National Public Radio recently did an on-the-street survey asking people to finish this sentence, “You know you are wealthy when…” Most people cited economic stability, others religious rewards. One girl, who sounded about 7-8 years old, said you know you are wealthy when “you have a good job, like maybe a doctor…”

Indeed, most people do believe that doctors make a good salary.  And they do. A salary survey done in September 2011 by ProfilesDatabase.com found that median starting salaries among different specialties are around $142, 000 a year (family practice) to more than $390,000 a year for a surgeon. In nephrology, the median starting salary is around $180,000 and around $252,000 after six years in a practice. A Medscape survey done in 2010 shows similar results; median compensation was around $230,000 (go to www.medscape.com/sites/public/physician-comp/2011, click on the “nephrology” tab for more details).

Keep in mind, however, that these responses represent base salaries and don’t account for other revenue physicians can generate or draw from in a practice. In nephrology, that can include bonuses from joint ventures, medical directorships, payment incentives from Medicare’s EHR /meaningful use initiative, drug research studies, and the challenging but still lucrative interventional nephrology business. The Renal Physicians Association 2012 Benchmarking Survey, which drew from 111 nephrology practices around the country showed the average revenue generated per FTE nephrologist rose from $660,000 a year in the 2009 survey to $717,000 in 2011. Much of that additional revenue came from the ancillary sources noted above.

What about performance?

That’s not a bad payday, and with the loathed, down-but-not-out-yet sustainable growth rate feeding the volatility of Medicare pay for physicians, finding outside sources of revenue is a good idea for practices.

Yet we keep hearing about the stories that give dialysis care a black eye: a stubbornly high mortality rate of around 20% (improvements have been seen in the first year); over 80% of new patients starting on the so-called “White Tube of Death” –– central venous catheters; a dismal percentage of patients who are being dialyzed at home compared to other countries (this is changing slowly, but mostly fueled by economic incentives); and Medicare surveys, which only take place every three years, that continue to show deficiencies in basic things like infection control practice in the dialysis clinic (a recent story talked about five patients possibly being exposed to Hepatitis B because of poor infection control practices at a Boston dialysis clinic).

These aren’t all the responsibilities of the nephrologist. But the welfare of your patient is. You may not be placing that CVC, but when the U.S. Renal Data System notes that 44% of patients still have them in place six months after initiation of dialysis, it’s time to act. Being your patient’s advocate can sometimes mean doing something they don’t want to do.

Last month, a group of chief medical officers from dialysis companies across the country gathered for a 1-½ day discussion on how health care providers can change practices and reduce morbidity and mortality among dialysis patients. In essence, doctors and staff talking among themselves about what they could do better.

This meeting was an opportunity to showcase some positive approaches to improving care, including pilot projects that could have a very positive impact. Ultimately, there was a strong feeling that the chance for change rested on the shoulder of the nephrologist. Demand better care, and the outcomes should follow. As the little girl said in the NPR survey, make this “a good job.”