Nephrology is Dead - stay away

[sloh]

These days some of them do transplant and go academic. Believe it or not they do hire transplant nephrologists even without a US residency in the academic setting due to a severe shortage of transplant physicians. They get an institutional license. Once again, if you think general nephro is bad then transplant is 10 X worse. Literally any of the patient's minor complaints become your problem but if you desperately want to work in the US it is possible.

Wow TIL transplant nephrology is not all that it's cracked up to be. I always thought it sounded like a sexy subspecialty. Kidneys! Transplants! Cool!

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[NewYorkDoctors]

Apocalypse Nephrology

This summer I was really optimistic. I was riding a #Flozin high that was being further buoyed by the successes of finerenone. Long dormant fields were yielding fresh life. How long has it been sin…

pbfluids.com

This Dr topf is a leader of the field and he’s onto something . But even so most renal jobs out there are NOT going to split up consults clinic and outpatient HD.

Anyway one of my former med students who is now an IM resident at a new and relatively unknown IM program done in Florida has IM faculty who are mostly neprhologists (lol) and whom started a renal fellowship as the first one . The other cardiologist GI and Pccm to come . But lol what was the point other than to get some cheap labor ?

Right big picture to establish their “academic non med school attached “ medical center .

Nephrology Fellowship at [censored] Hospital Center​

Nephrology is considered to be among the most intellectually demanding subspecialties. Expertise in this field is a result of lifelong learning built upon the foundation of excellent fellowship training. The Nephrology fellowship program at [censored[ Hospital Center provides that foundation.

yeah nothing against this fellowship program (I know of no one there). But this is the extreme arrogance of Nephrologists as a whole that turns many non-diehard nephrology fans away. They keep insisting nephrology is the most intellectually rigorous IM subspecialty. stop it! before UpToDate (which was created by nephrologists in the beginning , ironically) you may have a point.

But what is the basis of this statement? the ability to do arithmetic for a triple acid base equation that only happens in very rare situations? (probably the most common is a DKA patient who got too much NS and who is also vomiting nonstop... but even an IM resident can figure that one out...)

Glomerulonephritis? trust me as someone who knows how to work up GN and ILD, I can say that both are analogous in their workup. I am sure a rheumatologist who is working up undifferentiated CTD, hepatologist working up less common hepatitides, hematologist working up pancytopenia, CHF cardiologist working up restrictive cardiomyopathy have the same kind of "intellectual rigor and puzzle solving."

writing a dialysis prescription? lol puhlease. optimizing Kt/V and URR? puhlease. Optimizing the UF rate on HD? puhlease.
knowing how about the reverse osmosis and carbon filters work? puhlease.
knowing how the engineering aspects of HD work? i dont think most nephrologists know that kind of engineering detail...

"being a good internist who can tie in all of the organ systems?"
stop it. all other subspecialties do this. some more than others.
Cardiology - they have to run a CCU and protect their cardiac patients. they have to know about all other organ systems to a decent degree
GI - sure screening colonoscopies don't demand much. but IBD, malabsorption syndromes, motility issues, hepatology workups etc...
PCCM - just the critical care part ties in all organ systems alone much less working up some of the interstitial or cystic lung diseases.
HemeOnc - oncology itself have to know about all organ systems
Endocrine - hormones affect everywhere
Rheumatology - manifestations of CVD can occur in any organ system not just the joints
ID - have to be a good internist and know how infections affect all organ systems

im sure im missing some but you get the point

okay being a nephrologist is more rigorous intellectually than doing a screening colonoscopy or ordering a nuclear stress test... but cannot compare apples to oranges like that.

is ordering a renal panel (CMP, Mg, Phos, CBC, PTH, 25D, 125D Iron TIBC Ferritin + U/A + UPC + UACR + renalbladder ultrasound) really that much more intellectually rigorous than a screening colonoscopy or cardiac stress test?

"yepp gotta reduce animal protein intake. gotta reduce phosphorus in the diet. by how much? dunno let me refer you to the dietitian"

then again none of this would matter if career prospects were lucrative.

 

[CptNemo]

Logistically, it would be difficult to split nephrology jobs as the nephrologists doing HD rounding would have the best $ and lifestyle, while those doing inpatient and clinic only would have a painful lifestyle that would yield less money.

Unlike hospital medicine or critical care medicine, inpatient nephrology is not subsidized by the hospital, so you really have to grind to make your money (both critical care and hospital medicine inpatient billing also sucks, but the hospitals need to pay them to keep them around to run things...)

The big issue is:


I began fellowship before the 2011 changes happened, then entered a market where they were being implemented - not a fun time.

 

[Renal_Prometheus]

Here’s another reason why match rates are low. How about the increasing awareness among residents that nephrology is all smoke and mirror, promises for equal partnership gets broken in private practice, and that fellowship programs are selling them hopium to get cheap labor. They see many neph grads working as hospitalists in the community, what do you think they will think of the specialty? They come on SDN and see this discussion, what do you think they will think of this specialty? They see fellowship programs all filled by IMGs and some without US residency, what do you think they will think?

If there’s a checklist of red flags for a specialty, nephrology certainly will fill all those boxes.

 

[NewYorkDoctors]

Here’s another reason why match rates are low. How about the increasing awareness among residents that nephrology is all smoke and mirror, promises for equal partnership gets broken in private practice, and that fellowship programs are selling them hopium to get cheap labor. They see many neph grads working as hospitalists in the community, what do you think they will think of the specialty? They come on SDN and see this discussion, what do you think they will think of this specialty? They see fellowship programs all filled by IMGs and some without US residency, what do you think they will think?

This is especially true for the academic IM programs at tertiary care centers connected to USMD schools.
While there are amazing IMG/FMG physicians out there and there are plenty of dud AMG physicians out there, when AMG IM residents at a top academic IM program see that their in house nephrology program is filled with IMG / FMG who came from community IM programs, you can be certain that said AMG IM resident is less likely to consider said internal house program.

Internal Medicine Residents’ Perceptions of Nephrology as a ... : Kidney360

reer in nephrology among internal medicine residents. Methods We recruited focus groups of internal medicine residents (N=25) from the University of Colorado, and asked questions aimed at exploring perceptions, attitudes, and barriers to a career in nephrology, and ways to increase interest in...

journals.lww.com

UColorado is a well renowned academic IM residency program.

These comments from their residents a few years ago perfectly encapsulates the "systemic issues" that RP alludes to

 

[CptNemo]

This is especially true for the academic IM programs at tertiary care centers connected to USMD schools.
While there are amazing IMG/FMG physicians out there and there are plenty of dud AMG physicians out there, when AMG IM residents at a top academic IM program see that their in house nephrology program is filled with IMG / FMG who came from community IM programs, you can be certain that said AMG IM resident is less likely to consider said internal house program.

Yes, that factor is part of the downward spiral, but I don't see it as the primary cause.

I feel that the main issues are:
1) the huge hits that nephrology took in reimbursement in the 2000s and early 2010s (and the failure of our nephrology leaders to adapt/diversify the nephrology business model - instead, they were overly reliant on chronic dialysis and sold out to the government and big businesses).
2) nephrology is not a chill lifestyle specialty (and never has been).
3) with inflation coupled with reimbursement cuts, a standard physician's salary isn't all that impressive.

Although it is taboo to admit it in medicine, people are mainly driven by $ and lifestyle.

This will continue to be a huge issue as the current crop of med students and residents are even more focused on lifestyle. While I'm in no way saying that med school is easy now, it has been made more med student friendly in many institutions: lecture attendance is optional, all classes are pass/not-pass, schools have gotten rid of AOA, and then on wards med students often don't take call with teams plus get let out early routinely. Again, this may be better for their overall wellness, but does not prepare people well for the following years (in our current medicine environment). As a result, many IM programs have had to significantly reduce team/admission caps to be able to attract good candidates - as there is more focus on lifestyle. Nephrology programs have had to do the same - most nephrology fellowships now are much more chill than they were about 5-10 years ago. It is a buyers market - without such changes, the "difficult" University nephrology programs would fare terribly in the match.

In many desirable cities, if you are getting $220-240K as a nephrology associate (and have student loans), you better hope that you are married to a spine surgeon or hospital CEO, or you won't even be able to buy a house (I guess you could buy a condo conversion if you wanted to...) So, after 4 years med school, 3 years IM residency, 2 years nephro, the best case is that you'll likely have to wait several more years just to even buy a house.

 

[Renal_Prometheus]

The situation in nephrology is a lot more complicated than people think, and unfortunately is more sinister than what the numbers show. Simply put, many people don't know what they are getting into. There's a lot of half-truth and intellectual dishonesty coming from neph attendings who are obviously desperate to fill their fellowship spots. Even though fellows are somewhat aware of money/lifestyle being bad in nephrology, they are still surprised it's "that bad" when they get out into the real world. As someone who is very vocal here, I've received many PMs from various people in different stages of their nephrology careers.

These are the kind of PMs I have received from neph applicants/fellows/attendings:

1) applicants who couldn't match into their first choice specialty, but took an offer for neph in the scramble due cultural preference to be a specialist. It's IMG phenomenon and they justify it by saying they need a specialty to go back to their home countries.

2) Older IMG applicants who couldn't get into IM residency, and begrudgingly took a neph spot to work themselves into the US medical system. Trust me, fellowship programs who do this know full well what the power dynamic is here and are looking at these people as bodies to exploited.
I'm going to coin the term "captive fellow" here.

3) Neph fellows who dropped out several months into fellowship because the workload was too heavy. They realized that attendings were being overly personal during the interview process in order to lure them into the program to be used as "warm bodies".

4) I've spoken with practicing nephrologist several years into private practice asking me whether they should try another group or go back to hospitalist. This is after he was offered partnership but had to take a large loan to buy into the practice. Even being a partner he would not be making the kind of money that's worth driving to 5-6 locations per day. I highly doubt he knew this situation is common in private practice when he was an neph applicant.

So it's not like everyone applying to nephrology was because they were passionate about the specialty and knew the risks they were taking. It's not an informed decision, and many go into it out of desperation to escape something else, and took neph because it was easy to get, with plenty regrets later on. There's a lot of cajoling, half-truth mixed with hopium, and psychological manipulation to get someone to agree to get underpaid and overworked for many years with the "hope" that his future partners will treat them fairly. In my personal experience, a lot of promises gets broken when it comes to money, especially in the current macro environment where practice revenue is declining across the board.

 

[NewYorkDoctors]

Still there is nothing stopping a renal graduate from opening up GIM PP and merely using your “super internist” background to be a better internist . Down with the dialysis industrial complex

 

[Renal_Prometheus]

Another common trap that new grads fall for are these rural job ads stating partners make over 500k/yr. They assume that if they do their time, they will eventually make the same amount. The devil is in the details. Really depends on the structure of the group and whether they share existing JV/MDA fees equitably, and if they do, you are looking at least 3-4 yr grind to full partner. Those groups that promise 2 yrs to full partner usually means I don’t share existing JV money from current units, but if a new dialysis unit opens up we will all share that with you; or some sort of buy in at the time of partnership. And there might not be any new units opening up. From what I’m seeing among my friends who made it to partner, they are making about 350k/yr, which is not a lot considering how much they are working. You are also taking the risk that you get told you didnt make partner and start all over again. The ones making over 500k/yr are rare among new grads, but completely common among older generation. So you essentially have 2 classes of nephrologist: older generation that own all the JV, MDAs, real estate, and the newer generation of nephrologists who own nothing and don’t have the same opportunities to grow because dialysis units are saturated in this country and their is limited ESRD pt growth potential. The young guys rely on the old guys to share in this ancillary income, but many are not willing. This is the biggest disconnect I see among applicants when they see established nephrologists doing well and they think they will have the same opportunities.

 

[NewYorkDoctors]

Dr topf is a leader on nephrology and he is a highly respected individual in academia

But two things are abundantly clear :
- he reads SDN for sure
- he has never been in the private practice market before (thank his lucky starts he has not ) and cannot empathize with the struggles of those graduates whom are not able to enter the ivory tower that he abides in

He also does indeed bring up a great point about the lifestyle side of things .
He can only control the academic side of things . The academics have no control over how predatory private nephrologists run their private practices .

The key to successful private practice Is to run solo or at least not be at the mercy of as senior partner and to be able to generate plenty of revenue through office based cpt codes

My suggestion is to get renal bladder ultrasonography back as something that a nephrologist cna be boarded in like echo to cardiology

I have the Emory certification and I use my butterfly IQ ultrasound and go billing for renal bladder US for my patients . Good revenue stream

 

[Renal_Prometheus]

Just delusional some of these academics in still denying the fact that nephrology is underpaid. Why else do you think specialty has 1/3 of fellowship spots unfilled? The market KNOWS!!

 

[NewYorkDoctors]

to the academic's credit, they can only control what they can control

the only issue with making fellowship life too easy is that these same fellows willl graduate and be UNPREPARED for the horrors of private practice life out there.


at the end of the day, there is nothing that the academic nephrologists are doing wrong.

they cannot fix the broken model of ESRD and CKD care. Why? because the US government controls it. antyhing the government controls goes to ****. if you think about it, dialysis is unique in that the government pretty much controls and sets the prices. while this is true of all of the CPT codes, the INABILITY for any doctor to just hang a shingle and start using the HD CPT codes speaks to how constrained this specialty is in terms of revenue generation.

subsequently. they cannot control the predatory practices of senior older nephrologists who had to struggle and pay their dues and now want to abuse the next generation.

purely private practice nephrologists are merely slaves and slavedrivers of the dialysis industrial complex honestly.
unless they manage their own tough cases and do not turf to the university setting unless it's truly a rare case without much clinical data for, then that's what they are for the most part. if the primary revenue stream is dictated by a 'scarce and limted' resource, you can bet there will be some shady business going on regarding how this gets split up.

all subspecialties have had cuts to individual CPT codes over time. how do they over come it? increase volume. (quality may or may not worsen depending on how this volume is increased)

but can a nephrologist simply "increase ESRD volume?"

can a young nephrologist one day decide "i'm going to increase ESRD and HD volume this month!"

you can see how this is the factor that limits private practice expansion and growth. ESRD and HD are rare scarce commodities.

other subspecialties (including GIM) - the more you see the more you make.
this is not necessarily true for nephrology in that if you just spend more time billing the same as an internist (without those HD patients), then your revenue / effort ratio will be quite low.

whereas everyone over 45 gets a screening colonoscopy
anyone with any cardiac complaint gets echo and stress test
etc...

 

[deleted1164820]

Just for clarification, how much of the market in general is private practice vs academic?

Is it more academic in the north east and less of private practice? Or is it highly variable that no one will be able to know and there is no pattern to it.

 

[CptNemo]

Just for clarification, how much of the market in general is private practice vs academic?

Is it more academic in the north east and less of private practice? Or is it highly variable that no one will be able to know and there is no pattern to it.

Generally, from what I've seen, academia only manages about ~10-20% of dialysis patients in cities that I've worked. Though, I'm not sure what the overall stats are on this (it likely depends on the region and local practice patterns). Where I trained, at a big research center, chronic dialysis was kind of looked down upon back in the day - like "that's what the private practice hacks do"... "we are focused on complex cases and research." We did run a dialysis unit, but that was mostly for educational purposes and to serve as the HD unit of last resort. We would start people on HD in the hospital/clinic and then just hand off most of them to the private practice group. That was a pretty viable business model when NIDDK funding was freely flowing, but now not so much.

Academia handles most of transplant work and typically has fancy lupus/GN/specialty nephrology clinics. Some places do apheresis (which private practice generally doesn't do). Academics tend to still do more biopsies and lines (compared to private practice), but overall, the vast majority of the nephrology market share is in private practice.

 

[CptNemo]

they cannot fix the broken model of ESRD and CKD care. Why? because the US government controls it. antyhing the government controls goes to ****. if you think about it, dialysis is unique in that the government pretty much controls and sets the prices. while this is true of all of the CPT codes, the INABILITY for any doctor to just hang a shingle and start using the HD CPT codes speaks to how constrained this specialty is in terms of revenue generation.

This is basically the crux of the matter. For all those who promote single payer government run health care, nephrology should be the canary in the coal mine that makes you think twice about supporting that.

I really like Joel Topf. I remember learning lots of things from his blog when it was in its infancy. Terrific resource. But, sometimes things are just simple:


-Dialysis reimbursement is capped at a rate that has been going down over the years (inflation adjusted)
-I can't do anything innovative in the dialysis unit, because I can't get paid for doing anything extra that is ESRD related for my ESRD patients in or out of the dialysis unit. We have tried to partner with industry/engineering schools to develop devices/innovations to improve dialysis, but no one is interested in investing/buying these as you can't bill anything extra for them. Same with POCUS - go ahead, do POCUS on all your HD patients. You'll increase your rounding time, but won't earn a penny more.
-Clearly, the above would be expected to kill any innovation in the world of dialysis (unless you happen to develop a cheaper dialysis machine).
-As mentioned, we can't just ramp up our speed or number of procedures (such as ophtho or GI) to counteract funding cuts. The above, coupled with this, kill salary growth.

People generally like $ and quality of life
-Now this is more important than ever as true inflation has been off the charts. Other industries seem to be catching up (some of our medical specialties, not so much). Pretty much any halfway decent job pays 6 figures now. Lots of gov't/union jobs pay much more. Lots of tech jobs pay a lot more just out of undergrad.
-Plus, the new generation coming through med school has a big focus on their schedule/lifestyle (and they have not been beat down by the system like we were in the past)

 

[NewYorkDoctors]

to be fair the government needs to rein in excessive costs.
HD was an easy target since medicare was the one who set rates on it since it became a Medicare benefit after the whole Clyde Shields dialysis in congress thing.

but why do the cardiologists have such great procedures? why do cardiologists to angiograms when radiology could do it also?
lobbyists. thanks to the AHA/ACC

where are the renal lobbyists? dunno.


while academic nephrology in tertiary centers will keep doing its best and doing decently, I honestly think most independent or smaller practice PP nephrologists should consider piggy backing GIM/PCP into their practices. try to make your own practice as analogous to the general cardiologist versus interventional as much as possible.
for solo independent nephrologists, go GIM + renal. limit your HD patients to a center close by only. for those who are too far, let the in center nephrologist take care of it. your patient can follow up with you as PCP subsequently
see my prior posts. hire an NP/PA for that and oversee the patients. be the "super internist" that you claim to be.

"but I specialized not to do PCP" - right. so do academic nephrology then. a pretty good gig

"but I want to open a private practice and not do PCP and still be able to print money " - if you want the best of both worlds, you'll have to practice both worlds now. let's be real now . you dont have the same office procedures like GI or cardiology

 

[NewYorkDoctors]

for anyone who failed to match PCCM or cardiology and is tempted to take a renal spot, you should stop.
let's do a logical thought exercise

even if you decided "yeah renal is interesting enough and it has the whole heart - lung - kidney connection" AND you read this entire thread and could feel happy as an academic nephrologist and you have no student debt or whatever...

then you WANT to reapply to renal next year to the TOP ACADEMIC RENAL PROGRAMS

you don't want any of these bottom barrel trash feeding scramble programs. (unless incidentally a top academic program has an open slot... but those fill quickly)

if you feel like "what do I do for a year?"

- do hospitalist and make some real money
- or focus on research and do a gap year (with per diem hospitalist?) and focus on your initial subspecialty of choice


don't be a pawn and warm body for a trash bottom feeding program

 

[Renal_Prometheus]

Applicants need to figure out all the smiles and warmth displayed during the interview process was a ploy to lure people in to take terrible night calls. Some figure it out early, others too late. And some don’t bother to think why it’s so easy to get in a big name program.

 

[Renal_Prometheus]

Neph PDs right now are circling like sharks for any unmatched applicant. Why pay for a Midlevel when you get a fellow for free, and get payed by GME! No brainer!

 

[NewYorkDoctors]

a midlevel will do HD roudns and help do consults and write notes

a midlevel will NOT COME IN OVERNIGHT for urgent HD.

the only reason why someone has to come in the middle of the night is for that on HD note and to ensure things are stable and safe during the HD. The HD nurse knows to hold UF if BP drops but needs the nephrologist around to give definitive orders


anyway anyone who does nephrology should go to a LARGE program that has night float. yes it will be busy at night but you'll feel refreshed doing it in the daytime.

smaller programs dont want that because it compromises who covers the daytime and affects didactics

hence all the more reason to avoid smaller programs



stay AWAY from 2 fellows per year small programs. that is four fellows
call q4 and no night float
if someone is on vacation or on another rotation or something, it temporarily becommes call q3. BRUTAL

BRUTAL


PCCM fellows don't even work this hard. the larger hospitals have NIGHT INTENSIVISTS with the IM residents some places. PCCM fellows some places have ZERO NIGHT DUTIES. Otherwise PCCM fellows might stay overnight but at least the expectation is to be in the call room and not go home and frantically come back.

Cardiology fellows also have it tough with night CCU coverage and overnight consults/ followups. but at least their hard work is handsomely rewarded.

where is the pot of gold at the end of the nephrology rainbow? more like a chamber bot

 

[Renal_Prometheus]

I just think it's completely unfair that academics continue to woo applicants and talk of nephrology as if it's still the lucrative
specialty it was 20 years ago. They keep saying things like starting salaries are low, but you will make a lot of money after partnership.
Well, most people grads now a days don't make a lot of money post-partnership; they just work really hard to make to fill HD units with
pts and make the senior partners rich, who owns all the dialysis units. They are not being truthful about the career risk that some grads get taken advantage of and don't get offered partnership. And of those who are offered partnership, most will not make the same as the senior partners(again, dialysis unit ownership, medical director fees, and real estate all belong to the seniors). Most will have to take out a large loan to buy into the practice, and still won't make the same as the senior partners. A decent percentage of neph grads will eventually figure they are working more and making less than a hospitalist, and will leave the specialty. One neph colleague once made this remark to me, " I'm already making less than a hospitalist(income per hr basis), I need to at least have a better lifestyle to justify keep doing this." Money is not everything, but continuously getting underpaid gets exhausting, and it comes back to money and lifestyle in the end.

 

[Renal_Prometheus]

and I understand from the academics point of view, the specialty is already having a hard enough time filling spots, how I can I tell them there's no hope of making money? well, isn't that the truth? But the alternative is you getting your night calls covered, but then watch all your fellows graduate and get screwed in private practice. And then act innocent and say things like they knew what they were getting into, completely forgetting all the hopium you sold them to get them join your program.

 

[Renal_Prometheus]

again, you have a situation where one party(fellowship programs) stands to gain from cheap labor in a field that requires a lot of cheap
labor and is very undesirable among applicants. You have another party(fellows) who are taking all the career risks. And fellowship programs
can lie about current market compensation without repercussions. It's not a fair relationship. It's an exploitative relationship. And I hate for the
specialty to fall to this level of lowness, but programs taking desperate IMGs with no US residency to exploit them is hardly an example of training the next generation of nephrologists, yet this is widely common in nephrology today.

 

[NewYorkDoctors]

what would an "academic nephrology fellowship" with no fellows do?

come in the middle of the night for every dialysis? lol.

i'd like to see that.

addendum: as I mentioned in some prior posts, one of the community hospitals I have affiliation with has an IM residency but no fellowship. the renal group is a private practice group that is contracted by the hospital. if there is a missed HD overnight, there will be so much stalling and arranging for HD first thing in the morning.

 

[Renal_Prometheus]

How do you sell a specialty with bad lifestyle and low pay? By selling hope that some people can still make it big. Isn’t this the only playbook neph fellowship has left? Selling hope to those who are looking for hope.

 

[NewYorkDoctors]

How do you sell a specialty with bad lifestyle and low pay? By selling hope that some people can still make it big. Isn’t this the only playbook neph fellowship has left? Selling hope to those who are looking for hope.

i recall the academics selling how "academically rigorous nephrology is" and espoused the wonders of "marrying endocrine, hematology, rheumatology, and cardiology to the kidneys" as well as being a "cardionephrologist" and how many wonderful extracorporeal therapies there are and the marvels of renal transplant

yes academic nephrology is very intellectually diverse and varied and a great field.


but private practice nephrology is just a grind with no guarantee of loot.

it's funny all of the PCCM fellows at the program i am associated with love it when a renal intensivisit (a few are in the hospital system) round on ICU because "they learn so much."

it is true, nephrology has a lot of "pearls" in a sense relevant to ICU. kind of like having a walking talking "Nephrology Secrets" book on rounds.

still... no one wants to do renal lol.

 

[Renal_Prometheus]

ASN Data

Takeaways from ASN’s 10th Annual Nephrology Fellow Survey

data.asn-online.org

Perspectives—Recommend Nephrology​

The challenge of the physiology, the mentorship, the close relationships with patients, the reliance on a strong internal medicine skillset and importance in a wide range of pathophysiology, the opportunities for research and discovery in the field.

I developed an interest in nephrology because of my interest in math and physics, but chose the field because my father developed kidney disease and had an amazing relationship with his nephrologist. You have the ability to really connect with your patients and develop this long-term care relationship with them. I love that you see your patients often and get to share both good times and bad times with them. Witnessing ESRD patients undergo transplantation is one of the most gratifying situations in this field.

Nephrology offers job security, a broad scope of practice, intellectual stimulation, multidisciplinary collaboration, long-term patient relationships, and research opportunities. With a high demand for nephrologists and the complexity of kidney diseases, it’s a rewarding field for medical students seeking a fulfilling career in healthcare.

Nephrology is a field with lot of future potential and diminishing supply of physicians. If a med student or resident has an interest in the specialty, I’d certainly advise pursuing it. Nephrologists practice can be very flexible depending on individual goals and one can achieve a great work life balance while still earning competitive remuneration.

I will say there is a little bit of hesitation in the recommendation because I think burnout in this field is a huge issue, but I love the field because it’s interesting medicine, and you are involved in every aspect of patient care.

Perspectives—Would Not Recommend Nephrology​

Although I love Nephrology and I do think I made the right choice, overall Nephrology is underappreciated, undercompensated and overworked as a field and overall I do not recommend it for most students unless there is a very strong and unique interest in the kidney physiology and patients with renal disease.

The compensation is not adequate for the amount of work we are doing. Night calls and week-end calls make it less appealing as well.

Pediatric nephrologists are grossly underpaid, it is an emotionally challenging field and it seems that because the workforce is scarce, our workload will increase in the coming years.

The future reimbursement will continue to be poor, we are giving away intervention and dialysis to others, it is just a matter of time when we will have given away our unique skills.

Lifestyle is difficult and reimbursement is low when you account for the effort required. Medicare reimbursements also continued to be cut which makes it difficult to care for those who need it and still be financially viable. As interesting as the field can be, it’s difficult for most to sacrifice both income and quality of life. Many can give up one or the other but not both.

 

[NewYorkDoctors]

how do you get the best of both worlds for the Pro and Con nephrolgoy?

easy join academic faculty and do q8 call or something and have the fellows bear the brunt of the weekend and night call situation

 

[Renal_Prometheus]

I have to say those fellows who are pro-nephrology, they have not yet experienced the brutality of private practice. A significant percentage will drop out over time and peoples opinions will change with maturity. A better indicator of how nephrologists are fairing is to do a survey of private practice nephrologists 5 yrs out of training; but I doubt ASN will do it because they won’t like the results. ASN is in the business of expanding membership, not discouraging neph applicants from applying.

 

[CptNemo]

what would an "academic nephrology fellowship" with no fellows do?

come in the middle of the night for every dialysis? lol.

i'd like to see that.

addendum: as I mentioned in some prior posts, one of the community hospitals I have affiliation with has an IM residency but no fellowship. the renal group is a private practice group that is contracted by the hospital. if there is a missed HD overnight, there will be so much stalling and arranging for HD first thing in the morning.

Why would anyone come in at night for every dialysis? It's not like the nephrologist is stringing up the machine. Many hospitals now have a policy that they accept once per lifetime hemodialysis consents, so no need to come in to consent (I wish that was the case when I was a fellow!)

E.g., chronic HD pts comes in overnight for hypervolemia: chances are he's been to our hospital and has been consented before. I look at the labs, vitals, and xray remotely, call the HD nurse to come in, and quickly put in orders. Job's done. I go back to sleep. If he's our MCP patient, I can't bill for ED/Obs services anyway (aside from an extra MCP visit) even if I did come it.

A lot of academic programs have developed contingencies for having less fellow coverage. Plus, very few academic programs can survive getting a reputation of being too tough on fellows (as there is intense competition in the match even among top tier academic programs for a small number of highly qualified candidates). It is totally a buyer's market for fellows! Programs have come up with ways to take the load off of fellows. Attending only night coverage already does exist in academia (not for all services and not at all programs, but it exists).

Also, fellows aren't that cheap (considering that they cannot independently bill for nephrology services). CMS also pays less for fellows than for residents. With that plus GME overhead, the department has to make up the difference. Fellows are making ~$90-100K around here (plus benefits on top of that).
-Honestly, it may be a better deal to hire junior faculty for the low to mid $200s who can independently bill (i.e., cover his/her own salary) and take the load off from research faculty.

 

[Renal_Prometheus]

The mentality among neph programs have shifted to let's trap a warm body to take terrible night calls for us. These academics know full well a good chunk of their graduates will quit this specialty once they figure out how terrible the pay:lifestyle ratio is in private practice. It's very psychologically disturbing this is the attitude now a days.

 

[Renal_Prometheus]

Being outspoken on SDN, I get PMs from practicing nephrologists on whether they should switch jobs or go back to hospitalist. Here's an example of one message that's all too common in any medium to large city where there's multiple competing groups. Yet I doubt this guy's neph PD would warn him of these market conditions, and would mostly likely say with a straight face how lucrative nephrology can be, given the false impression that anyone who makes partner will make a lot of money. People don't realize the intellectually dishonesty practiced by these academics just to get a warm body to take their night calls.


"Hey! I really appreciate all your posts. I was recently offered a partnership after working my ass off and I have been working until I sign a backdated contract. I really dislike the current state f what I do. I have clinic three times per week, same days I have to go to dialysis units and also have to cover many hospitals, most of which are far from my clinic and I usually round once per week in the place, to change the next day. Clinic is full of new patients which I do not see in the hospital, and my units are also far from each. My clinic is also in three different places. In total, I go to 5 different hospitals with different EMRs, 4 dialysis units with 3 shifts each on MWF, TTS, and my 3 clinics, all in a week. Of course, I was offered a partnership, but the bonus of my production of this year will only be honored after signing the contract. I have not been looking for other options because it just recently started getting worse and worse as someone retired and another longer term nephrologist left.

My question is, do you think it's worth changing now to hospitalist position vs another neph practice without maybe all these hassles. I really don't know how I have survived these years with 190K.

Thanks for your input. Now, back to doing notes. "

 

[NewYorkDoctors]

Being outspoken on SDN, I get PMs from practicing nephrologists on whether they should switch jobs or go back to hospitalist. Here's an example of one message that's all too common in any medium to large city where there's multiple competing groups. Yet I doubt this guy's neph PD would warn him of these market conditions, and would mostly likely say with a straight face how lucrative nephrology can be, given the false impression that anyone who makes partner will make a lot of money. People don't realize the intellectually dishonesty practiced by these academics just to get a warm body to take their night calls.


"Hey! I really appreciate all your posts. I was recently offered a partnership after working my ass off and I have been working until I sign a backdated contract. I really dislike the current state f what I do. I have clinic three times per week, same days I have to go to dialysis units and also have to cover many hospitals, most of which are far from my clinic and I usually round once per week in the place, to change the next day. Clinic is full of new patients which I do not see in the hospital, and my units are also far from each. My clinic is also in three different places. In total, I go to 5 different hospitals with different EMRs, 4 dialysis units with 3 shifts each on MWF, TTS, and my 3 clinics, all in a week. Of course, I was offered a partnership, but the bonus of my production of this year will only be honored after signing the contract. I have not been looking for other options because it just recently started getting worse and worse as someone retired and another longer term nephrologist left.

My question is, do you think it's worth changing now to hospitalist position vs another neph practice without maybe all these hassles. I really don't know how I have survived these years with 190K.

Thanks for your input. Now, back to doing notes. "

honestly if one did all that work and was purely private and the boss (kill what you eat) you would be pulling in over seven figures no doubt.

in fact one of my nephrology mentors is a private practice nephrologist who works at Mt Sinai now (and use to be the director of nephrology at WCMC many decades ago when it was New York Hospital) does this and he is banking serious bank.

the 4 HD units he has (he has 160 chronic patients) are all within approximate walking or subway distance from his park avenue office and he gets all the CRRT and acute HD consults at mt sinai as the non-medical intensivists all want him on board (especially CTICU) as he is fast and does whatever the patient needs and intensivists/surgeons want.

he is solo and he is making it big time

lesson is


YES nephrology can be very lucrative....


but not as the junior partner slave.

 

[CptNemo]

Being outspoken on SDN, I get PMs from practicing nephrologists on whether they should switch jobs or go back to hospitalist. Here's an example of one message that's all too common in any medium to large city where there's multiple competing groups. Yet I doubt this guy's neph PD would warn him of these market conditions, and would mostly likely say with a straight face how lucrative nephrology can be, given the false impression that anyone who makes partner will make a lot of money. People don't realize the intellectually dishonesty practiced by these academics just to get a warm body to take their night calls.


"Hey! I really appreciate all your posts. I was recently offered a partnership after working my ass off and I have been working until I sign a backdated contract. I really dislike the current state f what I do. I have clinic three times per week, same days I have to go to dialysis units and also have to cover many hospitals, most of which are far from my clinic and I usually round once per week in the place, to change the next day. Clinic is full of new patients which I do not see in the hospital, and my units are also far from each. My clinic is also in three different places. In total, I go to 5 different hospitals with different EMRs, 4 dialysis units with 3 shifts each on MWF, TTS, and my 3 clinics, all in a week. Of course, I was offered a partnership, but the bonus of my production of this year will only be honored after signing the contract. I have not been looking for other options because it just recently started getting worse and worse as someone retired and another longer term nephrologist left.

My question is, do you think it's worth changing now to hospitalist position vs another neph practice without maybe all these hassles. I really don't know how I have survived these years with 190K.

Thanks for your input. Now, back to doing notes. "

Totally depends on the setup.

If he has ~20 patients per shift * 6 shifts = 120 pts plus full clinics and lots of inpatient consults then he's getting massively taken advantage of as an associate and should start making mid 6 figures at the very least for that type of work as a partner - that would be a ~14,000-15,000 wRVU/year very busy job (just clinical production alone would easily cover that type of salary). If the group would fairly distribute income based on production and fairly offers medical directorships, may be worthwhile to stay.

However, if the setup is that he sees 3-5 patients each shift plus a couple consults at each hospital/day, then he's stuck in a very inefficient job with lots of driving that won't yield much income even if he gets to keep all that he bills for.

 

[NewYorkDoctors]

Totally depends on the setup.

If he has ~20 patients per shift * 6 shifts = 120 pts plus full clinics and lots of inpatient consults then he's getting massively taken advantage of as an associate and should start making mid 6 figures at the very least for that type of work as a partner - that would be a ~14,000-15,000 wRVU/year very busy job (just clinical production alone would easily cover that type of salary). If the group would fairly distribute income based on production and fairly offers medical directorships, may be worthwhile to stay.

However, if the setup is that he sees 3-5 patients each shift plus a couple consults at each hospital/day, then he's stuck in a very inefficient job with lots of driving that won't yield much income even if he gets to keep all that he bills for.

all true statements

nevertheless some doctors who need visas might be held hostage over the visa sponsorship and have no leverage to ask for more.

Indentured servitude indeed.

 

[Renal_Prometheus]

If the group would fairly distribute income based on production and fairly offers medical directorships, may be worthwhile to stay.

And that’s the disconnect between you and me. The truth is that most nephrology groups do not distribute income/medical directorships fairly between older and newer partners. If the older guys share equally, they wont take home enough to make it a worthwhile so they need to live off the back of new guys. And that’s the dilemma most grads find themselves in several years into private practice, they are not making enough to justify working this hard, but don’t want to try another group and start all over again at the bottom. This is why this specialty is non-competitive, because the market has foreseen all of this and is “priced in” to the level of interest in fellowship match.

 

[NewYorkDoctors]

I pay my primary care NP more than some junior nephrologists get paid . Let that sink in . Some might say uh why don’t you pay a doctor ? I do I installed my friend doctor as site director at a new office branch I’m opening.

 

[NewYorkDoctors]

ASN Data

Matched Candidates in Nephrology Down 11% in AY 2024

data.asn-online.org

based on the statistics it might seem at first glance that "this thread is not dissuading applicants from pursuing nephrology."

But that misses the point of this thread. The goal of this thread is not "die nephrology die."

It is those who do NOT prefer nephrology (i.e. undecided applicants who know they are not strong candidates for more competitive subspecialties or those who failed to match into cardiology or PCCM) should stay away from nephrology with a ten foot pole.

But those who ARE Interested should be encouraged to apply and pursue their preferred subspecialty

Moreover, it is clear the problem is not not enough interest in nephrology. It is tremendous oversupply of nephrology fellowships slots.
The number of applicants has been increasing over the years.

 

[Renal_Prometheus]

If it’s free, it’s not something you want. A specialty that has no barriers to entry will cause more harm to you career than benefit, you just haven’t figured out the “catch”. These neph fellows will end up paying a heavy price down the road, but the hopium is blinding them from seeing the truth and getting out before more damage is done.

 

[Renal_Prometheus]

But those who ARE Interested should be encouraged to apply and pursue their preferred subspecialty

This is on the assumption people know what they are getting into? But do they? Most Neph applicants I talk to are completely shocked that academics are looking at them like meat to be preyed on, sold a bag of hopium, and take their terrible night calls. Do they know that private practice guys are looking at new hires as suckers to be worked to the bone, and be offered a fake partnership at the end(partner in name only, but share none of the revenue).

 

[NewYorkDoctors]

This is on the assumption people know what they are getting into? But do they? Most Neph applicants I talk to are completely shocked that academics are looking at them like meat to be preyed on, sold a bag of hopium, and take their terrible night calls. Do they know that private practice guys are looking at new hires as suckers to be worked to the bone, and be offered a fake partnership at the end(partner in name only, but share none of the revenue).

i have always rationalized that those who really want to do it are seeking to become full academic nephrologists who become leaders of the ASN, do transplant, get grants, etc... should go ahead and do it.

anyone who is "interested in nephrology" but does not plan to go that full academic route should really take a pause and read this thread and think some more.

the logic is anyone who goes through the match the first time probably has some plan in place about an academic job or at least being a clinical educator and does not want to enter the PP market.

 

[CptNemo]

ASN Data

Matched Candidates in Nephrology Down 11% in AY 2024

data.asn-online.org

Moreover, it is clear the problem is not not enough interest in nephrology. It is tremendous oversupply of nephrology fellowships slots.
The number of applicants has been increasing over the years.

I think decreased interest is a big issue. The number of applicants did go down this year. It wasn't included in the ASN report, but you can grab the ERAS 2024 prelim data here: ERAS® Statistics
I'm not sure why the numbers don't fully match up with the NRMP numbers, but are pretty close and can infer the trend from them.

Specialty

Grad Type

ERAS 2019

ERAS 2020

ERAS 2021

ERAS 2022

ERAS 2023

ERAS 2024

Nephrology (Internal Medicine)	DO	40	48	43	65	64	63
	IMG	206	196	244	232	245	217
	MD	80	72	84	98	103	77
	Overall	326	316	371	395	412	357

Interest is down quite a bit. Many years ago, when I was applying, nephrology had barely joined the match and wasn't "all in" yet and had much more interest from applicants in the match.

2009 was nephrology's first year in the match. See the data below:

https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2009.pdf

https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2010.pdf

2009: Nephrology had 576 application for 374 positions.
2010: Nephrology had 578 application for 367 positions.
Now, we generally have about 200 fewer applicants on average than we had in the early years of the nephrology match (roughly a 35% decrease in applications despite having more positions available).

For comparison, in 2009-2010, both pulm/CC and GI had about the same amount of applicants as nephrology.
Currently, both have roughly doubled (usually in the 1100s to 1200s of applicants).

 

[NewYorkDoctors]

In PP , a general cardiologist could do a diagnostic cath but would prefer to defer those to interventional. A general cardiologist could do dccv in hospital but would prefer to have ep so it. A general pulm would like to have a dedicated bronch person in group or have IP do even basic non IP bronch techniques . This set up maximizes PP outpatient visits and procedures (hence revenue )

If renal had more office procedures then PP groups could set up a rotation of sorts to be analogous to make lifestyle easier . But alas no such office procedures exist outside of dipstick UA pays peanuts and possibly getting a ASDIN renal sono certificate to so focused limited renal bladder sonos

 

[Renal_Prometheus]

I think decreased interest is a big issue. The number of applicants did go down this year. It wasn't included in the ASN report, but you can grab the ERAS 2024 prelim data here: ERAS® Statistics
I'm not sure why the numbers don't fully match up with the NRMP numbers, but are pretty close and can infer the trend from them.

Specialty

Grad Type

ERAS 2019

ERAS 2020

ERAS 2021

ERAS 2022

ERAS 2023

ERAS 2024

Nephrology (Internal Medicine)	DO	40	48	43	65	64	63
	IMG	206	196	244	232	245	217
	MD	80	72	84	98	103	77
	Overall	326	316	371	395	412	357

Interest is down quite a bit. Many years ago, when I was applying, nephrology had barely joined the match and wasn't "all in" yet and had much more interest from applicants in the match.

2009 was nephrology's first year in the match. See the data below:

https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2009.pdf

https://www.nrmp.org/wp-content/uploads/2021/07/resultsanddatasms2010.pdf

2009: Nephrology had 576 application for 374 positions.
2010: Nephrology had 578 application for 367 positions.
Now, we generally have about 200 fewer applicants on average than we had in the early years of the nephrology match (roughly a 35% decrease in applications despite having more positions available).

For comparison, in 2009-2010, both pulm/CC and GI had about the same amount of applicants as nephrology.
Currently, both have roughly doubled (usually in the 1100s to 1200s of applicants).

This is entirely predictable based on how badly nephrologists gets abused in private practice. The market always knows what’s going on. My only surprise is those applicant who continue to apply to nephrology, going against the market/common sense, and expect a different outcome.

 

[CptNemo]

This is on the assumption people know what they are getting into? But do they? Most Neph applicants I talk to are completely shocked that academics are looking at them like meat to be preyed on, sold a bag of hopium, and take their terrible night calls. Do they know that private practice guys are looking at new hires as suckers to be worked to the bone, and be offered a fake partnership at the end(partner in name only, but share none of the revenue).

I can assure you that most academics at top programs do not look at fellows this way. A lot of them are either focused on their research, love to geek out on complex renal cases, and/or are in the bubble of academia without paying much attention to the world of private practice. And, even if they wanted to treat fellows this way, they can't because it is such a buyers market for fellows that their programs would not fill with good quality fellows if the program developed a bad reputation (and then the program directors and department chiefs would not be happy). Additionally, GME departments at large legit universities are very strict about what schedules are allowed for fellows - currently big universities are very focused on med student/resident/fellow wellness, so a lot of work that residents/fellows used to do has gotten shifted to attendings.

Honestly, some of the candidates applying to nephrology are pretty bad and remain unranked by programs (despite the difficulties filling) because the perception is that having them on board would make life harder for the program than just being one fellow short. Just having a warm body filling a spot is not generally helpful.

I'm sure that there are some low quality programs that are exploitative, but there is no reason to go to those programs in the current climate.

 

[Renal_Prometheus]

Just having a warm body filling a spot is not generally helpful.

You really need to get out more and see what the rest of the country is doing. Majority of nephrology programs are not top 10 and get their pick of the litter. They are salivating over warm bodies and ready to pounce on anyone who show's the slightest interest in nephrology.

 

[NewYorkDoctors]

I can assure you that most academics at top programs do not look at fellows this way. A lot of them are either focused on their research, love to geek out on complex renal cases, and/or are in the bubble of academia without paying much attention to the world of private practice. And, even if they wanted to treat fellows this way, they can't because it is such a buyers market for fellows that their programs would not fill with good quality fellows if the program developed a bad reputation (and then the program directors and department chiefs would not be happy). Additionally, GME departments at large legit universities are very strict about what schedules are allowed for fellows - currently big universities are very focused on med student/resident/fellow wellness, so a lot of work that residents/fellows used to do has gotten shifted to attendings.

Honestly, some of the candidates applying to nephrology are pretty bad and remain unranked by programs (despite the difficulties filling) because the perception is that having them on board would make life harder for the program than just being one fellow short. Just having a warm body filling a spot is not generally helpful.

I'm sure that there are some low quality programs that are exploitative, but there is no reason to go to those programs in the current climate.

yep those are most of the programs in the scramble/SOAP

Hence no unmatched cardiology or PCCM candidate should ever ever consider those programs.

 

[Renal_Prometheus]

The whole thing was a lie. Most neph grads coming out today will eventually figure out the job is worst than being a hospitalist. Dangling a carrot in front of a donkey to make him pull the cart that nobody else wants to pull.

 

[CptNemo]

You really need to get out more and see what the rest of the country is doing. Majority of nephrology programs are not top 10 and get their pick of the litter. They are salivating over warm bodies and ready to pounce on anyone who show's the slightest interest in nephrology.

The point is that no one really gets the pick of the litter anymore. Even the top programs are all interviewing the same 50-100 candidates within a given region. Of those, maybe about 10-20 are really exceptional candidates that multiple programs are "salivating" over - and some of those candidates have research/clinical preferences or geographical preferences that guide their decisions. This is why even good programs sometimes don't fill.

I stand by my statement that I would rather do work by myself without a fellow than to be stuck with a fellow who is either poorly qualified, is overwhelmed, has personality issues, and/or just doesn't work well with others - they can totally make my life much more difficult (while likely also complaining to the GME office in the process) .

 

[Renal_Prometheus]

I stand by my statement that I would rather do work by myself without a fellow than to be stuck with a fellow who is either poorly qualified, is overwhelmed, has personality issues, and/or just doesn't work well with others - they can totally make my life much more difficult (while likely also complaining to the GME office in the process) .

You can make that statement. But most academics are more than overjoyed that someone is willing to cover their night calls. That doesn’t change the reality of what’s going on.