Starting a Career in Nephrology

STARTING A CAREER IN NEPHROLOGY

What Does a Nephrologist Do?

Nephrology is an internal medicine specialty focused on diagnosing and treating diseases of the kidneys, as well as systemic conditions that result from kidney dysfunction. These can include glomerular diseases, tubulointerstitial kidney diseases and tubular defects, disorders of the kidney vasculature, infections and neoplasms of the kidney, and abnormalities of the kidney, as well as systemic diseases with significant kidney involvement such as vasculitis, heart failure, hypertension, and fluid, electrolyte and acid-base disturbances.

Nephrologists may also oversee dialysis, including hemodialysis and peritoneal dialysis, and the kidney transplant process, do basic or clinical research in an academic environment and/or teach students.

Why Nephrology?

The field of nephrology is growing and, with it, so too are the career opportunities. Unfortunately, within the United States, the incidence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) is increasing, which requires more specialists than ever before. Today, about 15% of nephrology fellowships remain unfilled, creating great opportunities for those entering the field.

Beyond the basic opportunity, there are several draws to nephrology:

Compensation and Growth

The starting salary for a new graduate can range from $175,000 to $225,000 and many receive sign-on bonuses and additional financial incentives. Many positions also offer support for maintenance of certification and training and it’s not unusual to be offered relocation expenses. 

In addition, nephrologists tend to see quicker growth than other specialties as well as the options for additional revenue streams. Often nephrologists can make partner within a few years, and potentially see income jump upwards of $400,000 in a relatively short time.

Relationships

In studies conducted with nephrology fellows, a common theme arises: the value of relationships—with patients, staff and other nephrologists.

Further, as many kidney patients need long-term care, the opportunity to build lasting relationships with patients and drive continuity of care is an attractive prospect. While that personal relationship is not unique to nephrology, nor is it the standard in the healthcare space.

Patient Diversity

While many kidney patients need long-term care, there are also many acute indications providing nephrologists both the common opportunities as well as the kick of adrenaline—and with many options for where to practice, each nephrologist can find the balance that he or she is looking for.

In a study published in the Clinical Kidney Journal, one respondent noted:

“I think renal [nephrology] is the one specialty in medicine that offers absolute everything…looking after really sick patients, which I enjoy because of the adrenaline rush and chronic care…. You are an absolute specialist and within renal there are many subspecialist areas, but you are also a generalist, you often are the patients’ GP once they have had a transplant or are on dialysis…it encompasses every single part of a medical career, and most specialties don’t.” (Mark)1

In the Survey of 2018 Nephrology Fellows, 78.8% would recommend nephrology to medical students and residents, an increase of almost 10% over five years earlier.2

Decide Your Career Path

New physicians may choose to pursue nephrology in a variety of settings:

Privately Owned Practice

Private practice involves caring for patients through their journey with kidney failure, dialysis and potential transplant. In private practice, the physician owns the practice, alone or in partnership with others, and runs a small business in addition to practicing medicine. A nephrologist in private practice assumes the financial risk of running a business, paying for overhead costs and collecting payments and reimbursements. But for those who enjoy the personal freedom of working for themselves, private practice is a strong option. There are companies that offer professional practice management to help nephrologist run their practice should they desire assistance. Physician compensation in private practice is what is billed/collected less expenses.

Nephrologists can also be employed by hospitals and/or health systems, multispecialty groups and dialysis companies. This model allows the nephrologist to focus exclusively on providing care to patients. Compensation is typically a base salary and bonuses for productivity and quality outcomes.

Academia

Academia provides an opportunity to perform clinical research, care for unusual cases or conduct studies to advance the science of nephrology treatment. Working in academia gives a nephrologist opportunities for continuous learning. For physicians who love research, experimentation, acquiring information and contributing to the state of the art, academia is an excellent option.

For an academic nephrologist, a day at work could include research analysis and experimental design, writing grants and research publications, meeting with research coordinators to discuss clinical study recruitment, submitting Institutional Review Board (IRB) proposals and progress reports, reading manuscripts and grants for peer review, and budgeting grant funds.

Locum Tenens

While not necessarily a long-term career, locum tenens are opportunities for short-term placements, where a seasoned nephrologist (often someone retired but looking to stay active) covers work for other nephrologists who are on vacation, traveling for conferences or continuing medical education credits, or for practices who are trying to fill a permanent position and need someone to cover the gap.

Specialties within Nephrology

Nephrology encompasses several subspecialties, from focusing on vascular access to transplant and post-transplant medicine.

Practicing Nephrologist

Practicing nephrologists see patients both as consultants for primary care providers and as primary physicians for some patients who need extensive renal care. These specialists focus on kidney disorders and techniques for managing the systemic sequelae to kidney dysfunction.

A nephrologist may see patients in an individual or group practice. His or her day may be split between a hospital setting and a clinic.

Interventional Nephrologist

Interventional nephrology is the specialty concerned with vascular access creation and dialysis access management, <links to https://fmcna.com/patient-care/vascular-care/> performing procedures such as thrombectomy, angioplasty and stenting to restore blocked access.

Transplant Nephrologist

A transplant nephrologist specializes in kidney transplant and post-transplant support. He or she may work in hospital-based kidney transplant programs and/or private practices that focus on pre- and post-transplant care. This physician interprets immune compatibility results for transplantation, maintains the immunosuppressant regimen that prevents organ rejection and provides specialized internal medicine.

Immunosuppression and history of kidney disease can lead to unique presentations and increased risk of conditions such as recurrent glomerular disease, infectious disease, malignancy, cardiovascular complications, diabetes and bone disease, requiring the specialized knowledge of a transplant nephrologist to quickly diagnose and treat.

Steps to Finding a Career in Nephrology

Beginning a career in nephrology takes a great deal of classroom education and medical practicum, and also some planning outside of the formal training.

Education and Training

Aspiring nephrologists must graduate from medical school and, post-graduation, serve an internal medicine residency in a hospital for three years. Upon completion, one would pursue a nephrology fellowship, which can be two or three years. After completing a nephrology fellowship, doctors take the American Board of Internal Medicine (ABIM) Nephrology Certification examination.

The Board Exam is offered annually. Candidates can expect to sit for approximately 10 hours including breaks and tutorials, with 8 hours of testing time.

The Nephrology Certification exam includes:

• Sodium and Water Abnormalities
• Acid‐Base and Potassium Disorders
• Calcium, Phosphorus, and Magnesium Disorders and Stones
• Chronic Kidney Disease
• Hypertension
• Tubular, Interstitial, and Cystic Disorders
• Glomerular and Vascular Disorders
• Kidney Transplantation
• Pharmacology
• Acute Kidney Injury and Intensive Care Unit Nephrology
   

Investigate Practice Locations 

Relatively large disparities in available jobs and potential income make some locations ideal for new nephrology fellows. Nephrologists can find a wealth of jobs available in rural areas, remote locations and regions such as the American Midwest and South, particularly areas with large dialysis providers. By comparison, the job market is tighter in major metro areas, California and the Pacific Northwest, and in academia.

Incentives to recruit more nephrologists to rural locations include higher salaries for practitioners in these areas. Mean income in rural areas in 2018 was $269,300 while in major cities, the mean income was only $190,300.2

The availability of high-paying jobs in rural areas may be an important consideration for new nephrology fellows deciding where to practice.

Search Public Job Boards

The American Society of Nephrology, the New England Journal of Medicine, Nephrologymatch.com and PracticeMatch.com are good sites visit to get a feel for the nephrology jobs available and which you may be interested in applying for.

Network with Your Peers

Apart from finding a job in clinical practice and providing social support, networking can also help a nephrologist find nontraditional positions that use his or her medical expertise, such as medical journalism, healthcare communication, medical education, healthcare administration or pharmaceutical medicine.

Through peer networking, a nephrologist can also build a referral network to ensure continuity of care for his or her patients, bringing in new patients by referral from primary care physicians and referring patients out to trusted partners when those patients need help from a different specialty.

Nephrologists can find networking opportunities at conferences, in professional associations for general medicine or nephrology, and networking websites such as LinkedIn.
 

You’ve Found a Job in Nephrology…Now What?

Finding a job is just the beginning. Nephrologists have many mechanisms to ensure their continued success and growth:

• Continuing education—This includes both formal continuing medical education (CME) requirements and on-the-job learning about the specifics of the new practice.
• Building a network of peers—A new nephrology position brings with it a new peer group of fellow nephrologists, specialists in other disciplines and general practitioners who can give referrals, consult on difficult cases and share opportunities.
• Exploring advancement opportunities—Industry affinity groups such as the American Society of Nephrology provide resources for auditing whether a position is leading down the right path, sharpening negotiation skills and successfully asking for promotion in a staff position.
  
   

Healthcare and the Law

To forge a successful career in nephrology, new physicians should consult with their healthcare attorney before finalizing contracts.

Find a Healthcare Attorney in Your Location of Practice

Healthcare attorneys ensure that healthcare organizations and healthcare professionals comply with regulations that govern institutions such as hospitals, dialysis centers and nursing homes. These include the Anti-Kickback Statute, the Stark Law and the False Claims Act. A healthcare attorney may also help a practice deal with contracts and company policies or government investigations of the site.

Before beginning private practice, a new nephrologist should hire a healthcare attorney to help craft policies and contracts that follow current regulations and anticipate changes. A nephrologist who is offered an employment contract should similarly engage a healthcare attorney to review the contract. The attorney can help determine which items of the contract need clarification or negotiation and prevent a physician from conceding to costly terms. Points to pay particular attention to in the contract may include termination clauses, liability insurance and non-compete requirements.

As contract laws vary from state to state, physicians should ensure they retain an attorney licensed in the state where the physician intends to practice.

Medical Malpractice Insurance

Medical malpractice insurance covers expenses related to allegations of medical negligence and malpractice. These expenses can include legal fees, fees for expert witnesses or settlement costs. Not all medical malpractice insurance is limited to patient-facing practice; some policies can also cover work done for peer-review panels.

Two general types of malpractice insurance can protect physicians from legal claims: occurrence or claims-made.

Claims-made policies cover incidents that occurred and were first reported during the period the policy was in place. To cover claims made outside the policy period, a physician may need an additional policy, such as nose coverage or tail coverage. Nose coverage protects against claims that occur before a claims-made policy is in place, whereas tail coverage protects against claims that are made after the end of a claims-made policy, for incidents that occurred while the claims-made policy was still in effect.

Occurrence-based policies cover incidents that occur when the policy is in place, regardless of when the claim is first made. If coverage lapses or ends, incidents that occurred when the policy was in place remain covered.

A career in nephrology offers a variety of subspecialties and experiences for a new physician and the opportunity to make a difference in patients' lives. It can be rewarding in a number of ways.

References:

1. Beckwith H, Kingsbury M, Horsburgh J. Why do people choose nephrology? Identifying positive motivators to aid recruitment and retention. Clin Kidney J. 2018;11(5):599–604. doi:10.1093/ckj/sfy076
2. Quigley L, Salsberg E, Collins A. Report on the Survey of 2018 Nephrology Fellows. Prepared for The American Society of Nephrology by George Washington University Health Workforce Institute. Available from: https://www.asn-online.org/workforce