Nephrology is Dead - stay away

[NewYorkDoctors]

dont forget Jack died on the Titanic everyone

maybe just maybe if he and Rose fit on that door (like mythbusters said they could), then he would be alive

then they would have a miserable life as shown in Revolutionary Road lol

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[Renal_Prometheus]

View attachment 377901

dont forget Jack died on the Titanic everyone

maybe just maybe if he and Rose fit on that door (like mythbusters said they could), then he would be alive

then they would have a miserable life as shown in Revolutionary Road lol

The opportunity cost of doing nephrology is quite high. You are looking at 2 years of fellowship plus 2-4 years of indentured servitude to find out:
A) whether you were granted partnership and
B) how much you will make post-partner. Just making partner does not mean all JV/MDA fees gets share equally in the group. Most will require you take a loan to buy existing JV

And if none of the above things happen to you, you are back to square one. All those years squandered away chasing a failing specialty that programs couldn’t give away fellowship spots to. Be smart people!

 

[NewYorkDoctors]

or they could just go academic, accept they will never be the richest doctor (which is totally fine everyone!) in the world, and enjoy the academic virtues of nephrology!

they simply should NOT enter the PP market without a clear plan in place.

I totally get not everyone can be a cardiologist or GI doctor. duh. but one needs to have a clear plan (perhaps GIM + renal - HD like I mentioned before) versus find some large mid pay employer that has a LOT of nephrologists like Kaiser and just enjoy the better parts of life.

but if money is what you want (which is totally fine! just don't cut corners with patients), then there are better ways of doing things than nephrology

 

[CRRT]

The opportunity cost of doing nephrology is quite high. You are looking at 2 years of fellowship plus 2-4 years of indentured servitude to find out:
A) whether you were granted partnership and
B) how much you will make post-partner. Just making partner does not mean all JV/MDA fees gets share equally in the group. Most will require you take a loan to buy existing JV

And if none of the above things happen to you, you are back to square one. All those years squandered away chasing a failing specialty that programs couldn’t give away fellowship spots to. Be smart people!

I have been bombarded with job offers for nephrology recently. To me the market seems quite good. Its obviously up to the nephrology fellow to not become a victim of a predatory group but then that can happen in any field.

I think right now there are a lot of choices and most fellows will get plenty of job offers.

 

[CRRT]

The field is sweet if you like IM in general rather than a procedural field like GI or interventional cardiology. Lots of opportunity to become a very good IM physician.If you do GI or interventional cardiology you will rapidly lose any ability to exercise your mental faculties.

 

[Renal_Prometheus]

The field is sweet if you like IM in general rather than a procedural field like GI or interventional cardiology. Lots of opportunity to become a very good IM physician.If you do GI or interventional cardiology you will rapidly lose any ability to exercise your mental faculties.

Are you a nephrologist or Intensivist? Couldn’t tell from your replies.

 

[NewYorkDoctors]

The field is sweet if you like IM in general rather than a procedural field like GI or interventional cardiology. Lots of opportunity to become a very good IM physician.If you do GI or interventional cardiology you will rapidly lose any ability to exercise your mental faculties.

only for community GI doctors and academic ICs.

academic GI (with all that IBD stuff, dysmotility stuff, etc...) and if they do hepatology still still use their brains quite a bit
community IC has to do general so... they use their brains more than someone who just lives in the cath lab

there are also quite a bit of brain dead community nephs out there who dont give a **** and just want the patient on the HD machine the same way the interventional cards want the patient on the table lol.

but yes in general academic Nephrology uses their brains quite a bit more then many other IM subspecialties.

 

[CRRT]

Are you a nephrologist or Intensivist? Couldn’t tell from your replies.

Both. I am lucky to be doing critical care and outpatient nephrology on the same day.

 

[Renal_Prometheus]

I have been bombarded with job offers for nephrology recently. To me the market seems quite good. Its obviously up to the nephrology fellow to not become a victim of a predatory group but then that can happen in any field.

I think right now there are a lot of choices and most fellows will get plenty of job offers.

There are plenty of Job offers. There’s very few Neph groups worth joining. Most Neph groups struggle to generate revenue. That’s why you see high turnover or Nephrologists choosing to practice something else. Just have a lot of job offers doesn’t mean anything. The specialty is the problem!

 

[Renal_Prometheus]

Both. I am lucky to be doing critical care and outpatient nephrology on the same day.

You are lucky to run away from private practice nephrology by doing cc, but that gives you even less credibility when talking about general nephrology.

 

[Renal_Prometheus]

Its obviously up to the nephrology fellow to not become a victim of a predatory group but then that can happen in any field.

True. But I don’t think card, GI, HO, pulm/cc has starting salaries in the low 200k range and I don’t recall rheum/endo having as bad of a call schedule as Neph. Let’s put it optimistically, Neph has unique characteristics all onto its own.

 

[CRRT]

I had been doing critical care for a while but with the improving job market I got a new job that combined both nephrology and critical care.

Its been fun so far. One of my first pts was a young man with carditis who was seem by IM and cardiology and started on indomethacin. His creatinine went to to 1.4 and they asked me to see him in consult. I looked at his UA and he had proteinuria and hematuria for a couple of years.

I ordered basic proteinuria work up and his anti DNase was a little high.

I became a little suspicious re rheumatic fever and ordered ASO which was pretty high. Repeated anti DNase and it was climbing even further.

I noted pt had strep throat 2 years ago. I asked pt and he told me he had sore throat 4 weeks back 2 weeks prior to carditis.

Dx clinched. Told cardiology the guy had rheumatic fever and referred to ID for monthly PCN injections.

Pretty gratifying.

So far I am refusing to play the game of driving to multiple hospitals / dialysis center as PP physician. Smooching butts of hospitalists for AKI consults.

 

[CRRT]

True. But I don’t think card, GI, HO, pulm/cc has starting salaries in the low 200k range and I don’t recall rheum/endo having as bad of a call schedule as Neph. Let’s put it optimistically, Neph has unique characteristics all onto its own.

Most starting salaries are at least 300 K.

 

[Renal_Prometheus]

Most starting salaries are at least 300 K.

I don’t know what part of country you are practicing, but that’s not the norm. I’m not talking hospital employed. I’m talking private practice groups where you have to put in the sweat equity for a potentially higher payoff post partner. New hires can’t make their salary if you pay them 300k. Their collections only go up once they start accumulating more dialysis pts.

 

[NewYorkDoctors]

I had been doing critical care for a while but with the improving job market I got a new job that combined both nephrology and critical care.

Its been fun so far. One of my first pts was a young man with carditis who was seem by IM and cardiology and started on indomethacin. His creatinine went to to 1.4 and they asked me to see him in consult. I looked at his UA and he had proteinuria and hematuria for a couple of years.

I ordered basic proteinuria work up and his anti DNase was a little high.

I became a little suspicious re rheumatic fever and ordered ASO which was pretty high. Repeated anti DNase and it was climbing even further.

I noted pt had strep throat 2 years ago. I asked pt and he told me he had sore throat 4 weeks back 2 weeks prior to carditis.

Dx clinched. Told cardiology the guy had rheumatic fever and referred to ID for monthly PCN injections.

Pretty gratifying.

So far I am refusing to play the game of driving to multiple hospitals / dialysis center as PP physician. Smooching butts of hospitalists for AKI consults.

Well there you go! You found a great nephrology niche . Fact remains not every nephrologist can get your sweet gig. Most PP have to do that game you mention .

It’s a numbers game at the end of the day

Nephrology has some great peaks but most of it os a Grand Canyon

 

[Renal_Prometheus]

Fresenius Medical shares at 12-year low as labour costs weigh on profit

Shares in the world's largest kidney dialysis provider Fresenius Medical Care (FMC) plunged more than 12% to a 12-year low on Thursday after it cut its earnings outlook as costs surge and a U.S. staff shortage leaves it scrambling for nurses.

www.reuters.com

"Parent Fresenius, a diversified healthcare group, said it expected group net income to ease in a "low-to-mid single-digit percentage range" due to the decline at FMC, prompting its shares to fall 8.4% to a two-year low."

"Fresenius CEO Sturm said this year that FMC could be sold, but only if a very attractive price was offered. He said on Thursday that view had not changed but any bid for now appeared less likely."

Does anyone have any confidence that dialysis reimbursement is heading the right way when the insiders are running for the exit? Anyone looking to joint venture in a dialysis unit and hope to make it big need a wake up call.

 

[CRRT]

Odd part is that Fresenius stock in last 10 years has been at its peak while the nephrology job market has been in the dumps. Now as nephrology job market is picking up Fresenius stock is falling.

 

[Renal_Prometheus]

Odd part is that Fresenius stock in last 10 years has been at its peak while the nephrology job market has been in the dumps. Now as nephrology job market is picking up Fresenius stock is falling.

As I've stated many times before, an established nephrologist derives 30-40% of their income from dialysis unit joint ventures and medical directorship fees. That is directly tied to the profitability of the dialysis unit, which is being squeezed by medicare to the point where dialysis companies are thinking about exiting. So it really doesn't matter if there are more neph job offers or starting salaries are a little bit higher than years past; your ultimate earning potential as a senior nephrologist is being threatened and it will only decline over time. So anyone who is thinking ahead need to think for themselves and ignore the noise around neph is going to turn around and go back to the golden days.

 

[georgestone]

I think this thread has run its course. Nephrology was bad 5 to 10 years ago but that is no longer the case. Renal Prometheus now sounds like a broken record.
Yes, you have to be careful when joining a group; look at their past history etc but I think if you plan well, Nephrology is not a “doom and gloom” scenario at present. I was trying to recruit a nephrologist to our hospital. He had graduated in 2013 and was working in a smaller city. He was easily making more than 600 K at present in his current job.

I hate to say that you keep giving examples which are not only anecdotal but kind of out of touch , again you mentioned in prior posts about hypothetical ( but grossly unrealistic ) scenarios where a new grad would start out with 100 HD patients and would crank 500 k ?

Really ? where does a new grad start out with 100 HD patients ? May be

1. Inheritance from Parents/Grandparents ?
2. Prior Business Partner with Sudden Cardiac Death

or any other hypothetical Scenario which is Just plain BS

And again You mentioned some random Guy Who was practicing in Boonies and making 600 k ? Really and now how much are you paying him , I'm sure you are beating his salary expectations

With 80-81% of US population living in urban areas and with Majority of Nephrologists who are struggling to make ends meet , your Anecdotal but idiotic examples are laughable , and you gave random examples of rarity

You must be Smoking weed Bro !!

You are the embodiment of whts wrong with Nephrology ! unrealistic and out of touch , such people realize too late and their ship usually has sailed .

I dont Know Renal_Prometheus but this guy has balls to be so brutally honest and he is SPOT ON !! and he aint no broken record !

I was on side lines reading these posts after burning 2 years of my precious life in Nephrology fellowship and his Honesty prompted me to participate on this forum

I am grateful that now I am practicing Critical care and when my Nephrology colleagues offer me a week end call with generous compensation I just laugh and politely decline ,
because what they offer me for a 3 day call is less than what I make in 12 hours

FYI OH I LIVE IN BOONIES TOO !!

Thts what we are talking about , which you clearly aren't grasping , and I request you to participate on this forum and disagree with us and we will remain civil and respectful and once you run your business to the ground may be you can muster the courage to share your story and save future of many others .

No offense sorry !!

 

[georgestone]

I think we should welcome some fresh perspective in this thread. Some people telling how they found success and fulfillment while practicing Nephrology. We really want to hear from those people too.

I havent seen may encouraging posts , even though this forum is widely known and pretty open ( Thanks to Senior Members ) that means there are fewer and fewer success stories

 

[georgestone]

I will request y'all to give an opinion on another Looming disaster for Nephrology

SGLT2/ & GLP-1 drugs are now extensively used and have shut down & threatened alot of Bariatric Surgery Practices , their impact on CKD progression is significant /Established , not sure in future how bigger the impact would be on CKD patient heading to HD but looking at available data the number of HD patients is going to tank

with such a significant source of Revenue under threat ( I am happy for the patients though )how the financial future of Nephrology would be ?

again I dont want this to be all about $$$ but every one has to pay the bills and its about work to income ratio !!

 

[georgestone]

Good for you if you make seven figures. Looking at your posts it sounds like you work hard and also bill well. I am Hosp employed and not productivity based so I am too lazy to bill for things like lung ultrasound/renal ultrasound or bio impedance. It seems to me that you make a lot of your seven figures from general internal medicine rather than pulmonary. But to do that you have to be up to date with IM too.
The people who have suffered by doing a nephrology fellowship were those who are lazy residents or hospitalists who really wanted to do G.I or interventional cardiology and didn’t have the credentials to get into these fellowships. They wanted an outlet and got into nephrology wanting to put 2 K, 2.5 Ca , 35 HCO3 orders on everybody. Just look at creatinine and shut their mind to the rest of the patient.
Nephrology is not just creatinine and HD. You have to have a command of rheum, cardiology, ID , pulmonary , Endo , hepatology , geriatrics etc. if you are going into it expecting to behave like a scope/stent monkey definitely going to be disappointed.
My city’s (Southern US) university nephrology program didn’t treat their fellows well as a result a few dropped out and they have had trouble recruiting fellows for years. Now that city hasn’t had new nephrologists for years and has a surplus of nephrology jobs.
PP jobs advertising 2 year partnership tracks , JV opportunities and 600 K salaries. The partners in that group spread themselves out in too many hospitals at the same time and now they are stretched too thin seeing 35 pts in hospitals / 10-15 in clinic and going to multiple dialysis units and working 3 weekends a month. These guys were starting to see hospital pts at 4:30 am and finishing their day at 8:30 pm. They did it for a few years but now they are in their late 50s and want a break. If they wanted me to work for them I wouldn’t start out for less than 450 K with an iron clad contract guaranteeing full partnership with JVs in 2 years.

How many Nephrologist have you seen who have command of rheum, cardiology, ID , pulmonary , Endo , hepatology , geriatrics ??
barely any !! your program has clearly Indoctrinated you or you are very new at your job !!

Majority are creatinine & Urine out put following junkies ! or replace lytes like NP's or 2k/2 kg for HD

how many Nephrologist know who to judge volume via dynamic measures??? almost none except those who have done CCM (

NewYorkDoctors) is a clear exception ​

so I dont buy this BS that Nephrologist are know it all !! that aint true

You have clearly contradicted your self

Any NP, MD who works 27 days a month and sees 35 -40 patients / day can easily generate > 500 k

But
Is this sustainable and whats the shelf life of those individuals ? no one why your area is struggling to recruit !

Its not about throwing random numbers or quoting anecdotal examples of some Nephrologist who is making 600 k

You should mention details like work to income ratio etc

 

[georgestone]

I had been doing critical care for a while but with the improving job market I got a new job that combined both nephrology and critical care.

Its been fun so far. One of my first pts was a young man with carditis who was seem by IM and cardiology and started on indomethacin. His creatinine went to to 1.4 and they asked me to see him in consult. I looked at his UA and he had proteinuria and hematuria for a couple of years.

I ordered basic proteinuria work up and his anti DNase was a little high.

I became a little suspicious re rheumatic fever and ordered ASO which was pretty high. Repeated anti DNase and it was climbing even further.

I noted pt had strep throat 2 years ago. I asked pt and he told me he had sore throat 4 weeks back 2 weeks prior to carditis.

Dx clinched. Told cardiology the guy had rheumatic fever and referred to ID for monthly PCN injections.

Pretty gratifying.

So far I am refusing to play the game of driving to multiple hospitals / dialysis center as PP physician. Smooching butts of hospitalists for AKI consults.

Such a HERO

That is so typical of Nephrologists all over to give example of some random anecdotal GN which they diagnosed !!

 

[georgestone]

Both. I am lucky to be doing critical care and outpatient nephrology on the same day.

GOOD for you !!

Is there any comparison bw the 2 revenue sources ? meaning Neph vs CCM ?

People whom I spoke to notified that outpatient Neph revenue isnt enough to pay the bills & majority of their revenue is via CCM

please share your experience

 

[CRRT]

I hate to say that you keep giving examples which are not only anecdotal but kind of out of touch , again you mentioned in prior posts about hypothetical ( but grossly unrealistic ) scenarios where a new grad would start out with 100 HD patients and would crank 500 k ?

Really ? where does a new grad start out with 100 HD patients ? May be

1. Inheritance from Parents/Grandparents ?
2. Prior Business Partner with Sudden Cardiac Death

or any other hypothetical Scenario which is Just plain BS

And again You mentioned some random Guy Who was practicing in Boonies and making 600 k ? Really and now how much are you paying him , I'm sure you are beating his salary expectations

With 80-81% of US population living in urban areas and with Majority of Nephrologists who are struggling to make ends meet , your Anecdotal but idiotic examples are laughable , and you gave random examples of rarity

You must be Smoking weed Bro !!

You are the embodiment of whts wrong with Nephrology ! unrealistic and out of touch , such people realize too late and their ship usually has sailed .

I dont Know Renal_Prometheus but this guy has balls to be so brutally honest and he is SPOT ON !! and he aint no broken record !

I was on side lines reading these posts after burning 2 years of my precious life in Nephrology fellowship and his Honesty prompted me to participate on this forum

I am grateful that now I am practicing Critical care and when my Nephrology colleagues offer me a week end call with generous compensation I just laugh and politely decline ,
because what they offer me for a 3 day call is less than what I make in 12 hours

FYI OH I LIVE IN BOONIES TOO !!

Thts what we are talking about , which you clearly aren't grasping , and I request you to participate on this forum and disagree with us and we will remain civil and respectful and once you run your business to the ground may be you can muster the courage to share your story and save future of many others .

No offense sorry !!

This nephrologist who is making more than 600 K is practicing as a hospital employed nephrologist and director of 2 dialysis units. He has been in practice for 10 years and is very happy at current practice.
He works a full day but at 1 hospital only.
It takes time to build a HD population but can be built. Go to an area with relative shortage of nephrologists and show you can provide a service.

 

[georgestone]

or they could just go academic, accept they will never be the richest doctor (which is totally fine everyone!) in the world, and enjoy the academic virtues of nephrology!

they simply should NOT enter the PP market without a clear plan in place.

I totally get not everyone can be a cardiologist or GI doctor. duh. but one needs to have a clear plan (perhaps GIM + renal - HD like I mentioned before) versus find some large mid pay employer that has a LOT of nephrologists like Kaiser and just enjoy the better parts of life.

but if money is what you want (which is totally fine! just don't cut corners with patients), then there are better ways of doing things than nephrology

You make 7 figures??

you got a job bro

 

[CRRT]

I will request y'all to give an opinion on another Looming disaster for Nephrology

SGLT2/ & GLP-1 drugs are now extensively used and have shut down & threatened alot of Bariatric Surgery Practices , their impact on CKD progression is significant /Established , not sure in future how bigger the impact would be on CKD patient heading to HD but looking at available data the number of HD patients is going to tank

with such a significant source of Revenue under threat ( I am happy for the patients though )how the financial future of Nephrology would be ?

again I dont want this to be all about $$$ but every one has to pay the bills and its about work to income ratio !!

I will request y'all to give an opinion on another Looming disaster for Nephrology

SGLT2/ & GLP-1 drugs are now extensively used and have shut down & threatened alot of Bariatric Surgery Practices , their impact on CKD progression is significant /Established , not sure in future how bigger the impact would be on CKD patient heading to HD but looking at available data the number of HD patients is going to tank

with such a significant source of Revenue under threat ( I am happy for the patients though )how the financial future of Nephrology would be ?

again I dont want this to be all about $$$ but every one has to pay the bills and its about work to income ratio !!

If HD population is declining adapt to times. Build a CKD practice take interest in patient and keep them off HD.
See pts every month or two and keep close eye on what PCP is doing and keep eye on hospitalizations.
Ambulatory BP monitoring, counsel pts regarding BG checking and make sure the HgA1C is in range.

 

[CRRT]

How many Nephrologist have you seen who have command of rheum, cardiology, ID , pulmonary , Endo , hepatology , geriatrics ??
barely any !! your program has clearly Indoctrinated you or you are very new at your job !!

Majority are creatinine & Urine out put following junkies ! or replace lytes like NP's or 2k/2 kg for HD

how many Nephrologist know who to judge volume via dynamic measures??? almost none except those who have done CCM (

NewYorkDoctors) is a clear exception ​

so I dont buy this BS that Nephrologist are know it all !! that aint true

You have clearly contradicted your self

Any NP, MD who works 27 days a month and sees 35 -40 patients / day can easily generate > 500 k

But
Is this sustainable and whats the shelf life of those individuals ? no one why your area is struggling to recruit !

Its not about throwing random numbers or quoting anecdotal examples of some Nephrologist who is making 600 k

You should mention details like work to income ratio etc

Renal fellow education has been quite poor at many nephrology programs ( mine included ) . Entire focus on making nephrology fellows scut monkeys.
At the end of my nephrology fellowship I had a job but was entirely unsatisfied that I was becoming a dialysis / urine output / creatinine monkey.
I therefore did a full 2 year critical care fellowship so I could again get back to taking care of the whole pt.
Even now although I am well compensated as a CC-neph attending I am still not satisfied and am thinking of spending another year in doing a specially tailored fellowship working on my weaknesses including GN , ECMO , surgical and transplant.

 

[CRRT]

Such a HERO

That is so typical of Nephrologists all over to give example of some random anecdotal GN which they diagnosed !!

But thats what makes me keep going as a nephrologist. Dxing rare diseases and seeing cardiology faces on being told that the unspecific carditis which they were treating was actually rheumatic fever.

 

[CRRT]

GOOD for you !!

Is there any comparison bw the 2 revenue sources ? meaning Neph vs CCM ?

People whom I spoke to notified that outpatient Neph revenue isnt enough to pay the bills & majority of their revenue is via CCM

please share your experience

Its true I started out doing more CCM and still probably do more. However I figured out that in my mid 40s I couldn’t do full time CC anymore and then started dabbling in nephrology. Slowly building my practice while taking full advantage of my CCM work to be able to do it. So far its been fun.
I will always refuse to work at more than one hospital or go to more than one HD unit. I am not going to play the PP game.
Luckily more hospital employed jobs coming up these days.

 

[CRRT]

Leave the weekly dialysis rounds to the NPs. They are quite happy to do it.

 

[georgestone]

Renal fellow education has been quite poor at many nephrology programs ( mine included ) . Entire focus on making nephrology fellows scut monkeys.
At the end of my nephrology fellowship I had a job but was entirely unsatisfied that I was becoming a dialysis / urine output / creatinine monkey.
I therefore did a full 2 year critical care fellowship so I could again get back to taking care of the whole pt.
Even now although I am well compensated as a CC-neph attending I am still not satisfied and am thinking of spending another year in doing a specially tailored fellowship working on my weaknesses including GN , ECMO , surgical and transplant.

so again your main focus is unlikely to be Nephrology then

 

[georgestone]

If HD population is declining adapt to times. Build a CKD practice take interest in patient and keep them off HD.
See pts every month or two and keep close eye on what PCP is doing and keep eye on hospitalizations.
Ambulatory BP monitoring, counsel pts regarding BG checking and make sure the HgA1C is in range.

Hmm !!every month for CKD follow up is only reimbursed properly in case of CKD4/5 not otherwise , please correct me if I am wrong
A1c checks ?

 

[Renal_Prometheus]

Renal fellow education has been quite poor at many nephrology programs ( mine included ) . Entire focus on making nephrology fellows scut monkeys.
At the end of my nephrology fellowship I had a job but was entirely unsatisfied that I was becoming a dialysis / urine output / creatinine monkey.
I therefore did a full 2 year critical care fellowship so I could again get back to taking care of the whole pt.
Even now although I am well compensated as a CC-neph attending I am still not satisfied and am thinking of spending another year in doing a specially tailored fellowship working on my weaknesses including GN , ECMO , surgical and transplant.

So basically you are admitting that doing neph was a mistake and you only realized it after the fact and you corrected course. I’m happy for you. But no need to mislead applicants further into a failing specialty and ruin their careers. Their neph PD will do plenty of that.

 

[CRRT]

Some programs have started out a nephrology critical Care track but in my opinion, these programs are not well designed. Usually it ends up being a two-year Nephrology and then a one year critical care track. It doesn’t work that way.

Nephrology and Critical Care education must be completely well blended. With a good sprinkling of academic internal medicine as well to become a well-rounded physician.

Ideally some pulmonary / CC programs need to cut seats and give some to a neph CC track.

Neph CC needs to be a counter to the pulm CC track with more focus on trauma / CCU / CTICU / surgical ICU / transplant ICU / rather than a MICU based track which most pulm CC fellowship programs end up being.

As a result of which most pulm /CC fellows are most comfortable in MICU when they get out of fellowship.

 

[CRRT]

Hmm !!every month for CKD follow up is only reimbursed properly in case of CKD4/5 not otherwise , please correct me if I am wrong
A1c checks ?

NewYorkDoctors may comment on that.

 

[CRRT]

so again your main focus is unlikely to be Nephrology then

Cant be a good transplant / GN doctor if dont have a good grip of ID.

 

[georgestone]

yes

Cant be a good transplant / GN doctor if dont have a good grip of ID.

agreed but then again transplant Nephrology is interesting but after CCM , how is the job market going to be ? I spoke to a few Transplant Surgeons who were department heads and they weren't even sure how to model a Neph/CCM who had completed tx fellowship

how many ECMO fellowship programs' are around ? do they even accept Neph CCM candidates

 

[CRRT]

yes

agreed but then again transplant Nephrology is interesting but after CCM , how is the job market going to be ? I spoke to a few Transplant Surgeons who were department heads and they weren't even sure how to model a Neph/CCM who had completed tx fellowship

how many ECMO fellowship programs' are around ? do they even accept Neph CCM candidates

There are two tracks to do critical care. The pulm /CC track tends to focus on MICU while the Anesthesia/ED track tends to focus on surgical neuro ICUs.

Where neph CC comes in is that it could focus on a track that does some MICU but also focuses widely on trauma / neuro / surgical / transplant ICUs in fellowship. The advantage neph has on Anesthesia/ED is that both ED and Anesthesia tend to focus more on acute management and not on handling management of a population with multiple med problems. They are going to probably be better at procedures but not at getting an full picture of entire pt.

 

[CRRT]

ECMO is CRRT on steroids. I have seen a straight IM / CC physician do a ECMO fellowship. He told me he got real experience in CTICU only after starting ECMO fellowship.

 

[georgestone]

ECMO is CRRT on steroids. I have seen a straight IM / CC physician do a ECMO fellowship. He told me he got real experience in CTICU only after starting ECMO fellowship.

hmm Interesting
where did he do his ECMO fellowship ? one of my junior co workers , a very talented Nephro-crit is looking for one but has hit a wall

I haven't seen many programs and now in my mid 50's too old to go through it

 

[CRRT]

hmm Interesting
where did he do his ECMO fellowship ? one of my junior co workers , a very talented Nephro-crit is looking for one but has hit a wall

I haven't seen many programs and now in my mid 50's too old to go through it

He did it at a program in mid West. Non ACGME fellowship. He was single at that time so flexible in geography. Its surprising how receptive and flexible fellowship programs can be for a goal directed physician.

I wouldn’t recommend for you if you are in mid 50s.

 

[georgestone]

There are two tracks to do critical care. The pulm /CC track tends to focus on MICU while the Anesthesia/ED track tends to focus on surgical neuro ICUs.

Where neph CC comes in is that it could focus on a track that does some MICU but also focuses widely on trauma / neuro / surgical / transplant ICUs in fellowship. The advantage neph has on Anesthesia/ED is that both ED and Anesthesia tend to focus more on acute management and not on handling management of a population with multiple med problems. They are going to probably be better at procedures but not at getting an full picture of entire pt.

Agreed 100% they are rather incapable of Longitudinal follow up in ICU

 

[georgestone]

He did it at a program in mid West. Non ACGME fellowship. He was single at that time so flexible in geography. Its surprising how receptive and flexible fellowship programs can be for a goal directed physician.

I wouldn’t recommend for you if you are in mid 50s.

I wont definitely do it in my 50's , though Iam doing well with MICU and I really like it

 

[Renal_Prometheus]

back to nephrology. I think we all intrinsically subscribe to the Hippocratic oath of "first, do no harm". And when you see this many neph graduates not practicing in their own specialty, including many intensivists that were neph trained on this thread, there's something intrinsically wrong with this specialty that needs to brought to the forefront. You cannot claim to be transparent about what you are getting into if at least 1/3 of the neph graduates are going to be hospitalists. unless you have done a fellowship, I don't think neph applicants has fully picked up the nuances of what makes neph very risky career-wise. So we are here to make sure everyone fully knows what they are getting into and there are no surprises down the road.

 

[NewYorkDoctors]

Hmm !!every month for CKD follow up is only reimbursed properly in case of CKD4/5 not otherwise , please correct me if I am wrong
A1c checks ?

you can bill CKD1 (something like s/p nephrectomy eGFR > 90) to your heart's content.
same 99212/3 that a PCP bills for .
unless there is some issue with insurance near your neck of the woods

the real issue for CKD is unless it has a cause that is radiologically or biopsy proven and has defined treatments for (ADPKD, GN, just to name a few), the common HTN/DM patients come to you for a "cure." When you tell them the same thing their PCP , cardio, and/or endo told them, they get mad at you (or at least new yorkers do). its mind numbing honestly.

if they do like you, the patients (assuuming they do not have Medicaid and have to pay their copay/deductibles) often say something like "hey doc I Like you but do I really have to come every 3 months and pay this big copay? you're just checking labs like my PCP does!"

what do I say to that? nah your PCP is too busy with your screening and social issues. plus your PCP does not check uric acid, PTH, 25D, phosphorus and I need those to be complete.

 

[NewYorkDoctors]

There are two tracks to do critical care. The pulm /CC track tends to focus on MICU while the Anesthesia/ED track tends to focus on surgical neuro ICUs.

Where neph CC comes in is that it could focus on a track that does some MICU but also focuses widely on trauma / neuro / surgical / transplant ICUs in fellowship. The advantage neph has on Anesthesia/ED is that both ED and Anesthesia tend to focus more on acute management and not on handling management of a population with multiple med problems. They are going to probably be better at procedures but not at getting an full picture of entire pt.

in a community ICU (where most intensivists, regardless of them graduate), most intensivists are getting a mixed population that includes medical, surgical, cardiac, and neuro patients. They may not get trauma as that is more surgical of course.

it's only the big academic centers that have such stratification of the different units in which PCCM attendings work mainly in MICU (with occasional forays into the SICU for coverage)

Your statement has merit in that IM trained intensivists are trained since an intern to look at the whole chronic picture. But that's not as important as one might think for ICU patients. stabilize them and either downgrade them to the floors or upgrade them to heaven. it's not the intensivists job to fix every single issue. just the critical illness issue. chronic issues get the appropriate subspecialists on the case to follow up ICU and outside.

moreover, all intensivists (regardless of their initial residency background) eventually become more "internal medicine like" the more they do ICU.

I have several colleagues who are Emergency Medicine trained (one is EM/IM) who did CCM. Now they only do CCM (no more ER). When they were ED residents/attendings they did that usual "round during sign out" thing and "i chose EM over IM because I hate rounds." But once they entered CCM, they quickly adopted that "IM mindset." If that makes any sense.

 

[deleted1164820]

I am currently doing interviews for Nephrology/critical care combined programs. There is only less than 20 programs that offer combined programs in the country. I am wondering if the field can transform, like Pulmonology getting attached to critical care and it has been attracting more candidates than nephrology. Most of places where I do interview there is so much interest for combined programs among candidates and not a lot of people want to do just General Nephrology. I think combining would make the speciality a little competetive. I am not sure if a Pulmonologist would make as much money as Nephrologist if they don't have the critical care part. As far as I know no body would want to do just pulmonology without the critical care that's how bad it is. Pure Pulmonology is a terrible speciality to choose. I beleive general Nephrology needs an upgrade.

 

[NewYorkDoctors]

I am currently doing interviews for Nephrology/critical care combined programs. There is only less than 20 programs that offer combined programs in the country. I am wondering if the field can transform, like Pulmonology getting attached to critical care and it has been attracting more candidates than nephrology. Most of places where I do interview there is so much interest for combined programs among candidates and not a lot of people want to do just General Nephrology. I think combining would make the speciality a little competetive. I am not sure if a Pulmonologist would make as much money as Nephrologist if they don't have the critical care part. As far as I know no body would want to do just pulmonology without the critical care that's how bad it is. Pure Pulmonology is a terrible speciality to choose. I beleive general Nephrology needs an upgrade.

Outpatient pulmonology can make so much more money than outpatient nephrology trust me on that .

Cpt codes procedures make money .

As someone who has done all three I can attest

Academic nephrology is more interesting (more varied case loads inpatient and outpatient ) than critical care medicine on an intellectual level . academic pulmonary is interesting as an outpatient (PAH , cystic lung disease , ILD) but inpatient pulmonary is rather boring. (Asthma copd pneumonia pleural effusion )

Community nephrology is the absolute worst of the bunch. It’s not just the lack of money and reliance on chronic HD (see all the reasons RP has mentioned ), but it’s also the absolute sheer reliance on grinding through mind numbing DM obesity HTN related CKD.



I work 80 + hours a week but I stay in shape by doing 20,000 steps a day on average . How ? The seemingly odd habit of running in place at all times (when not in front of a patient ) and have a standing desk in my office room .

I try to tell these patients (whether dm htn ckd or osa ) I empathize with you that you do not need to go to a gym (I don’t have time either and I feel self conscious seeing steroid Heads ooh and ah ) look like a celebrity , or look like an athlete , and you are older and I don’t wish for you to injure your joints but you must get the AHA recommended exercise time in . Life’s busy and everyone has to hustle . I allow you to watch TV at night as long as you walk in place or walk around in your living room dining room for the step . They cannot even do that …

I digress

Your optimism is commendable but nothing will change as it’s all about the money money . The ACC/AHA has great lobbyists in Washington for cardiology . Nephrologists back in the day sold out to the government and HD is under government control now .

An INDIVIDUAL can tailor his her situation to be successful financially in renal . But not so for the population level

 

[Renal_Prometheus]

Nephrology is akin to gambling. There will always be the few that hit it big, but the majority will end with a loss and destroyed hopes. The casinos/neph programs will only advertise the winners; never the losers.