Nephrology is Dead - stay away

[MD46]

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

Ball park of how much he makes doing this?

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[NewYorkDoctors]

Ball park of how much he makes doing this?

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.

 

[NewYorkDoctors]

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.

 

[Renal_Prometheus]

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.

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.

 

[Renal_Prometheus]

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

 

[NewYorkDoctors]

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)

 

[Renal_Prometheus]

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.

 

[NewYorkDoctors]

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.

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

 

[NewYorkDoctors]

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.

 

[Renal_Prometheus]

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.