Nephrology is Dead - stay away

NewYorkDoctors said:

one of the renal attendings I trained under at a large academic upper east side academic renal program.. use to be a director of renal in the 70s and wrote lots of papers on renin and angiotensin1/2 went full private some time ago.

currently has a park avenue office. rounds at two hospitals in upper east side
the renal fellowship handles the renal fellowship.
the other "not learning cases" go to privates. he is one of the privates and goes around putting orders for HD, CRRT, etc... all the intensivists, surgeons, hospitalists love him as he is very receptive and gives his cell phone out.
he has 200 HD patients spraed across 4 HD centers - all within fair walking distance

he is in the 70s and took a career accumulating this

he made it big.

he is a "senior partner."

though he is solo. oh sure he has other solo doctors cover his patients if he is away and the such. but he does not employ junior partners to exploit. that is respect

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Ball park of how much he makes doing this?

MD46 said:

Ball park of how much he makes doing this?

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dunno he does a lot of hospital consults and followups (all himself he does not bother the fellows unless its a glomerular case or something interseting)

he told me before he just bills 99204 in the office and calls it a day. does not spend too much time in the office.

if we just did the ESRD panel 200 patients 4 visit a month = 200 * $400 a month * 12 months in a year = $960,000
that is without even accounting for his hospital consults, billing critical care time for ICU patients, billing for CRRT and acute HD.

so im sure he's banking good bank.

anyway one of patient's with nephrotic syndrome and primary hypoparathyroidism just got a renal biopsy back as primary membranous nephropathy PLA2R positive (I call this "plotter positive"). intriguing.

Kidney biopsy:-Diffuse membranous glomerulonephritis, stage 2-3, PLA2R positive.-Global glomerulsclerosis (3/30).-Rare foci of tubular atrophy.-Mild arterio- and arteriolosclerosis.-No segmental or global proliferative lesions noted.

here is some "beautiful" renal path images

diffuse glomerulosclerosis


look at that spike and domes!


look at that podocyte effacement!






now its time to update his age appropriate cancer screening and investigate his hypoparathyroidism a bit more deeply (as his PCP isn't following my reccs)

anyway this patient's insurance will cover calcitriol but not Tums go figure

This patient won't spend money on Tums so I've had to give calcium acetate (not indicated for his Ph of 5.5 I know and it has low elemental calcium compared to carbonate. but hey if hes not shelling out for Tums gotta do something)


anyway i find the rat inside this same patient's lungs far more interesting




addendum: this patient has nephrotic syndrome due to primary membranous nephropathy

he also ha tuberculosis 2 years ago treated. he has a cavity and now he has been diagnosed with chronic cavitary pulmonary aspergillosis
this might be hard to treat. doing okay on voriconazole at the moment
he is considered "moderate risk of progression" for his membranous so just doing ARB and dietary control at the moment
I'd hate to see what happens to his CCPA if I arranged rituximab (not in my office but a NY blood and cancer - third party infusion center) for him.

this kind of case really needs a multidisciplinary approach but this patient is.... not documented.... refuses to go into tertiary care center .... has managed Medicaid though (nice for this patient).... I am solo-ing this case. wish me luck.

Prehealth1011 said:

I spoke to a nephro fellow who picked it because you start at 250k but I’ll be a partner after 2 years and I’ll be good. I don’t think sdn has a strong IMG/FMG presence. Definitely think there’s utility in keeping this thread alive.

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And if neph applicants actually read through this thread, they will realize there’s a lot more to the story than I will make partner after 2 years and make a lot of money. In fact, they will discover they have fallen into a scam perpetuated people who have a vested interest in having a continual supply of fellows.

You know Nephrology is in a bad place when academics have to post on a nephrology bashing thread(this one), to recruit fellows.

if the "academic" program in question were a good one, they would have no need to worry as they will get their fellows no problems.

There are still AMG who enter nephrology and they go to the best of the best


The "rest" are garbage programs that have no business existing other than to get some free labor (paid by CMS)

I’ve often encountered this type of neph applicant. They say they know it’s a bad specialty(do they really?) but have a reason for applying. It’s basically someone who is desperate who doesn’t want to be a hospitalist and wants to take a gamble with their careers. 5 yrs later, they are back to hospitalist work. The repetitive nature which these scenarios play out is predictable at this point. People really don’t know the nuances of how bad the specialty is until they went into it and experienced all lies, half-truth, and rampant exploitation in pp. Then they look back and it now makes perfect sense why the specialty goes unfilled.

Renal_Prometheus said:

I’ve often encountered this type of neph applicant. They say they know it’s a bad specialty(do they really?) but have a reason for applying. It’s basically someone who is desperate who doesn’t want to be a hospitalist and wants to take a gamble with their careers. 5 yrs later, they are back to hospitalist work. The repetitive nature which these scenarios play out is predictable at this point. People really don’t know the nuances of how bad the specialty is until they went into it and experienced all lies, half-truth, and rampant exploitation in pp. Then they look back and it now makes perfect sense why the specialty goes unfilled.

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Though if this person derives personal satisfaction and “achievement “ by getting certified as a sub specialist , then that might be worth it for said individual .


It makes zero financial sense though

Look at the bright side , the remaining half are those who truly want to do nephrology and will thrive in their careers . Isn’t this what the academics want ?

Addendum: call us Thanos lol. No sacred timeline nonsense this time to correct the snap.

What? Only the top ivory tower academics want that ?

What ? Those bottom barrel programs with no reason to exist other than to get cheap labor don want that ?

Salty is the wrong word .
I enjoy the brain stimulation of a GN case . That’s all .

More like “even my primary care practice blows renal out of the water . “


One can peruse reddit and there is far more activity on reddit than on this thread (though the views on this thread continues to increase so this is not a case of "necro-bumping." After all, even loves to watch a train wreck in progress!)

but those recent graduated young attendigns, current renal fellows, IM residents, and med students all voice similar issues on that platform as this thread. This thread is just very visible given the fact it is 10 years strong now and has over 240K views. (everyone loves to watch a pile up on the interstate!)



the root issue here is how there are no office procedures to do.

do general cardiologists complain about how the interventional docs are "doing all teh caths?" heck no. they would rather NOT be on call and get orthopedic problems by doing their nucs and echos in their office.

do community GI complain about the advanced endo docs going all the cool ERCPs? heck no. they never want to go to the hospital again lol.


if nephrology had office procedures to do themselves, then it would thrive in the community.

no such luck exists as no such procedures exist

only thing somewhat close would be taking the USDIN emory course to get renal bladder sono certified and then you can go bill some renal bladder U/S 76705 in office.

I’m paraphrasing a bit, but there’s a common saying that good specialties sell itself. If a specialty needs to be “sold” to applicants, then there’s probably something seriously wrong with it.

To add things further, a specialty can’t be both lucrative and noncompetitive at the same time, as some academics claim. These 2 claims are inherently antithetical that defies common sense. It’s possible that a few people do well, but you may be sacrificial lamb that’s needed to balance the equation.

as there are 39 pages to this thread and most doctors have no time to read through this all, I just want to reiterate in every page that the goal of this thread is not to say "DIE NEPHROLOGY DIE." The reason is to ensure those who are bought in should join a top academic fellowship program and become a top doctor in nephrology.

But no ONE should join a useless bottom barrel program to become a community nephrologist as there is little to be gained in non-academic nephrology other than headaches and heartache.



The only individual who MIGHT actually read the whole thread are the residents who failed to match PCCM and Cardiology who get cold called by Nephrology PDs being sold a "bag of goods."
That is the individual I am trying to reach to ensure no one matches into Nephrology like that.
From multiple DMs over the years, I would say I think I have reached my target audience.

NewYorkDoctors said:

View attachment 386963
Look at the bright side , the remaining half are those who truly want to do nephrology and will thrive in their careers . Isn’t this what the academics want ?

Addendum: call us Thanos lol. No sacred timeline nonsense this time to correct the snap.

What? Only the top ivory tower academics want that ?

What ? Those bottom barrel programs with no reason to exist other than to get cheap labor don want that ?

Salty is the wrong word .
I enjoy the brain stimulation of a GN case . That’s all .

More like “even my primary care practice blows renal out of the water . “


One can peruse reddit and there is far more activity on reddit than on this thread (though the views on this thread continues to increase so this is not a case of "necro-bumping." After all, even loves to watch a train wreck in progress!)

but those recent graduated young attendigns, current renal fellows, IM residents, and med students all voice similar issues on that platform as this thread. This thread is just very visible given the fact it is 10 years strong now and has over 240K views. (everyone loves to watch a pile up on the interstate!)



the root issue here is how there are no office procedures to do.

do general cardiologists complain about how the interventional docs are "doing all teh caths?" heck no. they would rather NOT be on call and get orthopedic problems by doing their nucs and echos in their office.

do community GI complain about the advanced endo docs going all the cool ERCPs? heck no. they never want to go to the hospital again lol.


if nephrology had office procedures to do themselves, then it would thrive in the community.

no such luck exists as no such procedures exist

only thing somewhat close would be taking the USDIN emory course to get renal bladder sono certified and then you can go bill some renal bladder U/S 76705 in office.

Click to expand...

I honestly think it isn't even that--the big problem is that ESRD triggers medicare at any age and as a result the payor mix is terrible, probably the worst of any specialty, because it selects for Medicare. If medicare didn't cut reimbursements by record amounts in the face of rising inflation this wouldn't be so bad but here we all are.

Yes procedures help immensely in terms of upping revenues but even an E/M only clinic that runs lean can be very profitable but if you are taking 80-90% CMS that cuts reimbursement by 2-6% annually you are doomed. As an example, I bill a chest ultrasound, CMS pays $50, private insurance pays anywhere between $150-600. I have to do a minimum of 3x the amount of work on CMS patients for a single private patient. This internal mental calculus absolutely comes in to play when I am considering coming in for work on a day off. Not worth it to see a 65+ year old, but a private insurance patient absolutely can be. System is beyond ****ed, can't wait for it to implode.

chessknt said:

I honestly think it isn't even that--the big problem is that ESRD triggers medicare at any age and as a result the payor mix is terrible, probably the worst of any specialty, because it selects for Medicare. If medicare didn't cut reimbursements by record amounts in the face of rising inflation this wouldn't be so bad but here we all are.

Yes procedures help immensely in terms of upping revenues but even an E/M only clinic that runs lean can be very profitable but if you are taking 80-90% CMS that cuts reimbursement by 2-6% annually you are doomed. As an example, I bill a chest ultrasound, CMS pays $50, private insurance pays anywhere between $150-600. I have to do a minimum of 3x the amount of work on CMS patients for a single private patient. System is beyond ****ed, can't wait for it to implode.

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good point, that definitely plays a big role


but the way nephrology as a practice is structured just adds additional barriers to financial success in the private practice market

if we did a comparison of nephrology to general cardiology (which one thinks about it is analogous in practice in certain ways though different in many ways)

let's use a private practice model and not an employed hospital employee model since usually its the private practices that run lean and try to cut overhead and have the doctor do more tasks than just being the doctor.

Both see inpatient consults and both see outpatient consults. They often see the same patients as well that overlap.

Inpatient is inpatient. The same hospital codes. When a private cardiologist who rounds inpatient orders inpatient tests, that cardiologist is probably not the one billing for those echos, EKG, nucs, caths etc... the same goes for the private nephrologist who rounds inpatient and orders renal sono, NM lasix scan, CTAP etc...

As for outpatient , both see office consultations.

The cardiologist usually does a 12L EKG and takes a history and exam. Then orders TTE, Holter, US Carotid, US LEA, and treadmill stress test to be done in the same office by technician and cardiologist interprets (if has vascular medicine board which certain cards programs will have the fellows get during their 3 year gen cards fellowship then can do those vascular sono studies). Sure prior auth is needed for TTE and those others can bed one over the course of several visits. The cardiologist sits there writing reports and then sharing result swith patient on alternate days.

The nephrologist has no such office procedures. If the nephrologist has an HD panel, the nephrologist then travels to the HD center. If lucky and has a good set up, then can go to the center nearby without too much travel time. But always hustling around. If unlucky, then one has to hustle around and all that productivity is given to the senior partners who are using you as a glorified midlevel in terms of revenue sharing

For a solo provider (rare but it happens), when starting a practice without ESRD patients, who has to literally go to the hospital setting, hang out by the ER and the ICU and be available and be a "doctor's doctor" to get those ATN patients who might need HD or to get those CKD5s who are close. Yes every specialty has to work at it to get referrals and consults.

But least other more comfortable subspecialties can just "do everything when the patient walks into the office." A doctor with office procedures can hang the shingle and advertise and eventually will build up patients.

Even if a nephrologist hung up a shingle, one gets a lot of non-procedural AKI, CKD< electrolyte, issues

a GN is interesting enough but it's a lot of work. arranging a renal biopsy is not bad. but arranging for Rituximab at an infusion center when you do not have one is just a lot of extra uncompensated work.

That whole "you have to travel around everyday to make your money" is really not something I can think of is present for any other subspecialty.


anyway the point remains

If you love the beans do it and go academic. You will have a great career.

If you don't love the beans and think you can make it rich as nephrologist, you better have a plan in place or else you may end up losing the gamble and losing prime years of your life

If you are a resident who failed to match PCCM or cardiology, it is illogical to take a scramble spot for nephrology. Even if you can see yourself doing academic nephrology and have second thoughts about your competitiveness for cards or PCCM, you would want to apply NEXT YEAR and go into the top academic renal programs instead.

NewYorkDoctors said:

good point, that definitely plays a big role


but the way nephrology as a practice is structured just adds additional barriers to financial success in the private practice market

if we did a comparison of nephrology to general cardiology (which one thinks about it is analogous in practice in certain ways though different in many ways)

let's use a private practice model and not an employed hospital employee model since usually its the private practices that run lean and try to cut overhead and have the doctor do more tasks than just being the doctor.

Both see inpatient consults and both see outpatient consults. They often see the same patients as well that overlap.

Inpatient is inpatient. The same hospital codes. When a private cardiologist who rounds inpatient orders inpatient tests, that cardiologist is probably not the one billing for those echos, EKG, nucs, caths etc... the same goes for the private nephrologist who rounds inpatient and orders renal sono, NM lasix scan, CTAP etc...

As for outpatient , both see office consultations.

The cardiologist usually does a 12L EKG and takes a history and exam. Then orders TTE, Holter, US Carotid, US LEA, and treadmill stress test to be done in the same office by technician and cardiologist interprets (if has vascular medicine board which certain cards programs will have the fellows get during their 3 year gen cards fellowship then can do those vascular sono studies). Sure prior auth is needed for TTE and those others can bed one over the course of several visits. The cardiologist sits there writing reports and then sharing result swith patient on alternate days.

The nephrologist has no such office procedures. If the nephrologist has an HD panel, the nephrologist then travels to the HD center. If lucky and has a good set up, then can go to the center nearby without too much travel time. But always hustling around. If unlucky, then one has to hustle around and all that productivity is given to the senior partners who are using you as a glorified midlevel in terms of revenue sharing

For a solo provider (rare but it happens), when starting a practice without ESRD patients, who has to literally go to the hospital setting, hang out by the ER and the ICU and be available and be a "doctor's doctor" to get those ATN patients who might need HD or to get those CKD5s who are close. Yes every specialty has to work at it to get referrals and consults.

But least other more comfortable subspecialties can just "do everything when the patient walks into the office." A doctor with office procedures can hang the shingle and advertise and eventually will build up patients.

Even if a nephrologist hung up a shingle, one gets a lot of non-procedural AKI, CKD< electrolyte, issues

a GN is interesting enough but it's a lot of work. arranging a renal biopsy is not bad. but arranging for Rituximab at an infusion center when you do not have one is just a lot of extra uncompensated work.

That whole "you have to travel around everyday to make your money" is really not something I can think of is present for any other subspecialty.


anyway the point remains

If you love the beans do it and go academic. You will have a great career.

If you don't love the beans and think you can make it rich as nephrologist, you better have a plan in place or else you may end up losing the gamble and losing prime years of your life

If you are a resident who failed to match PCCM or cardiology, it is illogical to take a scramble spot for nephrology. Even if you can see yourself doing academic nephrology and have second thoughts about your competitiveness for cards or PCCM, you would want to apply NEXT YEAR and go into the top academic renal programs instead.

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Cardiology and pulm both get to see and do procedures on patients who on private insurance though--there are 50-64 year olds with jobs (or employed spouses) who have COPD/CAD/lung cancer etc etc. My worst private insurance contract is 2.7x CMS rates for E/M, 4x CMS rates for procedures. I could see 5 private insurance patients and make the same as seeing 13 CMS patients, do 2 bronchs on private patients or 8 on CMS patients etc. Allergy has an incredible payor mix, its why they never work more than 4 days a week--they dont need to churn volumes of CMS patients.

Nephrology will almost never get anything other than CMS rates for dialysis/lines/follow ups.

chessknt said:

Cardiology and pulm both get to see and do procedures on patients who on private insurance though--there are 50-64 year olds with jobs (or employed spouses) who have COPD/CAD/lung cancer etc etc. My worst private insurance contract is 2.7x CMS rates for E/M, 4x CMS rates for procedures. I could see 5 private insurance patients and make the same as seeing 13 CMS patients, do 2 bronchs on private patients or 8 on CMS patients etc. Allergy has an incredible payor mix, its why they never work more than 4 days a week--they dont need to churn volumes of CMS patients.

Nephrology will almost never get anything other than CMS rates for dialysis/lines/follow ups.

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i whole heartedly agree.

I primarily serve the Medicaid poor population in NYC . so it's a bunch of managed medicaid or Medi/Medis. ultimately pays nicely though that 2% cut every year for medicare population keeps getting wider and wider as you mention

I have very few commercial insurance patients

but when I do see the occassional Aetna commercial priviate insurance or empire BCBS and this patient is beyond deductible and out of pocket max, the payments for a PFT, CPET, broncho, etc... are higher than what I get


but therein lies the key, will the patient with private insurance pay me if still within their deductible? the answer is unequivocally ... No. I have sent bills before but many of those patients just never show up again daring me to send a collection agency.... which I do not have time for... so i cut my losses, put a note in my EMR patient cannot schedule without paying, then write a letter for PCP.

Great discussion. Academic nephrologist act like there’s nothing wrong with this specialty, when in reality everything is wrong, and heading in the wrong direction. Fellows graduate full of hope, and then get there optimism crushed in the first few years in private practice. Me and NYD have both been through the ringer, and know the kind of lies and misrepresentations these programs will say to get a fellow in the door. Ultimately, you just can’t trust what people say when they have trouble filling spots.

Private practice nephrology can be very profitable.....


if many things break your way. This includes having an ESRD panel, having a short commute distance, having old nephrologists allow you to buy into an HD center JV to get privileges there, having other doctors rely on you for quick renal consultation and dialysis, etc... too many factors required to make it profitable.

I don't think ANY other IM subspecialty has these "roadblocks" in place from the get go.

For a procedural subspecialty, hang a shingle and start doing procedures and never go to the hospital again unless you wanted to do so.

You are going into the fight with one arm tied behind your back.

I love it how people say nephrology has an optics problem. As if that’s the root cause of all its problems. As someone who has ran a nephrology practice for many years, it doesn’t have a optics problem, it has a billing problem.

well there is an optics problem in residency

the "cool" renal cases are mostly outpatient in renal clinic or in the transplant floor.

what most IM residents seen inpatient are the missed HDs and ATNs. uncontrolled DM and HTN leading CKD. borriinnnnggggggg

but even if you fix that optics problem, that just attracts af ew more residents to ACADEMIC nephrology


private practice has the billing shortcomings that makes it so a nephrologist cannot have money or lifestyle.

Lower barrier to entry = lower barrier to exit