Nephrologist

What the survey says

Nephrology has no wage code of its own. These are the figures for general internal medicine physicians, the group nephrologists are counted inside: a median of $256,560 a year, a bottom tenth at $73,570 and a top tenth at $475,430. Two warnings. The survey covers physicians who are employees, so doctors in their own practices or in partnerships are not counted at all. And the low end mostly reflects part-time and academic positions rather than a full-time salary.

While you are training

Residents and fellows are salaried hospital employees. It is real pay for brutal hours, and you are carrying medical school debt the whole time.

Dialysis is where the money sits

Most nephrologists build income around a panel of dialysis patients they see monthly, on top of hospital consults and clinic. Partners in a private nephrology group who also hold an interest in a dialysis facility earn well above the employed median.

What it costs to get there

Bachelor's degree, in-state public

4 years, roughly $10,000 to $12,000 a year in tuition and fees

Medical school, in-state public

4 years, commonly $35,000 to $50,000 a year in tuition and fees

MCAT (Medical College Admission Test), applications and interviews

$2,000 to $6,000 all in

Licensing exams

The three steps of the USMLE (United States Medical Licensing Examination), around $1,000 each

Roughly, all in

$185,000 to $260,000

Tuition, fees, exams and kit. Not rent, food or travel

The low end is a four year bachelor's degree at in-state public rates of about $10,000 a year, four years of in-state public medical school at $35,000 a year, admission testing and applications, and the three licensing examination steps at around $1,000 each. The high end is the dearer end of that same route, closer to $50,000 a year for medical school, and private schools cost more again. Residency and the kidney fellowship afterwards are salaried jobs, so they add three or four more years of training but no tuition. Hospitals and academic centers are non-profit or public employers, so the Public Service Loan Forgiveness program can cancel the remaining federal balance after 10 years of payments.

Median medical school debt in the United States runs well into six figures. Hospitals and academic centers are nonprofit or public employers, so PSLF (Public Service Loan Forgiveness) cancels the remaining federal balance after 10 years of payments, and residency and fellowship years count toward that clock.

What the job usually comes with

• Employer paid malpractice insurance

  Standard in a hospital or group contract, and expensive if you buy it yourself.

• Signing bonuses and loan repayment

  Common in rural and underserved areas, which are chronically short of kidney specialists.

• A continuing education budget

  Conferences and courses, because certification has to be maintained.

• Call pay

  Nephrology takes nights and weekends, and contracts usually price that in separately.

The path

One of the longest routes on this site. Thirteen years from high school graduation to independent practice.

1. 1

   Bachelor's degree

   4 years

   Any major, with the pre-medical science prerequisites and a high grade point average. Sit the MCAT (Medical College Admission Test).

2. 2

   Medical school

   4 years

   Two years of science, two years of clinical rotations, ending with a Doctor of Medicine or Doctor of Osteopathic Medicine degree. You pass the first two steps of the national licensing exam along the way.

3. 3

   Internal medicine residency

   3 years

   Paid hospital training in adult medicine, accredited by the ACGME (Accreditation Council for Graduate Medical Education). You get your state medical license during this.

4. 4

   Nephrology fellowship

   2 years

   Subspecialty training in kidney disease, dialysis, transplant and blood chemistry. Longer if you add transplant or research training.

5. 5

   Board certification

   Exams

   Certify in internal medicine, then in nephrology, through the ABIM (American Board of Internal Medicine), and keep it current afterward.

High school courses that help

• Chemistry

  Nephrology is the most chemical of the medical specialties: salts, acids, bases and fluid balance.

• Biology

  Physiology is the whole foundation.

• Math and statistics

  You will read research papers critically for the rest of your career.

• English

  Medical school admission turns heavily on writing and on interviews.

Time and money, at a glance

Years after high school

13 to 14

Tuition, in-state public

Roughly $190,000 to $250,000 for college plus medical school

Paid while training?

From year 9 onward, as a salaried resident then fellow

License required

Yes, a state medical license, plus board certification in practice

How doctors get licensed here

Medical licenses are issued by state medical boards, not by the federal government. Everyone takes the same national exam on the way there: the USMLE (United States Medical Licensing Examination), in three steps spread across medical school and the first year of residency. Board certification is separate and voluntary in law, but in practice every employer requires it. You certify first in internal medicine and then in nephrology through the ABIM (American Board of Internal Medicine), and you keep it alive with ongoing assessment for the rest of your career. If you move states you apply to the new board, which is paperwork rather than another exam.

Subspecialties within the subspecialty

• Transplant nephrology

  An extra year working with transplant surgeons on donor matching, rejection and immunosuppression.

• Interventional nephrology

  Placing and fixing dialysis access, a procedural skill that pays and that many groups lack.

• Critical care nephrology

  Kidney failure in the intensive care unit, often combined with a critical care fellowship.

• Onconephrology and glomerular disease

  Narrow academic niches built around rare and difficult disease.

Nice-to-haves

• Research during medical school

  Nephrology fellowships in academic centers care about it.

• A second language

  Kidney failure falls hardest on communities where English is not the first language.

• Comfort with long relationships

  You will see the same dialysis patients every month for years.

• Business sense

  Private nephrology groups are businesses, and partnership terms matter to your income.

Rural practice and loan repayment

Kidney specialists are scarce outside metropolitan areas, and patients in small towns often drive more than an hour three times a week for dialysis. Federal and state programs pay down student loans in exchange for a few years of service in a designated shortage area, and hospitals add their own signing bonuses on top. It is one of the few ways to arrive at the end of this training with the debt already gone.

A typical day

Early rounds at an outpatient dialysis unit, 15 or 20 patients you have known for years, checking labs, access sites and blood pressure. Then the hospital: consults on patients whose kidneys are failing for six different reasons, an argument with a cardiologist about fluid, a decision about whether to start dialysis on someone who may not want it. Afternoon clinic is slower kidney disease, transplant follow-ups and blood pressure. You are on call for the hospital's dialysis service one week in three or four.

The honest trade-offs

Work life

Typical hours

50 to 60 a week, plus call

Remote work

Some telehealth clinic, but rounds are in person

Physical demand

Low, though you are on your feet and driving between sites

Unionized

Rare for attending physicians, increasingly common for residents

Similar paths

• Internal Medicine DoctorThe adult body, all of it, and the complicated patients nobody else can sort out. Eleven years of training.
• UrologistThe surgeon for kidneys, bladders and prostates. Thirteen years of training, then some of the best pay in medicine.
• CardiologistA heart doctor who diagnoses and treats heart disease, often without ever opening the chest.

Kidney failure has its own federal program

The United States covers dialysis and kidney transplant for people of any age through Medicare, a benefit created by Congress in the early 1970s. It is the only disease in the country with its own national entitlement, and it shapes how the whole specialty is paid.

Your kidneys filter your whole blood supply many times a day

Blood passes through the kidneys continuously, and the volume processed over 24 hours is far larger than the amount of blood in your body. Nearly all of the fluid filtered is reabsorbed, and only a small fraction leaves as urine.

The transplant waiting list is enormous

Kidneys are the most transplanted organ in the country and the most waited for. Tens of thousands of people are on the list at any time, and many spend years on dialysis before a match appears, which is a large part of what nephrologists manage.

Fellowship spots go unfilled

Nephrology is one of the internal medicine subspecialties that regularly struggles to fill its training positions, even though the patient population keeps growing. If you want it, the competition is milder than for cardiology or gastroenterology.