Nephrology is Dead - stay away

[georgestone]

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.

I agree , they are out of depth , esp for icu world they have literally nothing to Add except for Anuria so that they can start CRRT, they cant even interpret basic hemodynamic data like PPV or SVV and are clueless about it , all they do is to monitor creatinine and write a lousy progress note and thts it
but despite your and others statements which are eye openers , candidates will still fall prey and this story will linger on
until
ABIM /ACGME no longer allows this extortion or Nephrology suffers more crippling losses from CMS

---

Members don't see this ad.

 

[NewYorkDoctors]

I agree , they are out of depth , esp for icu world they have literally nothing to Add except for Anuria so that they can start CRRT, they cant even interpret basic hemodynamic data like PPV or SVV and are clueless about it , all they do is to monitor creatinine and write a lousy progress note and thts it
but despite your and others statements which are eye openers , candidates will still fall prey and this story will linger on
until
ABIM /ACGME no longer allows this extortion or Nephrology suffers more crippling losses from CMS

A few years back there was a recorded lecture from the Rogosin institute lecture series circa 2013 (for the Weill Cornell medical center ) in which a pccm physician is lecturing to the Nephrologist
S about pocus and hemodynamics. The nephrologist seemed bored and only wanted to talk about whether there is evidence of renal swelling or not . Sigh ... it’s a closed minded community

 

[Renal_Prometheus]

I agree , they are out of depth , esp for icu world they have literally nothing to Add except for Anuria so that they can start CRRT, they cant even interpret basic hemodynamic data like PPV or SVV and are clueless about it , all they do is to monitor creatinine and write a lousy progress note and thts it
but despite your and others statements which are eye openers , candidates will still fall prey and this story will linger on
until
ABIM /ACGME no longer allows this extortion or Nephrology suffers more crippling losses from CMS

There will always be IMGs who fall prey to their smiling faces and promises of lucrative career. It’s a easy out for those who otherwise could not get into a competitive specialty. Hope is what keeps dreams alive. If you extinguish hope, then there would be no more tragedies

 

[NewYorkDoctors]

The biggest gripe with nephrology education I have is how many of the old timers do not participate in MOC . While this is not a personal issue about knowledge (as the older docs have published much in their specialized niches ), it is a problem when the education is centered around “unlearning what you learned in internal medicine .” This one old timer nephrologist who published a paper in the 1980s along with cardiothoracic surgeons on pericardial effusions got livid when he asked one of his fellows how to manage pericardial tamponade . Yes the answer is ultimately pericardiocentesis or pericardial window . But that cannot be done stat . All residents in ccu learn that you need to maintain preload in that situation until definitive therapy can be done . When the fellow answered IV fluids - the old timer lost his mind and berated the fellow for being stupid and that will overload the patient (not realizing that does NOT happen in that situation )

had the old timer participated in MOC and read mksap at the very least , such a berating experience would. It have happened .

I’m all for beratement as a form of punishment if the trainee were totally off base and did the wrong thing that harmed the patient .

but not for this nonsense .

anorwhr common grip is ongoing use of urine electrolytes forget vlume status. The only paper I know of that is a small RCT was how you can use urine sodium to distinguish prerenal from ATN in a 1980s university of Colorado paper in n=60 . The gold standard wasn’t even biopsy ... al icu literature shows urine electrolytes agave an AUC of 0.5 - flip a coin ?

again bye bye boomer . Times up . Our generation will maintain MOC and be better in our advanced age . If I go demented in my later years , I’ll retire and stop educating housestaff and fellows . I’m not go by to live on the coattails of past glories and strut around like I’m anything important if I ever stop putting out new research .

again - I have the utmost respect for elderly physicians who remain active in academia and continue to contribute their knowledge and expertise to help field . I just do not respect the older nephrology generation who are way past their prime and have nothing left to offer other than “get off my lawn.”

 

[rokshana]

The biggest gripe with nephrology education I have is how many of the old timers do not participate in MOC . While this is not a personal issue about knowledge (as the older docs have published much in their specialized niches ), it is a problem when the education is centered around “unlearning what you learned in internal medicine .” This one old timer nephrologist who published a paper in the 1980s along with cardiothoracic surgeons on pericardial effusions got livid when he asked one of his fellows how to manage pericardial tamponade . Yes the answer is ultimately pericardiocentesis or pericardial window . But that cannot be done stat . All residents in ccu learn that you need to maintain preload in that situation until definitive therapy can be done . When the fellow answered IV fluids - the old timer lost his mind and berated the fellow for being stupid and that will overload the patient (not realizing that does NOT happen in that situation )

had the old timer participated in MOC and read mksap at the very least , such a berating experience would. It have happened .

I’m all for beratement as a form of punishment if the trainee were totally off base and did the wrong thing that harmed the patient .

but not for this nonsense .

anorwhr common grip is ongoing use of urine electrolytes forget vlume status. The only paper I know of that is a small RCT was how you can use urine sodium to distinguish prerenal from ATN in a 1980s university of Colorado paper in n=60 . The gold standard wasn’t even biopsy ... al icu literature shows urine electrolytes agave an AUC of 0.5 - flip a coin ?

again bye bye boomer . Times up . Our generation will maintain MOC and be better in our advanced age . If I go demented in my later years , I’ll retire and stop educating housestaff and fellows . I’m not go by to live on the coattails of past glories and strut around like I’m anything important if I ever stop putting out new research .

again - I have the utmost respect for elderly physicians who remain active in academia and continue to contribute their knowledge and expertise to help field . I just do not respect the older nephrology generation who are way past their prime and have nothing left to offer other than “get off my lawn.”

You really think paying the abim 2000 bucks to do MOC makes anyone a better physician??
Please MOC is beyond worthless.

doing CME for your specialty and keeping up with the literature as an effort for life long learning helps with maintaining knowledge… not lining the ABIMs pockets.

 

[Renal_Prometheus]

You really think paying the abim 2000 bucks to do MOC makes anyone a better physician??
Please MOC is beyond worthless.

doing CME for your specialty and keeping up with the literature as an effort for life long learning helps with maintaining knowledge… not lining the ABIMs pockets.

I never understood your fascination with this nephrology thread even though you don’t practice it.

 

[NewYorkDoctors]

You really think paying the abim 2000 bucks to do MOC makes anyone a better physician??
Please MOC is beyond worthless.

doing CME for your specialty and keeping up with the literature as an effort for life long learning helps with maintaining knowledge… not lining the ABIMs pockets.

Fair enough. I do not request the old timers to pay $2000 every 10 years (or the 2 year check in).

But do you really think a general subspecialist (not the niche super specialized like glomerular disease, bone marrow transplant, interventional cardiology, EP, just to name a few) is better off without an updated broad base of Internal Medicine knowledge? I didn't think so. Not a personal attack on you. Rather, I am dispelling the straw person argument about the MOC $2000 fee.

To reiterate my point - when Nephrology older and out of touch program directors and directors are trying to "Make Nephrology Great Again," they are not doing new trainees any favors by not staying up to date with Internal Medicine updates (which can be obtained easily by just reading MKSAP) and then trying to make new fellows "unlearn what they learned" in IM residency. Furthermore, these old timers do not even take MOC for Nephrology. THe younger (I merely mean age 65 and under - my post is pointing out how some progrmas still have 80+ directors of nephrology holding back advancement because they want to keep lining their pockets from JVs and their chronic HD center that is attached to the hospital - making money is fine but please go private and do not prevent the advancement of academically rigorous younger academicians) and more academically rigorous programs do not have this problem. It's the mid tier and lower tier neph programs that have these intellectual black holes.

I never understood your fascination with this nephrology thread even though you don’t practice it.

Now now no need to get personal. Rokshana is just adding his/her two cents. All comments welcome. Beside endocrine overlaps quite a bit with nephrology and we do share the same subforum page.

 

[Renal_Prometheus]

What I saw on the news this week reminded me of the parallels to nephrology. Apparently, US intelligence was shocked and blind sighted by the fact that Taliban took control of afghanistan within 10 days of our troops departing. Well, if you actually went on the ground and talk with the locals, this was not shocking at all, and completely expected if you knew what was happening on the ground. Same parallel in private practice nephrology. Academics will deny(knowingly or not) that specialty is not worth doing and that half of the graduates are returning to hospitalist medicine because there's no money to be made in nephrology. But if you go ask a private practice nephrologist, who is willing to be honest with you and not stuck up with pride, nephrologist turning to hospitalist medicine is completely expected and common outcome. So who do you believe? People on the ground or academics sitting in ivory tower who want you to believe a certain narrative because they needs bodies to feed to scut work machine?

 

[NewYorkDoctors]

While comparing nephrology to an unconstitutional war (all is wars since Korea have been unconstitutional in that there was no Congress declaration of war ) is a bit of a stretch , the point is well taken. Personally it further highlights the parallels between the “industrial complexes .” Nephrology and chronic dialysis is just a prime example of subspecialization within the medical industrial complex - the dialysis industrial complex .

 

[Crayola227]

Here's a question. When you say IMGs with no residency can get a nephro fellowship spot, would this be something that US grads with no residency could try to get into? Those grads that can't match or washed out of a residency program without completing a year, even if the nephro spot wouldn't lead to board cert, not sure it would count for an intern year so they could get licensed. Even if it didn't count for licensure, most any grad looking to get their foot back in the door for residency would gladly sell their left kidney to get a couple years of true clinical PAID practice and positive LORs for getting into a real residency leading to licensure and board cert in the future. If this population could use nephro training to have any chance getting back into residency, it would be worth it to many of them just for that.

 

[rokshana]

I never understood your fascination with this nephrology thread even though you don’t practice it.

I don’t practice emergency medicine, but o go there…I dont practice on/gyn bhave gone there as well.
as nyd stated, there is a great deal of overlap with endocrine and nephrology…lord knows I keep getting consulted along with nephrology for many a condition… wish they would pick one or the other…and many times when nephrology is consulted for something that doesn’t have a renal etiology, they will recommend call me…but then I have a very good relationship with the nephrologists at my hospitals.

and I too don t understand your need to be constantly harping on the evils of nephrology…if you don’t like it, don’t do it, but you seemingly have a mission or vendetta against the field…someone musta hurt you bad…

 

[rokshana]

Fair enough. I do not request the old timers to pay $2000 every 10 years (or the 2 year check in).

But do you really think a general subspecialist (not the niche super specialized like glomerular disease, bone marrow transplant, interventional cardiology, EP, just to name a few) is better off without an updated broad base of Internal Medicine knowledge? I didn't think so. Not a personal attack on you. Rather, I am dispelling the straw person argument about the MOC $2000 fee.

To reiterate my point - when Nephrology older and out of touch program directors and directors are trying to "Make Nephrology Great Again," they are not doing new trainees any favors by not staying up to date with Internal Medicine updates (which can be obtained easily by just reading MKSAP) and then trying to make new fellows "unlearn what they learned" in IM residency. Furthermore, these old timers do not even take MOC for Nephrology. THe younger (I merely mean age 65 and under - my post is pointing out how some progrmas still have 80+ directors of nephrology holding back advancement because they want to keep lining their pockets from JVs and their chronic HD center that is attached to the hospital - making money is fine but please go private and do not prevent the advancement of academically rigorous younger academicians) and more academically rigorous programs do not have this problem. It's the mid tier and lower tier neph programs that have these intellectual black holes.


Now now no need to get personal. Rokshana is just adding his/her two cents. All comments welcome. Beside endocrine overlaps quite a bit with nephrology and we do share the same subforum page.

No, I was constantly reminded by my endocrinologist attending that did gen Med service when I was a resident and on an endocrine rotation that as endocrinologists, we are also BC internal medicine physicians as well…and understanding general medicine is crucial to being an endocrinologist…and he was right… so much of endocrine requires understanding of IM.
But that is where CME comes into play as a life long learner…going to say ACP or SHM or doing mksap helps keep you in the loop…and there are IM for the specialist conferences that can keep you utd… as will as UTD itself.
Do I know by heart the current abx for say aspiration pna? Or even a uti? No… but I can look that up on the antibiogram for my hospital…but do I still know how to diagnose and w/u those things?Sure…I don’t necessarily need to shell out money to abim to keep up.

I do remember having an attending that use to say that one practices the way they were trained…and in pp, they get stuck in the past because it is hard to keep current… you do have to work to make the time as pp to do so…

I happen to like conferences and actually go to the lectures! And stay involved in my societies as committee members which makes me have to stay current…not everyone has that luxury.

I can’t speak to nephrology, but in endo, those in academia ( at least those that I have been involved with) are in the front of the edge for current knowledge… but where I did my fellowship is an area highly concentrated with the leaders in endocrine, so I could be a bit skewed…

 

[Renal_Prometheus]

I don’t practice emergency medicine, but o go there…I dont practice on/gyn bhave gone there as well.
as nyd stated, there is a great deal of overlap with endocrine and nephrology…lord knows I keep getting consulted along with nephrology for many a condition… wish they would pick one or the other…and many times when nephrology is consulted for something that doesn’t have a renal etiology, they will recommend call me…but then I have a very good relationship with the nephrologists at my hospitals.

and I too don t understand your need to be constantly harping on the evils of nephrology…if you don’t like it, don’t do it, but you seemingly have a mission or vendetta against the field…someone musta hurt you bad…

As you can see from the postings here, many people have been hurt badly by this specialty. My mission is to warn others so they don’t get hurt badly. No need to beat around the bush, I’m just coming out and speaking the truth.

 

[Renal_Prometheus]

Here's a question. When you say IMGs with no residency can get a nephro fellowship spot, would this be something that US grads with no residency could try to get into? Those grads that can't match or washed out of a residency program without completing a year, even if the nephro spot wouldn't lead to board cert, not sure it would count for an intern year so they could get licensed. Even if it didn't count for licensure, most any grad looking to get their foot back in the door for residency would gladly sell their left kidney to get a couple years of true clinical PAID practice and positive LORs for getting into a real residency leading to licensure and board cert in the future. If this population could use nephro training to have any chance getting back into residency, it would be worth it to many of them just for that.

I would think it’s theoretically possible, but I just haven’t seen it. I’ve only seen IMGs who have done this. The whole thing is a very shady, and I would not recommend it just to get back into clinical medicine.

 

[NewYorkDoctors]

I would think it’s theoretically possible, but I just haven’tdo seen it. I’ve only seen IMGs who have done this. The whole thing is a very shady, and I would not recommend it just to get back into clinical medicine.

Though if more US med schools keep opening and residencies do not expand (though recently congress did approve a new package to slowly phase in more residency slots over the following year ) then we might get the first AMG to do a fellowship first one day soon. Though unlikely if it will be nephrology.

I mean its either that or family medicine - not that anything is wrong with family medicine. it's just the specialty that underperforming AMG who want orthopedics (or something else out of their reach) end up scrambling into.

 

[NewYorkDoctors]

The TL;DR of this thread is
1) I show respect and reverence to the field of nephrology (and Homer Smith ). The top academic nephrology programs are amazing places to train and become a respected academic nephrologist. I focus my attacks on mid to low tier nephrology fellowships that have nothing of significance to offer other than indentured servitude and two years of exhaustion and beratement.
2) renal Prometheus shines light on the how private practice nephrology is a career death trap for those without a plan or without connections .

bottom line : if you have a clear career plan and you love nephrology - by all means apply to the best possible program and become an academic physician .

if you want to be a private practice doctor and make a ton of money , other subspecialties (-‘d even primary care ) can generate lots of revenue without the headaches of being a nephrologist .

 

[Renal_Prometheus]

I think ASN should not waste their time with initiative programs trying to convince med students/residents to go into nephrology. If they truly believe there is a shortage, they should spent the energy to convince nephrologist turned hospitalist to come back to nephrology. oh wait... those people have figured out the trap. Maybe better to target young, unsuspecting med students.

 

[NewYorkDoctors]

I think ASN should not waste their time with initiative programs trying to convince med students/residents to go into nephrology. If they truly believe there is a shortage, they should spent the energy to convince nephrologist turned hospitalist to come back to nephrology. oh wait... those people have figured out the trap. Maybe better to target young, unsuspecting med students.

To be fair , they are grooming these young med students to an academic renal career . So it’s more of a research interest . But yeah it’s rather sad to see this kind of groveling as a means of increasing interest in the field .

American Society of Nephrology | Grants & Funding - Travel Support

<asp:Literal id=

www.asn-online.org

I think offering dual certification pathways (not necessarily with CCM) would be a great way to increase interest . Guarantee two subspecialties would definitely increase interest . I know easier said than done .

but look at the top IM fellowships -
Pulm + CCM
Heme + Onc
Gi + Hepatology
Cardiology (these programs also have sub boards within like echo nuclear to name a few )
Allergy and Immunology (okay fine it’s one board but two disciplines )

and the rest
Nephrology ( hypertension is a separate board)
Infectious disease
Rheumatology (though this does have infusions and procedures )
Geriatric medicine
Palliative care

and a few more i’m missing .

 

[renalfellow937]

Here's a question. When you say IMGs with no residency can get a nephro fellowship spot, would this be something that US grads with no residency could try to get into? Those grads that can't match or washed out of a residency program without completing a year, even if the nephro spot wouldn't lead to board cert, not sure it would count for an intern year so they could get licensed. Even if it didn't count for licensure, most any grad looking to get their foot back in the door for residency would gladly sell their left kidney to get a couple years of true clinical PAID practice and positive LORs for getting into a real residency leading to licensure and board cert in the future. If this population could use nephro training to have any chance getting back into residency, it would be worth it to many of them just for that.

The programs are taking IMG with no residency because the context here is they go back home after the fellowship. The program gets a monkey to type out the notes and take calls for two years and the candidate gets a shiny US degree in Nephrology which might still have some value back home !! The program has absolutely 0 liability or responsibility to what happens to these candidates. Even during an interview if someone asks what the previous graduates did they can say "went back home" whereas that will not be the case with us grads without a residency. The answer in this case would be
"they are applying for residency" which will reflect really bad on the program ! Probably the last nail on the coffin. If the us grads did not get a residency out of med school a nephrology fellowship wont improve chances later !!

 

[Renal_Prometheus]

The programs are taking IMG with no residency because the context here is they go back home after the fellowship. The program gets a monkey to type out the notes and take calls for two years and the candidate gets a shiny US degree in Nephrology which might still have some value back home !! The program has absolutely 0 liability or responsibility to what happens to these candidates. Even during an interview if someone asks what the previous graduates did they can say "went back home" whereas that will not be the case with us grads without a residency. The answer in this case would be
"they are applying for residency" which will reflect really bad on the program ! Probably the last nail on the coffin. If the us grads did not get a residency out of med school a nephrology fellowship wont improve chances later !!

I disagree with this. In my experience, the ones that are taken are IMGs who were unable to land a US residency, who did nephrology as backdoor to get into the system. They want to stay in the US. Unfortunately, all the ones I know were unsuccessful in landing a residency post-fellowship and so essentially they were exploited by the program for cheap labor.

 

[renalfellow937]

I think ASN should not waste their time with initiative programs trying to convince med students/residents to go into nephrology. If they truly believe there is a shortage, they should spent the energy to convince nephrologist turned hospitalist to come back to nephrology. oh wait... those people have figured out the trap. Maybe better to target young, unsuspecting med studen

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

That is true.. any smart mid level would go to ICU or surgical field where they have more to offer to the patient and make more money as well. Besides

These guys going into nephrology today will have a real shock couple of years down the road when they get out. They will realize there were fooled by their fellowship programs into signing on. They will figure out that realities of private practice is much worse than they were led to believe, and that the reason specialty doesn't fill, is guess what, because it's a bad specialty. It's almost common sense, but some people still need to be taught that lesson.

I realized within 3 months of my fellowship !! There was nothing we offered to the patient except dialysis. Or else it was just lots of discussion daily but ultimately "monitoring for need of dialysis". It is hilarious. I am actually surprised Nephrologist actually do not have this insight. Private practice pay is horrible anyone who thinks they want to do nephrology to make money should read everything here !! My co fellow was a hospitalist and the end of the fellowship wanted his old hospitalist job back but couldnt get it because they have newer smarter hospitalists. Now he is a nephrologist who makes half of what he used to and works twice as much.

 

[renalfellow937]

I disagree with this. In my experience, the ones that are taken are IMGs who were unable to land a US residency, who did nephrology as backdoor to get into the system. They want to stay in the US. Unfortunately, all the ones I know were unsuccessful in landing a residency post-fellowship and so essentially they were exploited by the program for cheap labor.

My experience has been with imgs who already had IM residencies from back home and wanted a fellowship from abroad!! Anyways ultimately "Nephrology is dead stay away" !!

 

[Renal_Prometheus]

That is true.. any smart mid level would go to ICU or surgical field where they have more to offer to the patient and make more money as well. Besides

I realized within 3 months of my fellowship !! There was nothing we offered to the patient except dialysis. Or else it was just lots of discussion daily but ultimately "monitoring for need of dialysis". It is hilarious. I am actually surprised Nephrologist actually do not have this insight. Private practice pay is horrible anyone who thinks they want to do nephrology to make money should read everything here !! My co fellow was a hospitalist and the end of the fellowship wanted his old hospitalist job back but couldnt get it because they have newer smarter hospitalists. Now he is a nephrologist who makes half of what he used to and works twice as much.

So why do you think applicants keep falling for the trap over and over again. Do you think it's because they are misled by fellowship programs into believing there's a better future? Or people are just grasping at straws to escape their current job? Clearly, the fact that the specialty is so non-competitive was clear red flag to any applicant with common sense.

 

[NewYorkDoctors]

If you look at the other less competitive IM subspecialties , there are at least silver linings . ID is also quite a cerebral field as well . Although it is non procedural (save for side learned wound care , possibly in office antibiotic administration, and the occasional fecal transplant at a major academic center ) , there are far fewer headaches and virtually no emergencies in ID .

as for palliative care , they have their goals of care talks which have extra cpt billing codes which can generate more RVU or revenue .

nephrology has the patient emergencies , bad work life balance if you see chronic HD, and the massive headaches. Also the procedures are all regulated by the big hd corporations . Triple strike. Why work as hard as a cardiologist for far less pay , far less prestige , and far more headaches ?

 

[NewYorkDoctors]

Nephrologists should join patients in embracing the ‘no dialysis’ option

there is a reason why this kind of patient centered approach is not done more often. There is a perverse incentive in nephrology to get as many “pieces of meat hooked up to chronic hd “ as possible because it generates revenue for the large HD corps (and the doctor will hustle for those small diminishing returns ). But it’s not always to the patients benefit . I feel this is the prime reason why non academic nephrology is languishing and in decline (not just financial but moral as well ) .

 

[Renal_Prometheus]

If you look at the other less competitive IM subspecialties , there are at least silver linings . ID is also quite a cerebral field as well . Although it is non procedural (save for side learned wound care , possibly in office antibiotic administration, and the occasional fecal transplant at a major academic center ) , there are far fewer headaches and virtually no emergencies in ID .

as for palliative care , they have their goals of care talks which have extra cpt billing codes which can generate more RVU or revenue .

nephrology has the patient emergencies , bad work life balance if you see chronic HD, and the massive headaches. Also the procedures are all regulated by the big hd corporations . Triple strike. Why work as hard as a cardiologist for far less pay , far less prestige , and far more headaches ?

People go into nephrology because they are desperate to get something. If they have better choices, they wouldn’t be considering this. It preys on your hope of escape. The more you hope, the more damage will incur on your career

 

[NewYorkDoctors]

Nephrology Board Meeting Summary, Spring 2021

Nephrology Procedures​

The Nephrology Board discussed its ongoing work with ASN related to perceived deficits in procedural competency in nephrology training. ABIM’s training and procedure requirements are available online. Specialty Board members discussed whether the procedure requirements for nephrology certification should change further, in particular related to temporary dialysis catheter placement, kidney biopsy, and home dialysis therapies. Board members recommended a plan to vet the question of changing procedure requirements with nephrologists and nephrology stakeholders, including surveying the nephrology community about practice patterns related to the currently requirements.

Nephrology Certification Exam Performance Analysis​

In recent years, nephrology fellowship programs have had lower fellowship match rates and examinees have had lower pass rates on the Nephrology Certification Examination compared to other disciplines. To understand factors associated with nephrology exam performance, staff is conducting an analysis of characteristics associated with exam performance which will be forthcoming.

This should be interesting. Hands on procedures have really been on the way out for most nephrology training programs because it's a time sink in private practice. unless you can consolidate one renal biopsy proceduralist within an academic faculty group (the "glomerular" guy/gal), it's not something worth doing once in a while. Same thing goes for temporary HD catheters. why struggle with it so hard (you have more on- HD notes to write after all!) in a patient with a giant pannus and undetectable neck when IR can do it better, faster, and safer?

As for the board exam issue, I am very interested to see what the research shows. Anecdotally, the reason for this is because of the perceived lower quality of the scramble candidates who match in (seriously not all AMG doctors are bright... when you are a silver spoon fed guy/gal who got into US medical school due to nepotism, you fall into this category), the intense workload of nephrology PA fellowship training, the suffocating q4 night calls in a smaller program, and the poor quality of education outside of the top academic programs. But that is anecdotal. Seeing the actual data should be interesting.


Addendum:

This is a procedure anecdote from when I was a renal fellow. one Saturday, there was a patient who had worsening AKI requiring hemodialysis. The covering attending (a private practice / part time faculty) physician got a signout that this was a stable patient. However the patient had worsening of her renal function over night. MICU was swamped that day. IR was not in house. When I offered to do the procedure as a femoral (this lady was not obese. normal BMI and anatomy) line, the neph attending got irritated ( "no way. You're not doing it. I am not doing it. I want you to call the MICU fellow and have him or her do it!) I stated I did a large number of these as a resident and have certification in the system. (in retrospect, I practiced under the attending's license at that time, so it is understandable from a privileges and malpractice standpoint)
Notwithstanding the fact that it is unusual to ask a fellow to ask another discipline's fellow to do something on a patient in which Internal Medicine is the primary service, I make the request to the MICU fellow (who was busy) who annoyingly asked "can't you do it?" Well yeah but the Neph attending said he doesn't want me to do it because its under his license. Scoffs.
Later on because the MICU team was so swamped, the ICU attending offers to just supervise me to do it. The HD nurse was already at bedside with the machine primed and ready to go. Once I Put in the femoral line, HD commenced instantly. The ICU attending ask me "what was the big deal and all the drama? Why was your attending calling me so much today?" I just shrugged and moved on.

 

[Renal_Prometheus]

My experience has been with imgs who already had IM residencies from back home and wanted a fellowship from abroad!! Anyways ultimately "Nephrology is dead stay away" !!

I think you have experience to share very similar to many of our stories. What did fellowship programs sell you on to get you into their program. And how does your perception change once you started looking for neph jobs. What I'm trying to get at is, you can save many peoples careers here and have them avoid the devastation and lies that you went through. You want to help them, and staying silent is not helping the applicants. Because if you are not talking, the fellowship programs are talking and giving their versions of reality. We need to save more people!

 

[renalfellow937]

I think you have experience to share very similar to many of our stories. What did fellowship programs sell you on to get you into their program. And how does your perception change once you started looking for neph jobs. What I'm trying to get at is, you can save many peoples careers here and have them avoid the devastation and lies that you went through. You want to help them, and staying silent is not helping the applicants. Because if you are not talking, the fellowship programs are talking and giving their versions of reality. We need to save more peopl

So why do you think applicants keep falling for the trap over and over again. Do you think it's because they are misled by fellowship programs into believing there's a better future? Or people are just grasping at straws to escape their current job? Clearly, the fact that the specialty is so non-competitive was clear red flag to any applicant with common sense.

I think its because img hospitalists are desperate to get some sort of specialization. And one tends too be blinded when a top program sends you interview. During interviews all the current fellows and the faculty paint such an amazing picture. It is quite hilarious.

 

[NewYorkDoctors]

I think its because img hospitalists are desperate to get some sort of specialization. And one tends too be blinded when a top program sends you interview. During interviews all the current fellows and the faculty paint such an amazing picture. It is quite hilarious.

Well it is one thing when a top academic program calls you. If you have a chance to escape the doldrums of community hospital medicine or primary care (when you are not the practice owner a.k.a. money printer owner) and enter academic medicine, then that might be worth it alone.

But I just dont get why scramble candidates would accept going to a low or mid tier program without transplant, without CRRT , without neph controlled plasmapheresis, without much glomerular exposure? That's just begging to be screwed over.

My takeaway is only the candidates who like nephrology, read this thread (and know what he/she is getting into), and have a clear career plan in place (join academic faculty, take over a private practice, etc...) should by all means apply to nephrology.

It's the ones who have no idea what they are getting into (usually the scramble candidates or the less competitive candidates who figure "let me give this virtual interview a try" ) who usually end up regretting their choice. This is the candidate pool that the less desirable training programs go after every scramble season with promises of "critical care! Cardiology exposure! yeah!"

"Dont hate the player, hate the game!"

 

[Renal_Prometheus]

I think its because img hospitalists are desperate to get some sort of specialization. And one tends too be blinded when a top program sends you interview. During interviews all the current fellows and the faculty paint such an amazing picture. It is quite hilarious.

I think its because img hospitalists are desperate to get some sort of specialization. And one tends too be blinded when a top program sends you interview. During interviews all the current fellows and the faculty paint such an amazing picture. It is quite hilarious.

You said something very important, which I don't think the applicants fully appreciate. And that is that faculty are willing to lie in your face in order to have their night calls covered. It makes perfect sense. But for some applicants who still respect senior academic physicians, they may not be used to such bold face lies and are caught off guard when realities of the specialty is completely different than what they thought they were getting into. In retrospect, everything makes perfect sense because bad specialties don't fill spots, and you entered into a bad specialty. People need to ask themselves if specialty is really as great as the programs are portraying it to be, why is it that fellowship spots don't fill? The market always tells the truth. Don't trust what people say, but trust what people do, and that is to avoid nephrology.

 

[renalfellow937]

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.

I was lucky in that sense !! My program never required going in at night. CRRT/HD/PD orders all placed remotely and patient was seen next day. We did not see new ones after 5 pm. They chose to make our life slightly easier over billing/RVU !! But no other program that I know of does that. There is no pot of gold at the end of fellowship. Honestly its not worth it if you are not passionate about nephrology. If you are not passionate and just "interested" it is a field full of disappointments. Not only compensation wise but also intervention wise. One could discuss a patient for hours but ultimately its just whether creatinine got better or worse , which happens by itself. Nothing the nephrologist can do about it. Dialysis can be more than adequately handled by APPs. Many patients ask why they are in CKD clinic because we don't even do anything there. Its just talking about labs with them which to them is just a number and does not mean anything.
I wonder if anyone has read our posts and changed their minds or we are just wasting our time !! It would be nice to know if we saved some souls !

 

[NewYorkDoctors]

I was lucky in that sense !! My program never required going in at night. CRRT/HD/PD orders all placed remotely and patient was seen next day. We did not see new ones after 5 pm. They chose to make our life slightly easier over billing/RVU !! But no other program that I know of does that. There is no pot of gold at the end of fellowship. Honestly its not worth it if you are not passionate about nephrology. If you are not passionate and just "interested" it is a field full of disappointments. Not only compensation wise but also intervention wise. One could discuss a patient for hours but ultimately its just whether creatinine got better or worse , which happens by itself. Nothing the nephrologist can do about it. Dialysis can be more than adequately handled by APPs. Many patients ask why they are in CKD clinic because we don't even do anything there. Its just talking about labs with them which to them is just a number and does not mean anything.
I wonder if anyone has read our posts and changed their minds or we are just wasting our time !! It would be nice to know if we saved some souls !

I like this statement. If you are passionate about anything, you should do it. The only argument to be made for "this specialty doesn't make enough money" is for those whose passion is making money (nothing wrong with that though... to each his/her own).

As for the CKD clinic - for CKD2/3 due to non glomerular causes, there may not be too much to do. Measure a BP, go over some labs, discuss diet , print out some sheets.
CKD4/5 has more to do because of need to discuss vascular access vs transplant, tweak the diuretics, tweak the bicarbonate, tweak the spironolacctone / Kerendia, tweak the Veltassa/Lokelma, tweak the BP meds, tweak the ferrous sulfate, etc...

When there is "tweaking" done, the patient feels better. But when you ask a CKD2/3 patient to pay $40 copay (usual rate for commercial insurance and Medicare without Medicaid), they tend to feel like it isn't worth it. When money is tight (and most CKD patients are lower SES), then they may defer that care.

For the zero copay / zero deductible Managed Medicaid + Medicare, they can go nuts and see you as much as they want.


Anyway the message is if you are passionate about nephrology, go for it.

If you are on the fence and think it can be a launching pad to critical care or cardiology, stop and walk away now. See this entire thread. If you are a hospitalist and are bored out of your mind, think strongly if you have a plan with nephrology. If you have saved up enough capital to start a primary care practice anyway (and joined an IPA), then sure do two years of neph and then do a PMD / Neph private practice. This can be lucrative. See my prior post somewhere.

If you have no plan, do not do nephrology. Period.

 

[Renal_Prometheus]

I was lucky in that sense !! My program never required going in at night. CRRT/HD/PD orders all placed remotely and patient was seen next day. We did not see new ones after 5 pm. They chose to make our life slightly easier over billing/RVU !! But no other program that I know of does that. There is no pot of gold at the end of fellowship. Honestly its not worth it if you are not passionate about nephrology. If you are not passionate and just "interested" it is a field full of disappointments. Not only compensation wise but also intervention wise. One could discuss a patient for hours but ultimately its just whether creatinine got better or worse , which happens by itself. Nothing the nephrologist can do about it. Dialysis can be more than adequately handled by APPs. Many patients ask why they are in CKD clinic because we don't even do anything there. Its just talking about labs with them which to them is just a number and does not mean anything.
I wonder if anyone has read our posts and changed their minds or we are just wasting our time !! It would be nice to know if we saved some souls !

People who want to be saved will look at our posts and reconsider their preconceptions of the specialty. People who are dead set, either because of desperation or misinformation, will always chase their impulses. There will always misery and regrets down the road, but that will take time for the graduate to figure out. Many will continue to practice neph despite the financial disincentives simply because they are too old to switch to another specialty. The best time to intervene is before fellowship, so that no further opportunity cost is wasted.

 

[Renal_Prometheus]

Young guns who want to take a stab at this specialty, I’m not opposed to this as long as they are aware the risks. The people who get really hurt are older applicants who come into Neph thinking it has to work out. It doesn’t have to work out, and for many people it doesn’t work out. Older applicants have less work years before retirement and cannot afford to throw away those years on a speculative hope that they will end up better than a hospitalist. Ive seen many sad cases around me, so please don’t hurt yourself or your families financial futures by trying. Fellowship programs are lying to you and new grad nephrologists are doing very badly and are quitting to go back to hospitalist en mass. The ones making money are older nephrologists with established dialysis joint ventures that he will not share with you equitably. Take this from someone who has been through it all and seen the majority of his Neph friends quit to do something else.

 

[NewYorkDoctors]

Annual Average Salary by State

Because these are on a site like ziprecruiter, this selects for those junior attending "employee" jobs. The higher paid partners or private practice doctors are not going to share their salaries on this kind of website.

If you do not have a plan (i.e. family/friend connection to be partner ASAP in private practice, launch your own private practice, join academia and faculty), then this is what you can expect to get paid. Far less than hospitalist to start and more headaches. See this entire thread,

 

[Tenesmus83]

You guys are wasting your breath. No offense intended. The people who are even considering this specialty are the type who can’t get into a more competitive specialty, but don’t want to be a hospitalist. It has been mentioned before that people come into it out of “hope” that it works out. I’m not sure how many will change their minds because they are desperate just to get something to begin with. I appreciate the warnings, which I agree with are true. it’s just that it’s falling on deaf years.

 

[NewYorkDoctors]

You guys are wasting your breath. No offense intended. The people who are even considering this specialty are the type who can’t get into a more competitive specialty, but don’t want to be a hospitalist. It has been mentioned before that people come into it out of “hope” that it works out. I’m not sure how many will change their minds because they are desperate just to get something to begin with. I appreciate the warnings, which I agree with are true. it’s just that it’s falling on deaf years.

Lucky for us we don’t actually have to say anything out loud

104k views since 2014 will reach some ears .

As for those who just want an escape , they should consider the other less competitive subspecialties that have fewer headaches than nephrology . Palliative care and ID come to mind .
But hey for those who still want to buy penny stocks in nephrology , go for it . Sometimes a child’s hand has to get burned on the stove despite all of the parents warnings .

 

[Renal_Prometheus]

106k views to be exact. Pretty impressive view count. If you're gonna invest this many years into a specialty without a guarantee that you will be better off than a hospitalist(either financially or lifestyle), you better be able to take the pain when you end back as a hospitalist. A top program is not going to protect you from a bad specialty. Everyone can get into a top program. Just think about it.

 

[NewYorkDoctors]

106k views to be exact. Pretty impressive view count. If you're gonna invest this many years into a specialty without a guarantee that you will be better off than a hospitalist(either financially or lifestyle), you better be able to take the pain when you end back as a hospitalist. A top program is not going to protect you from a bad specialty. Everyone can get into a top program. Just think about it.

Those with the most to lose (potentially ) are the candidates who did not match to cardiology or pccm the first time . They should by no means take nephrology inc the s scramble and hope for CCM year . They should take the hospitalist year and do more research, make some connections , and expand their geographical limitations . See this entire thread .

 

[Renal_Prometheus]

I wonder if fellowship programs have the conscience to self reflect why nephrology is such a bad specialty. They are too busy lying through their teeth on selling their program to some desperate applicant. That person graduates and end up back as a hospitalist and the program continues to sell their program as if nothing has happened. These programs knows no shame. How many actually do well in nephrology that they practice past the 5 yr mark? About half. These programs have no shame and in what they need to say to lure people in.

 

[Renal_Prometheus]

I’ve posted this link before. But they essentially admitted that they are taking anyone with a heart beat so they can use them for scut work. For those who think I’m just making this up.

Resizing Nephrology Training Programs

 

[NewYorkDoctors]

I’ve posted this link before. But they essentially admitted that they are taking anyone with a heart beat so they can use them for scut work. For those who think I’m just making this up.

Resizing Nephrology Training Programs

The second author dr Campbell is the program director of the mount sinai school of medicine nephrology fellowship . Very good doctor and academician . IMO Only the top fellowship programs (like his ) should be allowed to exist . In nyc outside of mr sinai , Weill Cornell Columbia and Cornell , montefiore , NYU , and northwell , I don’t think any other nephrology program merits any consideration outside of getting warm bodies . (See this whole thread )

all other programs for nephrology in nyc exist to trap warm bodies . Those have nothing to offer . The graduates of the top tier in nyc become faculty in the mid and lower tier . What is there to offer besides doom and gloom ?

aim big and get into a top neph fellowship or don’t bother

 

[Renal_Prometheus]

How much career damage do neph graduates have to take before the word finally spreads around. It is incredible that nobody talks to each other. Part of it may be pride of admitting that it was a career mistake. It's just sad when every year, same type of applicants fall for the same trap over and over again. You can't trust what the academics tell you. They are motivated by getting their night calls covered. You are taking all the career risks here; but nobody listens.

 

[NewYorkDoctors]

How much career damage do neph graduates have to take before the word finally spreads around. It is incredible that nobody talks to each other. Part of it may be pride of admitting that it was a career mistake. It's just sad when every year, same type of applicants fall for the same trap over and over again. You can't trust what the academics tell you. They are motivated by getting their night calls covered. You are taking all the career risks here; but nobody listens.

It's just a double standard. "Do as I say not as I do." At the smaller hospitals that have just an Internal Medicine residency but no fellowships (or at least no renal fellowship), the neph attending has no problem whatsoever if just waiting until the morning for urgent missed HD. BiPAP or MICU can intubate. Use kayexalate/veltassa/lokelma and give some bicarb pushes. Schedule for first thing in the morning. If there is no line, no qualms with the MICU residents for doing a femoral HD catheter (if there are access problems) and have the resident or HD nurse get consent for the attending to sign later.

With a fellow, you can do things the "full proper way." Send the fellow in for every nonsense call overnight. Fellow must get consent for HD even for the obvious no consent, schizophrenic /psych cases. Watch out for teeth. Access issues? Grovel and beg MICU for a line but under no circumstances does the renal fellow do the line (as liability is under the renal attending in that case).


On a side note:

A Night Float System in Nephrology Fellowship: A Mixed Methods Evaluation

Unclear why there would be any concerns when the newly minted renal attendings at a non-academic institution can just pull the trick I outlined above.

Too bad only the cream of the crop nephrology fellowships (the only ones that should exist and are worth attending for the academic career set up) have enough fellows for a night float. Any mid tier or lower renal fellowship will only have 4 fellows (two per year) and you will be on brutal permanent q4 call for 2 years. Then you can enter the bad private practice market (see entire thread) if you dont have a clear plan in place and then be q4 call or less (some junior attendings do q3 or q2 for their senior partners...without guarantee of partnership.... just be a hospitalist....) and never have good sleep again.

 

[NewYorkDoctors]

Prior to submitting a nephrology fellowship application, I heard mutterings of how unpopular the field had become. Online Student Doctor Network forums had toxic threads on nephrology:

Why Nephrology?

nice a shout out . I’m glad this doctor found her passion and calling as an academic nephrologist. We need more of them .

However , I doubt she would say any of these things if she were a private practice nephrologist who did not own or have partnership in the practice .


the five reasons she cites for nephrology can be applied to any medicine sub specialty and are not unique to nephrology . Beauty is in the eye of the beholder .

 

[Renal_Prometheus]

nice a shout out . I’m glad this doctor found her passion and calling as an academic nephrologist. We need more of them .

However , I doubt she would say any of these things if she were a private practice nephrologist who did not own or have partnership in the practice .


the five reasons she cites for nephrology can be applied to any medicine sub specialty and are not unique to nephrology . Beauty is in the eye of the beholder .

She is an academic so of course she would encourage others to go into nephrology. She has not seen the horrors that I’ve seen in private practice. High attrition rates, years of being underpaid to chase “partnership”. And in the end, most are just better off doing hospitalist medicine and picking up extra shifts on off weeks. Truth is always brutal.

 

[NewYorkDoctors]

She is an academic so of course she would encourage others to go into nephrology. She has not seen the horrors that I’ve seen in private practice. High attrition rates, years of being underpaid to chase “partnership”. And in the end, most are just better off doing hospitalist medicine and picking up extra shifts on off weeks. Truth is always brutal.

You don’t see this in cardiology (you can print money solo with all the office procedures ), Heme onc (you can print money giving chemo solo ) , pulmonary (you have some office based procedures And icu as backup built in) , rheumatology (you have some office based procedures ). You are not so dependent on “chasing partnership “ and have a chance to go solo or start your own with proper capital .

not so with nephrology. How can you start solo or small if you have to be at the office / hospital / and dialysis center at the same time ? It’s a set up to get new indentured servants into private practice .
Outside of academia , I hardly think any private practice doc has the time to go full academic on a regular basis (like actually using the Madias equation for hyponatremia cases as Dr ng alluded to in that blog article )

 

[Renal_Prometheus]

I think its because img hospitalists are desperate to get some sort of specialization. And one tends too be blinded when a top program sends you interview. During interviews all the current fellows and the faculty paint such an amazing picture. It is quite hilarious.

Sounds like you went to a top nephrology program. Does going to a top program protect you against a bad specialty?

 

[NewYorkDoctors]

so it seems the academic brass in nephrology do indeed read SDN . And to think we were wasting our breaths .

tl;dr if you read all of my posts - I do heap praise on nephrology the discipline . Please read all my posts before getting an itchy trigger finger . I caution the prospective fellows who do not plan on being a research oriented academician from joining in because there is. No pot of gold at the end of the rainbow for them .

I know dr kenar jhaveri - brilliant academic physician and he really goes out of his way to try to make renal a good field again .

but there it is - he enriches the academic experience (which is wonderful ) . But the academic doctors can’t fix the heavily corporatized dialysis industrial complex . They can’t help those poor souls who are not good enough for an academic position and no longer getting hired to be hospitalist .


There is speculation that nephrology is not well taught at the med school level and that physiology is too hard . Is it any harder than cardiac physiology with the preload/ afterliad business ? Is it any harder than pulmonary physiology with the ideal gas equation and those derivatives ? Is it any harder than the endocrine feedback loops ? Unclear how one would convince a prospective orthopedic surgery or psychiatry oriented med student to consider nephrology.

there is also speculation that the inpatient renal elective is just sad and unhappy with all the esrd and atn do nothing acutely other than HD . But is it any more boring than a general cardiology consult for the resident ? Preop clearance , atypical chest pain , Coumadin (if that is still used ) management ,etc? Is it any more boring than GI for the resident ? Rectal exam monkey for all the GIB consults .

what is the difference between those specialties ? Private practice compensation and ease of achieving it . Period . No amount of NephMadness or Twitter activity will change that . The cream always rises to the top and the top renal fellowships will always get their full . The only logical reason why it would affect academia is that they are getting less stellar and less research oriented fellows than they did in the past. For academicians - pubs = capital .

A New Breed of Nephrologists: Can We Change the Practice Paradigm?

I
want you to put yourself in the shoes of your average nephrologist, it
seems frenetic when looked at from a birds eye view. A typical day
begins with rounding on first shift dialysis patients, then on to seeing
hospital patients at a different location. After tucking in patients who need urgent care, the next stop is clinic, yet again at a different location.
Clinic time is peppered with phone calls with follow-up questions after
morning rounds diverting attention from the clinic patients there to
seek advice in front of you. We’re not factoring in the possibility of
urgent consults (i.e.emergent dialysis or severe hyponatremia) or
coverage at Long Term Acute Care Facilities (LTAC’s) yet. Add to this
the additional time needed to round on the evening dialysis patients or
going to see that late urgent consult, it all seems draining.
Underestimated in this picture is that of lag time, the distance between
the dialysis unit, the hospital or the clinic; depending on where one
works this can be upwards of one to two hours of pure driving/lag time.
Those two hours could have been spent seeing patients or focusing on the
ones already on the roster! The icing on the cake is night coverage –
the uncertainty of a restful sleep after a hectic day with the potential
to be called into the hospital in the middle of the night. Could this
be a reason why residents are not considering nephrology? They see the
clinical nephrologist stretched thin and starting to show signs of
burnout?.

yeah academic nephrologists do NOT deal with this .

they deal with advanced and more cerebral topics like oh say ordering plex in a transplant patient to prevent recurrent FSGS ... just to pull a hard case randomly out of a hat
And apparently they use the time to create NephMadness and other gimmicks that no other IM sub specialty has to do to garner interest .

Moreover it is unclear why nephrology has the reputation of “smartest doctor .” Because they routinely do basic arithmetic/algebra for acid base equations or Madias Androgue formula for hyponatremia ? As a non cardiologist I find EP very complex and cerebral . Don’t see the cardiologists bragging about that .
As a pulmonary physician (I’m also nephrologist so no bias see prior posts regarding this quirk of mine ) , I can say pulmonary physiology is as complex as renal physiology . In some ways renal physiology is a bit more straightforward.


The Happy PCP: $400K/Yr and Home in Time for Dinner

Additionally renal has to deal with happy PMDs who get to turf the creatinines of 2+ to you to handle as an urgent consult

I honestly cannot envision a one payer model or capitation model for most nephrology patients ie ckd and esrd .