Nephrology is Dead - stay away

[Renal_Prometheus]

Any scope for peritoneal dialysis unit ? I heard from nephrology friends, if done right PD has higher reimbursement than HD and with lower overhead costs.

I recommend you not waste your time with this specialty any further. However your hopes are for this specialty, the reality is always much crueler. I've only touched on the outer layers of what can go wrong when you do nephrology. In the end you will waste your time and be disappointed. The number of applicants applying to nephrology is a direct, and instant market reflection on the financial lucrativeness of the specialty. So stop trying to applying to a non-competitive specialty and expect a lucrative career.

---

Members don't see this ad.

 

[NewYorkDoctors]

I like to think of the success stories in Nephrology as the medical equivalent to being a time player on Wall Street. Yes there are those who made it big in the past. You can still make it big now if you have corporate / government connections. Otherwise, you are just wasting your money and life savings on a rigged market trying to play the stock market as an amateur.

Why bother trying to "go into business" against a rigged system? Do something else that makes you happier.

 

[Questionsaboutmedicine]

The simple answer is yes he can, but with significant opportunity cost. If it's truly a rural area, you cannot get an hospitalist to sign on for less than 300k/year, working 7 on 7 off. Even the hospitalists here, I would say a small city, make around 330k/yr(base + bonuses) working half the year!. Most of them also moonlight on their off days, so hospitalists are already making over 400k/yr in places outside of a major city. So then the question is whether it's worthwhile do a fellowship, then work several years to build a dialysis population that will get you to 400k/year. And if it's truly rural, are you going to be on call for your practice very night? How much do you have to drive between hospitals and dialysis units to see your patients? Furthermore, let's say you hate the small place and wants to move to a larger city, all your sweat equity will be gone. Are you going to join a neph group, start all over again with a starting salary of 200k/year and work 3-4 years and hope that they will make you partner? Do you start to see all the problems with this specialty? It's not a coincidence that nephrology is non-competitive.

Thanks for spelling everything out, esp the opportunity cost part. I didn't even think of being locked into that small town where all of your sweat equity will be gone.

My understanding is that he will be moving to a very rural area in the Midwest or South. He says he doesn't want to live in a metro area. So maybe he will be happy with this choice? FWIW, he seems to genuinely love nephro. Not for me, but kudos to him. Let's see if he regrets his decision in a few years.

 

[NewYorkDoctors]

If someone truly loves Nephrology (and there are those who do... I like it okay... ) and has NO DEBT and whose goal in life is NOT to make as much money as possible (there are people like this), then kudos to them and go ahead and apply to ACADEMIC nephrology and join faculty somewhere. (Get that glomerular, transplant, hypertension, apheresis training and be more than a Dialysis Doctor)

There is ZERO reason to enter private practice if one fits the criteria as above.

For other individuals who may have a lot of student debt and compounding interest, you should really not look to this specialty because debt is crippling. Whereas money does not buy happiness, debt leads to misery.

The Choices We Make Dictate The Life We Lead

Learn about Nephrology Fellowship Programs which offer the nephrologists to meet current and future needs in the United States.

nephrologyusa.com

This is from a nephrologist recruitment website. Just a few quotes (though one should read to article so as not to take isolated quotes fully out of context)

Even allergy and immunology, endocrinology and infectious disease make more in their first year than nephrology does with the median of $170,000. Many nephrologists look at going into Hospitalist positions, which start in the low to mid $200,000 range ($215,000 @ MGMA figures) and affords a better lifestyle. But starting salaries do not tell the whole story and this is where the American Society of Nephrology and the whole Nephrology community needs to do a better job of laying things out for Fellows and Residents.

Hmm okay so what is the whole story?

Dylan Steer, MD, Chief Executive Officer and President of Balboa Nephrology Medical Group, a 40 physician nephrology practice based out of San Diego, stated, “Starting salaries in nephrology are generally not great indicators of potential. In private practice nephrology, for example, the MGMA average for a small group nephrology practice is slightly over $300,000. This would indicate that there are significant growth potential and salary escalation over time. There are also many other lucrative revenue streams available to nephrologists that may not be captured in that income figure. Hospitalists generally have a flat income over time with limited options to develop ancillary revenue streams.

Nice so the politician is basically saying:

But hold on...

Besides compensation, Dr. Steer points out: “Some fellows I see are very interested in ‘work-life’ balance and believe that nephrology can’t accommodate that interest. I’d tell them that although nephrologists generally work fairly hard and take care of sick people, work-life balance is absolutely attainable in this specialty. I believe work-life balance is more a function of the physician than the specialty.

Okay I am done with this piece of propaganda. See all of the prior posts in this thread.

 

[renalfellow937]

View attachment 341255

Any chance of nephrology worth going up a decade or two later ? I guess most IMGs are hoping they are getting into fellowship before the nephro bull rally (if that ever happen$)

No chance of that happening ! There is nothing you can offer to the patients that a pa or np cannot. It’s just monitoring. There is ni treatment for aki and ckd. Pa or np can easily handle dialysis which they are already doing. I think the revenues will actually go down ! It’s just a matter of time that the payment gods realize nephrologists are not doing anything for the patient and are getting paid ! 😂

 

[NewYorkDoctors]

No chance of that happening ! There is nothing you can offer to the patients that a pa or np cannot. It’s just monitoring. There is ni treatment for aki and ckd. Pa or np can easily handle dialysis which they are already doing. I think the revenues will actually go down ! It’s just a matter of time that the payment gods realize nephrologists are not doing anything for the patient and are getting paid ! 😂

Glomerular disease is the only disease process within nephrology that only a nephrologist can handle and treat. These usually go to a Glomerular Center of Excellence anyway. Maybe some big private practices have an infusion center for LN Class 3/4/5, but usually not.

For most DM/HTN/ post ATN CKD it all boils down to some combination of

SGLT-2 inhibitor, GLP-1 agonist, ACE/ARB, Aldosterone blockade, potassium binder, diuretic, ferrous sulfate, ESA agent, sodium bicarbonate, vitamin D analogue, uric acid reducer.

A dedicated PMD who takes some CME credits or pharma talks can do this.

In fellowship, I had commercial insurance patients who say things like

"oh doctor, you are so thorough going over every single lab test result with me. But do I really need to see you? the copay is $40-80! My PMD can also draw blood work and go over these same tests."

What was I going to say? Your PMD doesn't want the headache of dealing with a creatinine of 2?

 

[georgestone]

Nephrology gets +1 for not having the risk of being replaced by midlevels unlike hospitalist/IM but not sure if it's worth 2 yrs of miserable fellow life and forever poor lifestyle.

Midlevel's have gotten smarter and even they know Nephrology is not worth their time
thts why Nephro programs hire candidates who don't have residency or flat out lie to them

 

[georgestone]

The simple answer is yes he can, but with significant opportunity cost. If it's truly a rural area, you cannot get an hospitalist to sign on for less than 300k/year, working 7 on 7 off. Even the hospitalists here, I would say a small city, make around 330k/yr(base + bonuses) working half the year!. Most of them also moonlight on their off days, so hospitalists are already making over 400k/yr in places outside of a major city. So then the question is whether it's worthwhile do a fellowship, then work several years to build a dialysis population that will get you to 400k/year. And if it's truly rural, are you going to be on call for your practice very night? How much do you have to drive between hospitals and dialysis units to see your patients? Furthermore, let's say you hate the small place and wants to move to a larger city, all your sweat equity will be gone. Are you going to join a neph group, start all over again with a starting salary of 200k/year and work 3-4 years and hope that they will make you partner? Do you start to see all the problems with this specialty? It's not a coincidence that nephrology is non-competitive.

you Nailed it

 

[georgestone]

I was discussing with one of our hospital nephrologist about the state of the speciality. He agrees with everything that is said here. But he said there are still options to earn money in rural areas. He said he knows one nephrologist who started a practice (10 yrs ago) in rural Midwest state, opened a dialysis unit, built a panel over 6 years and sold the practice/dialysis unit to Fresenius/Davita for 5 million. He repeated this in another rural town in another Midwest state but in a shorter time span of 4 years and sold it for another 5 million. It seems this guy has a net worth of 20 million now and he is in his mid 40s.

good for him , this aint the norm though , one can waste 2 years based on this story and try their luck out , likelihood of success is low but again there are outliers

 

[georgestone]

I was offered starting 300 k salary by a private practice in a small town and the members were making 500 k , but they had a crushing life style , working long hours , 40-50 patients on weekends
and guess what
when the competition arrived , their lives got even harder , they had to work even harder to provide a good service , more calls & even more weekends etc

I decided not to go with that offer and did CCM fellowship there after
I am happy with what I did and though shift work isn't ideal either , we all realize working 250-300 days a year or even more may shorten life span a little bit

 

[NewYorkDoctors]

When I started my second fellowship in PCCM, I attended a city wide ultrasound course. This is NYC so the faculty from Northwell - NSLIJ and Montefiore - which are big on CCM Ultrasound - conduct this course prepandemic. This is all new PCCM and CCM fellows in the tristate region. It is a POCUS course. There is some didactics on renal imaging. But the renal imaging is essentially just focused on hydronephrosis, nephrolithiasis, and maybe pyonephrosis.

One of the images was supposed to focus on the hydronephrosis but also had features of medullary sponge kidney. That is it seemed to have increased echogenicity of the renal pyramids and also findings nephrocalcinosis. One of the other Renal - CCM fellows was very excited and shouted that out.

He got laughed out of the room. it was purely in good fun and non malicious. But it also highlights how nephrology can't see the forest for the trees in general. (or maybe in this case, can't see the paintbrush..? no..? crickets? nvm...)

 

[Renal_Prometheus]

When it comes down to it, it's all about the money. 20 yrs ago when nephrology was highly lucrative, there were no complaints about quality of applicants or that the field was not innovative enough. If the money is right, people are happy to stick a camera up someones rear and still go home and smile about it. When there is lack of money, then you hear all these complaints about lack of innovation, quality of applicants, bad lifestyle, graduates not wanting to practice in their own specialty, etc... You can name a million things, but it all circles back to the almighty dollar, or lack thereof.

 

[NewYorkDoctors]

This clip always gave me a good chuckle. But we could really use something like this. This would no doubt destroy the Dialysis-Industrial Complex

 

[Renal_Prometheus]

"Nephrology is dead" has become the official 2021-2022 Nephrology Fellowship Application Cycle thread!

 

[NewYorkDoctors]

"Nephrology is dead" has become the official 2021-2022 Nephrology Fellowship Application Cycle thread!

No need to post interview dates ! You’re all guaranteed to match ! After that you’re all guaranteed to scramble fill ! Also with likely online interviews only , you won’t have a chance to see how miserable everyone actually is ! (Outside of the top academic programs of course - let’s give credit to where credit is due )

 

[georgestone]

2020 was a relatively better year for Nephrology , likely virtual interviews sparked curiosity among candidates to apply broader
the new cycle has started , lets see if this cycle breaks the cycle of Low number of applicants

 

[Renal_Prometheus]

Even before the pandemic, the lowered tiered fellowship programs were offering virtual interviews. Desperation knows no bounds.
If they could get away with taking a college grad, with no medicine training, they would. Right now they are preying on the IMGs who couldn't make into IM residency. Once that dries up, I'm sure there's always another group of desperate individuals they could prey on.

 

[NewYorkDoctors]

Even before the pandemic, the lowered tiered fellowship programs were offering virtual interviews. Desperation knows no bounds.
If they could get away with taking a college grad, with no medicine training, they would. Right now they are preying on the IMGs who couldn't make into IM residency. Once that dries up, I'm sure there's always another group of desperate individuals they could prey on.

Night Nephrology call is not hard at all. It just requires someone to physically be there in order to bill properly and to stave off potential lawsuits.

ICU night team can take care of severe hyponatremia just fine
Hospitalist/Nocturnist can take care of most other electrolyte issues
Other AKI? Trial of fluids for everyone vs trial of diuretics and then call renal in the morning if they have AKI on CKD.


But what is the one thing that the faculty renal attendings don't want the headache of? Missed HD fluid overload. Or if CTICU wants urgent stat CRRT started right out of the OR because the CT Surgeon cannot afford to have any bad outcomes for their high risk CABG patients (and from those patient's perspective, the CABG was usually an elective procedure. Therefore, I do agree all stops should be done to ensure they dont worsen after the surgery) Yes you can call the HD nurse in and set things up and remotely write an order. But one cannot legally bill without having someone... like the fellow... trudge in there... look at the ventilator screen blankly for a bit, squeeze for edema (it's everywhere!) and attempt to auscultate lung sounds (it's atelectatic due to laying down!) and then find someone to help them sign a consent form.
Since most of these things can be done with the remote EMR these days (chart reviewed and all), they just need a warm body to trudge in there. Therefore, anyone who is eligible to be a renal fellow can be one!

Most other specialties with 24 hour service (like CCU, MICU) usually implement night shift / night float.
I am not sure any other medicine subspecialty has such fatiguing night calls or emergencies otherwise.


And nothing against hard tiring work. But there is no pot of gold at the end of the rainbow for Nephrology (as detailed at length in previous posts) . Better to work super hard as a CCU or PCCM fellow overnight (which may not truly be night float at some places but be in an in house 24 + hour call with second day excusal of day time duties) and at least have something substantial to show for it afterward.

 

[Renal_Prometheus]

I think we just want applicants going into nephrology with complete transparency, realistic expectations, and understanding of where this specialty is at and why it’s non-competitive. I can tell you from my personal experience that fellowship programs will lie in your face and reality of private practice is much worse. Ultimately my co-fellows payed the ultimate price as one after the other eventually everyone left the specialty. It’s horrifying site to those people who are brainwashed by academics to believe that nephrology is still a lucrative specialty and that applicants misunderstand it because eventually you will make decent money after partnership. See all my previous posts about that trap. No, nephrology is much worse in the real world. In the end , most will end up back to hospitalist because you just get tired of the exploitation. They are dangling a carrot in front of you, but you will never reach the carrot. They prey on your hope. Don’t live on hopium. Reality is in front of your eyes; specialty can’t fill spots for a reason right? Don’t overthink it

 

[georgestone]

Night Nephrology call is not hard at all. It just requires someone to physically be there in order to bill properly and to stave off potential lawsuits.

ICU night team can take care of severe hyponatremia just fine
Hospitalist/Nocturnist can take care of most other electrolyte issues
Other AKI? Trial of fluids for everyone vs trial of diuretics and then call renal in the morning if they have AKI on CKD.


But what is the one thing that the faculty renal attendings don't want the headache of? Missed HD fluid overload. Or if CTICU wants urgent stat CRRT started right out of the OR because the CT Surgeon cannot afford to have any bad outcomes for their high risk CABG patients (and from those patient's perspective, the CABG was usually an elective procedure. Therefore, I do agree all stops should be done to ensure they dont worsen after the surgery) Yes you can call the HD nurse in and set things up and remotely write an order. But one cannot legally bill without having someone... like the fellow... trudge in there... look at the ventilator screen blankly for a bit, squeeze for edema (it's everywhere!) and attempt to auscultate lung sounds (it's atelectatic due to laying down!) and then find someone to help them sign a consent form.
Since most of these things can be done with the remote EMR these days (chart reviewed and all), they just need a warm body to trudge in there. Therefore, anyone who is eligible to be a renal fellow can be one!

Most other specialties with 24 hour service (like CCU, MICU) usually implement night shift / night float.
I am not sure any other medicine subspecialty has such fatiguing night calls or emergencies otherwise.


And nothing against hard tiring work. But there is no pot of gold at the end of the rainbow for Nephrology (as detailed at length in previous posts) . Better to work super hard as a CCU or PCCM fellow overnight (which may not truly be night float at some places but be in an in house 24 + hour call with second day excusal of day time duties) and at least have something substantial to show for it afterward.

Nephrology calls can be a real pain in the - - - -
regardless how little one has to do during that physical presence , imagine if you have to go to hospital 3 times a night for the same reason but diff patients and then you have to work from 7 am till 5 or what ever
these calls are dumb , useless , but yes they generate RVU/Billing at the expense of some one
Lot of programs mandate neph fellows to physically see the patient if its a ICU consult , which can be bogus a consult too
cr jumped from baseline of 1.9 to now 2.5 and there goes a Neph consult in the middle of night and the fellow has to see the patient , its Archaic , dumb
there is a reason why Neph attending's have little respect , they are known to be timid , indecisive and simply out of touch

 

[elgaeCB]

Nephrology calls can be a real pain in the - - - -
regardless how little one has to do during that physical presence , imagine if you have to go to hospital 3 times a night for the same reason but diff patients and then you have to work from 7 am till 5 or what ever
these calls are dumb , useless , but yes they generate RVU/Billing at the expense of some one
Lot of programs mandate neph fellows to physically see the patient if its a ICU consult , which can be bogus a consult too
cr jumped from baseline of 1.9 to now 2.5 and there goes a Neph consult in the middle of night and the fellow has to see the patient , its Archaic , dumb
there is a reason why Neph attending's have little respect , they are known to be timid , indecisive and simply out of touch

Bro what person consults nephro in the middle of the night for a Cr bump of 1.9 to 2.5? That's just says incompetent physician to me

 

[NewYorkDoctors]

Bro what person consults nephro in the middle of the night for a Cr bump of 1.9 to 2.5? That's just says incompetent physician to me

you’d be surprised ... PA led service , private not in house cardiology service , CT surgery , psych... but usually this is easily turfed to the morning - give some reccs for fluids / diuretics and lab orders and see in AM . As a second year fellow near the end I used to do this and then not tell the neph attending until morning . Oh they JuST called me as I was waking up ... lol

but as the fellow , you ar mandated by your attending to go in . To stave off potential bad outcome lawsuits (unlikely ) and also to get that extra calendar day of billing . Yes gotta work to get those RVUs

 

[Renal_Prometheus]

Nephrology calls can be a real pain in the - - - -
regardless how little one has to do during that physical presence , imagine if you have to go to hospital 3 times a night for the same reason but diff patients and then you have to work from 7 am till 5 or what ever
these calls are dumb , useless , but yes they generate RVU/Billing at the expense of some one
Lot of programs mandate neph fellows to physically see the patient if its a ICU consult , which can be bogus a consult too
cr jumped from baseline of 1.9 to now 2.5 and there goes a Neph consult in the middle of night and the fellow has to see the patient , its Archaic , dumb
there is a reason why Neph attending's have little respect , they are known to be timid , indecisive and simply out of touch

the quality of applicants going into nephrology is not the same vs a decade ago. I know IMGs who could not land an IM residency, get numerous interviews at mid tier university programs. He got into fellowship, but couldn’t get into a residency afterwards, so still can’t practice medicine in the US. These are the type of applicants that nephrology programs are fighting for nowadays. What do you expect the outcome to be. Does anyone actually expect to have a lucrative and fulfilling career when this is the reality on the ground?

 

[NewYorkDoctors]

a colleague of mine is a US IMG - did his residency at a mid tier academic affiliated tertiary care hospital . Loved nephrology. Did not rank in the in house nephrology program (he tells me 4 fellows total - they have CVVHD using the NxStage - no transplant in house - Heme runs PLEX- and IR does renal biopsies - no pocus training - no specialty clinics - frequent night consults for their fellows - shudders ... ) got into one of the nations best nephrology programs - then went back to his home institution to join the renal faculty.

While his career arc is certainly a fulfilling one and highlights one of the avenues that IMg/FMg can have academic success, it also highlights why these mid to low tier programs even exist ? He tells me all four fellows currently are a mix of foreign nephrologists no IM residency Done yet for whom they sponsored the visa and two others were cardiology fail to match who were sold on the fact they could be the “heart failure “ doctor and help their chances at doing a future fellowship . Sigh

 

[NewYorkDoctors]

A case for nephrology

I hope that with good mentorship and vocal enthusiasm, nephrologists can turn the tide of decreased popularity that has plagued our field of late.

www.kevinmd.com

This academic nephrologist is trying her best to sell the positives of nephrology . While I agree with many of her points about how an academic nephrology career can be very fulfilling for those who make it , this individual still does not seem to see what life is like outside of the ivory tower .

The Dialysis Industry is Failing America - Joe Lonsdale

America’s reactive model of kidney care enriches an oligopolistic dialysis industry, wastes billions of dollars a year, and creates worse health outcomes for millions of Americans each decade

joelonsdale.com

outside of the ivory tower of academia is a desolate wasteland that is marred by pure capitalistic greed . The dialysis - industrial complex is no different than any other of the industrial complexes . Dominated by corporations , deregulated by the government (to an extent - this is not as bad as fossil fuels ) , and multiple barriers exist preventing the “ordinary “ doctors without insider connections from making it big. See all prior posts .

yes you could work butt off and build your own HD patient panels and medical practice etc ... but that same effort can be used in other more lucrative specialties for far less headache and heartache

the unpopularity basically boils down to earning potential. The ivory tower academicians who are the leaders of the filed are just painfully unaware of these facts (or are aware and just want warm bodies so their own night calls are more bearable )

From a population perspective the current model of esrd care is just broken and favors profiting off of people as pieces of meat . There is also moral hazard in this specialty .

while I do practice non HD nephrology and do enjoy it as a side specialty to keep myself entertained , I am very glad I do not practice HD . I go full court on my ckd patients to keep them as healthy as possible . I don’t have non adherent patients because I do not advertise myself and only those patients who want to avoid HD come to me . I have a connection to renal transplant from where I trained .

 

[Renal_Prometheus]

a colleague of mine is a US IMG - did his residency at a mid tier academic affiliated tertiary care hospital . Loved nephrology. Did not rank in the in house nephrology program (he tells me 4 fellows total - they have CVVHD using the NxStage - no transplant in house - Heme runs PLEX- and IR does renal biopsies - no pocus training - no specialty clinics - frequent night consults for their fellows - shudders ... ) got into one of the nations best nephrology programs - then went back to his home institution to join the renal faculty.

While his career arc is certainly a fulfilling one and highlights one of the avenues that IMg/FMg can have academic success, it also highlights why these mid to low tier programs even exist ? He tells me all four fellows currently are a mix of foreign nephrologists no IM residency Done yet for whom they sponsored the visa and two others were cardiology fail to match who were sold on the fact they could be the “heart failure “ doctor and help their chances at doing a future fellowship . Sigh

2 of my buddies went to work in private practice, got completely exploited by their partners, had too much pride to go back to hospitalist, so ended up taking positions as academic nephrologists at university programs. Couldn't get the money, but at least have the lifestyle by living off the backs of residents/fellows. Some of these academic nephrologists are people who couldn't make it private practice. And their job now is to convince incoming applicants that nephrology is actually worth doing. I'm not joking at all. This is real. Just imagine the psychological acrobatics to justify these actions. It's like victim takes revenge on the specialty by exploiting new, unsuspecting residents. New grads sometimes have too much trust in authority figures. They don't realize these guys are looking at them as meat to be used for scut work and night calls.

 

[sloh]

2 of my buddies went to work in private practice, got completely exploited by their partners, had too much pride to go back to hospitalist, so ended up taking positions as academic nephrologists at university programs. Couldn't get the money, but at least have the lifestyle by living off the backs of residents/fellows. Some of these academic nephrologists are people who couldn't make it private practice. And their job now is to convince incoming applicants that nephrology is actually worth doing. I'm not joking at all. This is real. Just imagine the psychological acrobatics to justify these actions. It's like victim takes revenge on the specialty by exploiting new, unsuspecting residents. New grads sometimes have too much trust in authority figures. They don't realize these guys are looking at them as meat to be used for scut work and night calls.

Sounds like a pyramid scheme....oh wait....it is!

 

[NewYorkDoctors]

Publish or perish as they say in academic medicine . An academic doctor who doesn’t publish is like ... a duck who can’t swim ? The analogies are plentiful

Addendum:

This is amazing. 100K views.

 

[Renal_Prometheus]

At least the author here acknowledges that the income prospect of a nephrologist can be lower than a hospitalist. Some academics won't even acknowledge that. I've also said this in other threads: IMGs with visa issues should definitely not go into nephrology! You will get exploited and be much worse off!

Hospitalist medicine and nephrology​

The declining interest in nephrology perhaps parallels the rise in hospitalist medicine. Hospital medicine offers several potential advantages to IMGs, such as more geographic options, a better job market, and relaxed timelines for filing green card applications. The more favorable work schedules of hospitalist jobs are equally attractive to both USMGs and IMGs. The prospects of income in this field may be similar or slightly better, or they may be worse.

Some IMGs who train in nephrology choose a hospitalist job because of better opportunities in terms of geographic location and income. Typically, hospitalist employers may sponsor a green card ahead of time for a more qualified physician who has received advanced training in a subspecialty field and has taken care of patients with very complicated conditions. Many IMGs have heard the statement from recruiters that “nephrologists make excellent hospitalists.” Our IMG colleagues who have chosen to become hospitalists invariably base this decision on lifestyle, geographic preference, and easy-to-find green card jobs in a better location and—more importantly—in a timely fashion. Frequently, they aspire to return to nephrology, either full time or part time. Their hope is to make connections with local nephrology groups that will help them find a job and resolve immigration issues. However, depending on the time required for processing a green card, the available job opportunities in their preferred area, and the duration of a partnership track, IMGs may return to nephrology after several years or, in some cases, choose to continue a career in hospital medicine.

Although there are no easy solutions to these issues, a change in legislation regarding visa options to prevent a workforce crisis in nephrology may be of value. Changes to visa requirements may also attract more IMGs to fellowship training in nephrology. Collaboration by the international nephrology societies may be of value in preventing the global future workforce shortage we face. And attracting IMGs to nephrology may best begin in their medical schools and extend to residency training programs in community hospitals here in the United States, where enthusiastic, committed nephrologists can be seen as excellent teachers and role models.

Why Are International Medical Graduates Not Choosing Nephrology?

"Why Are International Medical Graduates Not Choosing Nephrology?" published on Jul 2015 by American Society of Nephrology.

www.kidneynews.org

 

[NewYorkDoctors]

An appeal to industry leaders: Take charge of the future of nephrology

The starting salary difference can be as high as $60,000, with an initial salary $240,000 for a hospitalist vs. approximately $180,000 for a private practice nephrologist.2

Even larger private practices that successfully sign new recruits have difficulty retaining them. Some 50% leave within the first 5 years.2 This is a huge resource drain on our specialty

this news article cites some papers that demonstrates the data . Touché

 

[blue.jay]

This thread has many similarities to this post

Why Liberal Arts Degrees Are Worthless

Today more than ever, it is critical for a serious-minded young person to avoid the pitfalls of picking a worthless major in college. Huge numbers of college grads have discovered that their degrees were next to worthless, and went on to get the exact same low-paying service jobs that their parents

www.linkedin.com

 

[NewYorkDoctors]

From a large community perspective, the nephrology workforce (physicians, nurses, dietitians, administrators, social workers / case managers, i might be missing a few) are just pawns for the big corporate behemoths. Crony capitalism is rampant in the West. This post is not meant to be a debate on the merits of socialism vs capitalism. But whereas laborers can unionize and strike, the medical professionals cannot do those things. What can you do? Choose to not enter Nephrology to begin with. Just like in other industries, there is outsourcing (in this case FMGs). If they give you a visa or a chance to enter the US, then that might be worth it for the individual.

Again the exception are if you do plan to be a clinician educator (and have job security at the expense of making more money ... which is fine btw for any new thread readers) or clinician scientist. Those are the Nephrologists worth respecting. The other alternative is if you plan to make something out of Nephrology yourself. See my prior posts on piggybacking Nephrology to IM or another specialty.

 

[Questionsaboutmedicine]

At least the author here acknowledges that the income prospect of a nephrologist can be lower than a hospitalist. Some academics won't even acknowledge that. I've also said this in other threads: IMGs with visa issues should definitely not go into nephrology! You will get exploited and be much worse off!

Hospitalist medicine and nephrology​

The declining interest in nephrology perhaps parallels the rise in hospitalist medicine. Hospital medicine offers several potential advantages to IMGs, such as more geographic options, a better job market, and relaxed timelines for filing green card applications. The more favorable work schedules of hospitalist jobs are equally attractive to both USMGs and IMGs. The prospects of income in this field may be similar or slightly better, or they may be worse.

Some IMGs who train in nephrology choose a hospitalist job because of better opportunities in terms of geographic location and income. Typically, hospitalist employers may sponsor a green card ahead of time for a more qualified physician who has received advanced training in a subspecialty field and has taken care of patients with very complicated conditions. Many IMGs have heard the statement from recruiters that “nephrologists make excellent hospitalists.” Our IMG colleagues who have chosen to become hospitalists invariably base this decision on lifestyle, geographic preference, and easy-to-find green card jobs in a better location and—more importantly—in a timely fashion. Frequently, they aspire to return to nephrology, either full time or part time. Their hope is to make connections with local nephrology groups that will help them find a job and resolve immigration issues. However, depending on the time required for processing a green card, the available job opportunities in their preferred area, and the duration of a partnership track, IMGs may return to nephrology after several years or, in some cases, choose to continue a career in hospital medicine.

Although there are no easy solutions to these issues, a change in legislation regarding visa options to prevent a workforce crisis in nephrology may be of value. Changes to visa requirements may also attract more IMGs to fellowship training in nephrology. Collaboration by the international nephrology societies may be of value in preventing the global future workforce shortage we face. And attracting IMGs to nephrology may best begin in their medical schools and extend to residency training programs in community hospitals here in the United States, where enthusiastic, committed nephrologists can be seen as excellent teachers and role models.

Why Are International Medical Graduates Not Choosing Nephrology?

"Why Are International Medical Graduates Not Choosing Nephrology?" published on Jul 2015 by American Society of Nephrology.

www.kidneynews.org

Wow. They flat out admitted that nephro makes less money than hospitalists.

Well, best of luck to all the nephro applicants.

 

[NewYorkDoctors]

Wow. They flat out admitted that nephro makes less money than hospitalists.

Well, best of luck to all the nephro applicants.

yes the only nephrologists making $300K plus have a large panel of HD patients. Using the CPT codes billing for seeing HD patients on HD 4 times a month is the "procedural CPT code" for nephrologist.

To get to that large panel of HD patients, you either need to be connected and your family/friends will let you become a partner and take over the business
or
You need to work super hard and live as an "ambulance chaser" of sorts for the hospital's ATN patients (and also smooch the internists / intensivists for consults) to build up that base.

Without chronic HD patients, the nephrologist does not have a "procedure" or a reliable CPT code to generate extra revenue from. Therefore, your office visits and hospital consults are the same as the internist's only with harder consults. moreover you cannot reliably set up a "99213 mill" by nephrology alone unless you have a large Managed Medicaid/Medicare population that has zero copay/coinsurance.
Commercial insurance patients have to pay about $40-$80 per specialist visit. Hence if the patients don't pay you, then insurance will pay you whatever was allowed minus that copay. So that complicated CKD5, HTN, anemia, secondary PTH, edema, i hate life patient that takes up 1 hour of your time (after all charting) that you can at most bill for as 99214 might allow $130 - but if it this is commercial insurance and patient has not yet reaached their out of pocket max, patient gotta pay it all. You send a bill and you get crickets and get google bombed for bad reviews since you didnt "cure their kidney disease."

Again, if you are THAT entrepreneurial, your efforts are better spent on another lucrative outpatient procedural based specialty like oh say.. general cardiology. go nuts with the echos, carotids, arterial duplexes, stress tests, nuclear scans, etc... print money at will. you don't even have to travel too far if you buy all the equipment yourself.

 

[Renal_Prometheus]

My issue with fellowship programs is that they engage in deception and false advertising to lure applicants into their program. If they would be straight up and say " hey, people are not coming into this specialty because money is bad and you work really hard; so please reconsider if money is really important to you", that would be perfectly good for both sides. You would get the applicants who are coming in for the right reasons. Instead, they lie in your face about the job prospects, applicants pin their hopes on false promises, and then when they graduate find out private practice is really horrendous and all these were lies, that's when resentment builds up towards the fellowship program. Why do you think we are trashing nephrology on this forum if we are doing well in private practice. So everything happens for a reason.

 

[georgestone]

Bro what person consults nephro in the middle of the night for a Cr bump of 1.9 to 2.5? That's just says incompetent physician to me

more than you can imagine
first year intern , or a senior staff all do it , I along with many other former fellows have experienced it way too many times

 

[georgestone]

Interventional Nephrology was once lucrative but in 2019 there were massive cuts and now unless one is a part of large group with hundreds of HD patients requiring TDC, fistulograms etc , it isnt worth doing either
the shortage in work force will be filled by IMG's etc and this will linger on for more years Till Kidney X project becomes fruitful LOL

 

[NewYorkDoctors]

Interventional Nephrology was once lucrative but in 2019 there were massive cuts and now unless one is a part of large group with hundreds of HD patients requiring TDC, fistulograms etc , it isnt worth doing either
the shortage in work force will be filled by IMG's etc and this will linger on for more years Till Kidney X project becomes fruitful LOL

Dunno if those artificial wearable kidneys will be allowed to flourish until the big HD duopoly can get in on the action and duopolize that too . Think fossil fuels and alternative energy . Its all about maximizing profits for the corporations . At least other medical specialties still give their doctors autonomy despite the corporate domination . Dialysis doctors (outpatient private practice ) are really no more than paper pushers and at best middle managers. Perverse incentives exist to “get as many pieces of meat to dialyze as possible.” There is a terrible job done at actual renoprotection and empowering ckd patients to make the right decisions . Why would you ? Less money that way . Sigh ..

Addendum: The excuse of "the patient is lazy, unhealthy, makes bad decisions, and has no willpower" is not a good excuse. There needs to be an attempt at tackling those issues first. If the patient really has no interest and blows you off despite a well meaning conversation and plan, then that person is hopeless and at least you tried. But most other private nephs really blow off CKD3/4 and do not make a real attempt at tackling each issue. Again why would they? the perverse incentive exists to get new "pieces of meat to dialyze."

 

[NewYorkDoctors]

ABIM sent out a Nephrology survey. Interesting. In general private practice nephs probably just do acute and chronic HD. CRRT probably is mostly limited to the faculty group at a larger university hospital as it requires full coordination between the ICU division and nursing staff. Probably only academic and transplant nephs do renal biopsies themselves.

For the applicants , be sure the program you want to match to will train you in all of these procedures . I mean temporary HD caths are okay to learn but even if you wanted to do it in real life (gigantic time sink unless you are also the ICU attending who has a dedicated time shift for this ) , your future hospitals and Lam practice insurance may not grant you the privilege of a central line placement.

But be sure your program has you do all of the other procedures at a steady clip

if the program does not offer you the chance to do all of these procedures regularly , then beware of going to that program .

Nephrology Certification Policy Survey​

The American Board of Internal Medicine Nephrology Board will be re-evaluating procedural requirements for ABIM Board Certification in Nephrology. The current requirements include the following:

• Placement of temporary vascular access for hemodialysis and related procedures
• Acute and chronic hemodialysis
• Peritoneal dialysis (excluding placement of temporary peritoneal catheters)
• Continuous renal replacement therapy (CRRT)
• Percutaneous biopsy of both autologous and transplanted kidneys

ABIM would like to know whether the list of currently required procedural competencies reflects how nephrology is currently practiced, or if some requirements should be eliminated or strengthened.

If your clinical work has been significantly different because of the pandemic, please base your responses on your typical (pre-COVID) practice when answering these survey questions.


Please indicate whether you have personally performed the below procedures or have supervised a trainee performing this procedure in the past year.
Temporary vascular access for hemodialysis and related procedures (non-tunneled dialysis catheter)

• No longer perform/none
• 1-5 per year
• 6-20 per year
• >20 per year

Percutaneous biopsy of both autologous and transplanted kidneys

• No longer perform/none
• 1-5 per year
• 6-20 per year
• >20 per year

Acute hemodialysis (e.g. acute hemodialysis for acute kidney injury) An infrequent part of my practice: Nephrologist is able to prescribe the therapy but the frequency is once or twice per year.

• Not part of my inpatient consult practice
• An infrequent part of my practice
• A regular part of my inpatient consult practice

Continuous renal replacement therapy (CRRT) - (PIRRT, CVVHD, etc.) An infrequent part of my practice: Nephrologist is able to prescribe the therapy but the frequency is once or twice per year.

• Not part of my inpatient consult practice
• An infrequent part of my practice
• A regular part of my inpatient consult practice

Chronic outpatient hemodialysis

• Not part of my practice
• Manage 1-20 outpatients on chronic hemodialysis
• Manage 21-50 outpatients on chronic hemodialysis
• Manage 51- 100 outpatients on chronic hemodialysis
• Manage > 100 outpatients on chronic hemodialysis

Chronic outpatient peritoneal dialysis

• Not part of my practice
• Manage 1-5 outpatients on peritoneal dialysis
• Manage 6-10 outpatients on peritoneal dialysis
• Manage > 10 outpatients on peritoneal dialysis

The procedures below, marked with an asterisk, are not on the current list of ABIM required procedures, but are possible additions.
Home hemodialysis*

• Not part of my practice
• Manage 1-5 outpatients on home hemodialysis
• Manage 6-10 outpatients on home hemodialysis
• Manage > 10 outpatients on home hemodialysis

Plasmapheresis* An infrequent part of my practice: Nephrologist is able to prescribe the therapy but the frequency is once or twice per year.

• Not part of my practice
• An infrequent part of my practice
• A regular part of my practice

Acute inpatient peritoneal dialysis for acute kidney injury*

• Not part of my practice
• Manage 1-5 inpatients on peritoneal dialysis
• Manage 6-10 inpatients on peritoneal dialysis
• Manage > 10 inpatients on peritoneal dialysis

Urgent-start peritoneal dialysis (initiating PD soon after PD catheter placement)*

• Not part of my practice
• Manage 1-5 urgent-start peritoneal dialysis
• Manage 6-10 urgent-start peritoneal dialysis
• Manage > 10 urgent-start peritoneal dialysis

Molecular adsorbent recirculating system (MARS)*An infrequent part of my practice: Nephrologist is able to prescribe the therapy but the frequency is once or twice per year.

• Not part of my practice
• An infrequent part of my practice
• A regular part of my practice

Please share any additional thoughts related to procedural competencies for ABIM Board Certification in Nephrology.

 

[Questionsaboutmedicine]

yes the only nephrologists making $300K plus have a large panel of HD patients. Using the CPT codes billing for seeing HD patients on HD 4 times a month is the "procedural CPT code" for nephrologist.

To get to that large panel of HD patients, you either need to be connected and your family/friends will let you become a partner and take over the business
or
You need to work super hard and live as an "ambulance chaser" of sorts for the hospital's ATN patients (and also smooch the internists / intensivists for consults) to build up that base.

Without chronic HD patients, the nephrologist does not have a "procedure" or a reliable CPT code to generate extra revenue from. Therefore, your office visits and hospital consults are the same as the internist's only with harder consults. moreover you cannot reliably set up a "99213 mill" by nephrology alone unless you have a large Managed Medicaid/Medicare population that has zero copay/coinsurance.
Commercial insurance patients have to pay about $40-$80 per specialist visit. Hence if the patients don't pay you, then insurance will pay you whatever was allowed minus that copay. So that complicated CKD5, HTN, anemia, secondary PTH, edema, i hate life patient that takes up 1 hour of your time (after all charting) that you can at most bill for as 99214 might allow $130 - but if it this is commercial insurance and patient has not yet reaached their out of pocket max, patient gotta pay it all. You send a bill and you get crickets and get google bombed for bad reviews since you didnt "cure their kidney disease."

Again, if you are THAT entrepreneurial, your efforts are better spent on another lucrative outpatient procedural based specialty like oh say.. general cardiology. go nuts with the echos, carotids, arterial duplexes, stress tests, nuclear scans, etc... print money at will. you don't even have to travel too far if you buy all the equipment yourself.

Oh deductibles didn't even cross my mind. They don't teach you that in residency.

Imo, people will pay when it comes to their heart. In fact they sometimes are requesting for a stress test, carotids, etc. I didn't do much outpt nephro in residency and mostly did inpt. I guess most nephro pts aren't asking of a UA or kidney US, lol.

 

[Renal_Prometheus]

I guess there really isn't going to be a 2021-2022 nephrology fellowship application thread this year hugh? Maybe for the best. Although I still think when everything is said and done, unfilled spots will fill in scramble and guess what, no real shortage of grads and no need to raise starting pay. More helpless grads for malignant neph groups to exploit because they don't have bargaining power. When did this specialty turn into a grinding machine on desperate IMGs.

 

[NewYorkDoctors]

I guess there really isn't going to be a 2021-2022 nephrology fellowship application thread this year hugh? Maybe for the best. Although I still think when everything is said and done, unfilled spots will fill in scramble and guess what, no real shortage of grads and no need to raise starting pay. More helpless grads for malignant neph groups to exploit because they don't have bargaining power. When did this specialty turn into a grinding machine on desperate IMGs.

It’s a byproduct of every other capitalist industry . When the goal is increase profits but the means of production are limited (only so many HD patients and Medicare fee schedule is capped ) , then one has to cut costs and outsource .

yes there is no need for a thread . Everyone who applies will match and likely get into their top three rank choices . They will deserve it also and they will enjoy their careers . It’s the scramble people or those who are “on the fence “ with the main match with other subspecialties who need to be sure they read these posts and know not to go into this without a definitive plan (see this whole thread )

again nephrology private practice is dead

Academic nephrology will keep thriving (as long as there are fellows to support it )

if you plan on joining academic nephrology , then pay your dues as a fellow and keep moving it forward . Perform groundbreaking research and improve kidney outcomes for the world .

otherwise don’t enter nephrology fellowship and expect to succeed in private practice nephrology unless you have a clear plan (see all prior posts )

 

[NewYorkDoctors]

The cause of this decrease is likely multifactorial. Surveys show the most prominent reasons trainees do not enter nephrology relate to workforce issues (long work hours, a poor life/work balance, an overwhelming and unpredictable workload, and stressful on call experiences) and patient factors (medical complexity and behavioral issues) (3,4). When trainees do enter nephrology, many of them are less than “extremely” or “very” satisfied with their selection, including approximately 10% who are frankly dissatisfied (5). Distressingly, nearly 20% of graduating nephrology fellows regret choosing nephrology, and approximately one quarter noted poor teaching and mentoring by faculty and an overall poor experience during fellowship (5,6).

What Are We Doing? A Survey of United States Nephrology Fellowship Program Directors

Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship’s educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and...

cjasn.asnjournals.org

if 1/4 of graduating fellows noted poor teaching and mentoring then one wonders why 1/4 of these programs don't fold.

The top fellowships have amazing teaching in the top academic university based fellowships. I would know.

The bottom 1/4 are just indentured servant mills. Trust me I know the type. Professor of Medicine in Nephrology is the director and program director. 80 years old+ who has a strangle hold on the Division and does not allow innovation. Does not participate in MOC and has little to offer except what he/she researched in the 1960s and 1970s. Gets flummoxed by the incoming new fellows who learned their Internal Medicine from modern physicians and MKSAP and just yells and screams at them. Wants them to "unlearn what they learned in residency." Wonders why the fellows don't get off his/her lawn.

It's the scramble candidates who should be very wary. Usually the positions that dont fill comprise of these type of programs.

 

[Renal_Prometheus]

Even with this knowledge, there are still enough applicants each year to keep the servant mills turning. Reason? Hope of escape from their current job. Whether nephrology will work out down the road is a different matter. For now, nephrology provides easy escape because it's easy to get into. That is it's greatest attribute. Anyone with logic would know that easy to get into specialties are not what you want to be going into. But we are talking about hope, and not logic.

 

[NewYorkDoctors]

Even with this knowledge, there are still enough applicants each year to keep the servant mills turning. Reason? Hope of escape from their current job. Whether nephrology will work out down the road is a different matter. For now, nephrology provides easy escape because it's easy to get into. That is it's greatest attribute. Anyone with logic would know that easy to get into specialties are not what you want to be going into. But we are talking about hope, and not logic.

Of my nephrology colleagues, the successful ones (success is not solely defined by how much money one makes) are the ones who did sub-subspecialty training and then got an academic faculty position in a top university program (many colleagues) or the ones who piggy backed their Nephrology training to Internal Medicine and run a successful private practice (one other individual I know other than myself who did this path)

The ones (many) who were not so lucky all did not find a satisfactory private practice traditional nephrology job otherwise are back as hospitalists now. They regret the two wasted years.

 

[Renal_Prometheus]

Same fate with majority of nephrology friends. Seems like the only ones practicing are older nephrologist with established dialysis JVs or other revenue streams. Younger guys just get worked to death and end up quitting

 

[NewYorkDoctors]

What The 2019 Fellowship Match Tells Us About The Future Of American Medicine

Last week, the National Resident Match Program released its annual data report on the most recent fellowship match for positions to begin in July 2019. The fellowship matches take place between May…

hospitalmedicaldirector.com

From the MGMA report, it is apparent that based on median wRVUs, nephrologists work very hard, in fact, harder than any other specialists except cardiologists. However, they make $140,000 less than cardiologists. When the MGMA data is expressed as total compensation per wRVU, it appears that nephrologists make the second lowest amount of money per wRVU compared to other specialists (note that the MGMA total compensation per wRVU is calculated with a complicated equation and that not all practices report both total compensation plus wRVUs so the reported values will be different than if you simply divide the mean total compensation by the median wRVUs for any given specialty).

this data does sum up how hard a nephrologist works. You work hard and you ... don’t ? ... play hard.

 

[Renal_Prometheus]

If you think that doing a specialty that is unable to fill fellowship spots and is desperate to take anyone with a heart beat, has no financial
consequences down the road, then please PM me as I want to sale you the Brooklyn bridge. But this is what fellowship programs are saleing to you. Beware, they take no responsibility when you destroy your own career

 

[Renal_Prometheus]

It's interesting how some these academic nephrologist act high and mighty and are completely oblivious to the fact that the specialty has become a laughing stock They act as if they are doing fellows a favor by taking them, when in reality it should be the other way around. Some of these old timers still hang onto a delusional sense of reality. Most of the younger attendings know, but they are too afraid to speak up and pop the old guy's bubble.

 

[NewYorkDoctors]

Yeah the told timers do not participate in MOC. Although most older doctors in all specialties do not , some are still actively engaged in scholarly activity . unless you’re still publishing high quality material at over age 70 but still staying on as director of nephrology , then I just have to say ... bye bye boomer