Should Nephrologists Earn More Money?

By Peter Laird, MD

Physician pay is an ever present preoccupation within our profession. The long years of schooling and deprivation of ordinary activities at an age when most of our peers enjoy the fruits of young and active bodies not ravaged by time pursuing sports and other forms of entertainment while doctors and medical students are instead locked into long hours of study and challenging clinical schedules. That lost freedom of youth reaches forth in later years in yearnings of compensation for time lost that can never be recovered. I believe all professionals in some manner or another feel that they are worth more than they are paid which is not surprising that those in the nephrology field would also harbor such sentiments. Dr. A.K. Singh spoke on this issue of compensation and incentives following my own post on incentives in nephrology:

Dialysis Unplugged: "Cutting off Your Nose to Spite Your Face"

There is no debate about the fact that dialysis patients are generally older, have several co-morbidities, are on many medications, and are frequently hospitalized. The nephrologist frequently becomes the principal care giver. However, the cost of the nephrologists professional fee is a fraction of the total cost of a dialysis to the payor; and, it doesn't reflect the amount of time and effort that goes into patient care and coordination (Fig.1). Being frugal with nephrologists means that less time is spent with individual patients, reducing the time for emotional support. All of this degrades the patient experience. As well, nephrologists have less time for coordination and thinking pro-actively about how to keep the patient out of the hospital (note: one-half of dialysis patient costs relate to hospital charges). Not paying nephrologists appropriately for the time that is really needed to take a patient-centered approach is a case of “cutting your nose to spite your face”.  

There is no doubt that nephrologists work hard and have a very complex patient mix. However, I would point out some interesting statistics that will place this discussion in its proper perspective. When looking at all of the sub-specialty pay, nephrology interestingly is the highest paid, non-procedure based specialty. In this slide from Medscape, if we look to the specialties higher paid than nephrology, they are all surgical or procedure oriented specialties starting with OB/GYN making about $240,000 per year compared to $210,000 for nephrology. Of all my physician colleagues, the most sleep deprived and beleaguered specialty with an 18 year malpractice tail in my opinion is the OB/GYN specialist who makes only a marginally better salary than nephrology with far much more at risk day in and day out.

The lowest paid internal medicine sub-specialty is rheumatology which paradoxically has in my opinion the most complex illness subsets and difficulty in diagnoses coupled with the most complex cytotoxic regimens outside of oncologists. They spend several years in additional training with great rigor and are paid equal to primary care physicians such as myself with half the years of post graduate education. If I were to make a plea for a pay raise for any of my colleagues, I would be impassioned about these highly trained and grossly underpaid specialists.

The highest paid internal medicine sub-specialty is cardiology which earns high pay mainly from their high risk cardiac interventions we are all familiar with. I would recommend that Dr. Singh and his nephrology colleagues learn some lessons on relative value from their cardiology colleagues who have produced excellent results from their high pay. In relative terms, there interventions are worth the gold we pay. Their bread and butter intervention is angioplasty and stenting patients during acute myocardial infarctions (heart attacks). In an eleven year study period from 1995 to 2006 looking at 30-day all cause survival, my colleagues in cardiology have improved outcomes substantially. Death from myocardial infarction especially in the first twenty four hours continues to decline dramatically at the hands of cardiology innovations in technology, pharmacology and procedural proficiency and training. The risk of dying from a heart attack today is dramatically less than when I first started practice in 1990 and continues to improve. In a very real sense, cardiology has earned it's top pay.

Best Practices in STEMI Management: The Cross Roads of Bleeding and Outcomes Condition: ACS

First, we have made tremendous progress in the management of acute myocardial infarction [AMI] in the past 20 years, and there have been serious improvements in morbidity and mortality outcomes. However, the hospital mortality and the 30-day mortality that are faced in everyday practice are probably higher than what is reflected in the ideal world of randomized clinical trials that we are constantly referring to. Although, it is common in randomized trials to have outcomes of a mortality in the range of 3%-5% at hospital discharge or 30 days, recent data from the US-wide database of hospitals show that the mortality overall, at 30 days in the United States in 2006, was still in the range of 15%. Therefore, we still have a long way to go before we bring the actual real-world mortality of 15% down to the ideal outcome of less than 5% mortality.

On the other hand, if we evaluate the effectiveness of nephrology and their bread and butter intervention, dialysis we enter into a world of stagnation and bitter debates over matters long since settled in the practical world on dialysis dosage and frequency while reaping huge profits from patients who admittedly are the sickest of any medical patient population, even more so than many "deadly" cancers. Many would rightly place the blame for these terrible outcomes at the hands of American nephrologists themselves when considered in a historical context as well as compared to other nations. The survival rates for dialysis patients in the last twenty years are essentially the same as they were when I graduated medical school in 1990. In fact, it is not inaccurate to state that nephrology has failed to improve its dialysis technology and outcomes in any substantial manner in the last twenty years. Dr Robert Lockridge noted no change in mortality rates in a ten year period of time. (here) 

I agree with Dr. A.K. Singh on two issues. First, I believe that nephrology has cut off its nose to spite its face for nearly four decades by failing to improve dialysis technology and producing lower mortality for their patients unlike nearly every other major medical specialty. Unlike their cardiology colleagues with their old fashioned approach, nephrology has instead squandered one of the most amazing life saving technologies in a lust filled, greed based exploitation of their dialysis patients that they were charged to serve and protect. I also believe that we should incentivize outcomes and pay nephrologists for improved survival and reduction of hospitalizations which if accomplished would result in higher pay for nephrology. Instead of endless and useless debates on how to proceed, it is time to put aside the excuses including crying that they are underpaid when in fact the data does not support that claim and move forward to serve and protect their patients with ever improving outcomes. How do they make money? The old fashioned way... they earn it.

Comments

[Sandeep Aggarwal]

Dear Dr Laird, first of all I would like to divert your focus towards the realm of preventive medicine and preventive cardiology, if you ever get a chance from cardiac interventions (which happen to produce no significant mortality benefit - Courage trial -N Engl J Med 2007; 356:1503-1516,) please read this another facinating NEJM article about how only 5% of total reduction of CV deaths were attributable to revascularization (Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. death from coronary disease, 1980-2000. N Engl J Med 356:2388-2398, 2007.) most of which were not PCI but - CABG. Also try reading Foley et al(American journal of kidney disease 1998) which tells us that a 20 yr old with ESRD has a CV risk of a 80 yr old without CKD, now while we know that traditional Framingham CV risk management has never worked in CKD 5 patients (eg 4D study) , do you really think its a cardiologist that is keeping a renal patient alive with their completely non evidence based love for beta blockers and Imdur/hydralazine combination (www.thelancet.com Vol366 October29,2005, and accomplish trial and ascot trial) no sir, with all due respect it's the nephrologist and its a much busier job than thought. Besides with the bundling I don't think nephrologists are in it for being the dialysis money sucking leaches. Thanks for your article, it was ... Interesting