage Nephrology diploma and board certification and do something else
4) take over a family/friend practice or have family/friends get you into a HD center JV right off the bat and get HD center privileges

If the plan is - let me try private practice and go from there. This makes ZERO sense. If you loved nephrology so much you should have done academics. If you want to try the private practice market you would have more luck as a PCP.

just do NOT go into the PP market with no plan thinking you can grind to make it work. You will not. See all the posts above

I suppose on that venn diagram is a subset of individuals who "love nephrology and don't mind working for a larger employer like Kaiser permanente and get paid below value but with acceptable quality of life." illogical to me but whatever.