Last year saw some modest good news for most physicians! More than 19,500 physicians in 25 specialties responded to this year's Medscape compensation survey and described their compensation, number of hours worked, practice changes resulting from healthcare reform, and how they have adapted to the new healthcare environment.
Physicians were asked to provide their compensation for patient care. For employed physicians, patient-care compensation includes salary, bonus, and profit-sharing contributions. For partners, this includes earnings after taxes and deductible business expenses but before income tax. According to this year's Medscape survey, the average compensation for specialists is $284,000 and for a primary care physician (PCP) is $195,000, which reflects a general modest trend upward, seen over the past few years. Data from a major 2009 study suggested that PCPs earned a cumulative average lifetime income of about $6.5 million compared with over $10 million for specialists.[1,2] Note: Values in the charts have been rounded. Caption sums may not agree with chart value sums due to rounding.
When asked about their compensation for patient care, the top three earners this year are orthopedists ($421,000), cardiologists ($376,000), and gastroenterologists ($370,000), and the lowest earners, starting from last place, are pediatricians ($189,000), family physicians ($195,000), and endocrinologists and internists (both at $196,000). The top earners have changed from the 2011 Medscape Compensation Report. Although orthopedists led that year as well, the next top earners were radiologists and anesthesiologists. The bottom earners then were still pediatricians, PCPs, and endocrinologists.
Orthopedists, who make the most from patient-care work, are also at the top of the list for compensation from non–patient care activities ($29,000). They are followed at $26,000 by urologists, plastic surgeons, and dermatologists. Those who make the least in this category are radiologists ($6000), pediatricians ($7000), and anesthesiologists ($8000). Non–patient care activities include expert witness duties, product sales, speaking engagements, and other activities. Physicians (and notably PCPs) who are at the lower end of patient-work compensation also tend to trail in non–patient care compensation.
When comparing compensation with the prior year's, only rheumatologists experienced any large decrease in income (4%). Urologists were the only other specialists to see a decline, but by only 1%. The rest of the physicians reported an increase. The greatest increases appeared among infectious disease physicians (22%), followed by physicians who mostly work in hospitals: pulmonologists (15%) and emergency medicine physicians and pathologists (both at 12%). Of interest, compensation for family physicians also went up by 10%.
In setting Medicare fees, the challenge for CMS is to address the higher cost of living in certain areas against the need to attract physicians to underserved places with lower cost of living. Additionally, competition and physician density play a role in physician salaries. This year, the highest earnings were reported in the Northwest ($281,000) and South Central ($271,000) regions, while the lowest were in the Northeast ($253,000) and the Mid-Atlantic ($254,000). In the 2011 Medscape Compensation Report, the highest earners were in the West and North Central regions and the lowest were in the Southwest and Northeast.
Numerous government policies are aimed at improving access to physicians in rural areas. As a result, surveys indicate that higher incomes are found in poorer regions. Salaries also tend to be higher in states with fewer physicians. In line with this, the three top-earning states in this year's Medscape report are North Dakota and Alaska, at $330,000, and Wyoming ($312,000).
In this year's report, the lowest-paying locations were the District of Columbia ($186,000), Rhode Island ($217,000), and Maryland ($237,000)—all on the East Coast, where nonphysician incomes in general are higher than in other parts of the country. In fact, the only non-Eastern states in the bottom 10 were New Mexico and Utah.
In this year's Medscape report, 63% of physicians said they are now employed, with less than a third (32%) in private practice. This follows the trend reported by a major physician recruiter, which revealed a hospital employment rate of 11% in 2004, rising to 64% in 2014. Gender affects this decision, with 72% of women and 59% of men responding to the Medscape survey that they worked for a salary. Slightly over a third of men (36%) and about a quarter (23%) of women are self-employed. (In the 2014 Medscape report on employed physicians, 22% of physicians who reported self-employment were women.)
Employed PCPs make $189,000, which is less than what their self-employed counterparts reported ($212,000). All PCPs make far less than the average compensation for employed ($258,000) or self-employed ($329,000) specialists. A number of factors in the very near future might negatively affect compensation for employed or self-employed physicians, including the end of ACO shared savings contracts, competing retail clinics, meaningful use penalties, payment-reporting websites, and changes in CPT codes.
This year, as in all previous years of the report, male physicians are earning more ($284,000) than their female counterparts ($215,000). The percentage difference between men and women does not vary much between self-employed (23%) and employed (22%) physicians. On a somewhat positive note, the overall percentage difference between men and women has decreased slightly since the 2011 Medscape report, from 28% in 2011 to 24% this year. Women tend to work shorter hours and fewer weeks than men, which may help account for the lower female compensation reported among employed physicians. Additionally, fewer women are in the higher-paying specialties, which affects the magnitude of the difference. (Note: This chart includes full-time workers only but does not control for hours worked.)
In 2010, 48% of medical degrees were earned by women. Given the growing physician shortage, it may be of some concern that nearly a quarter (24%) of female physicians who responded to the survey work part-time compared with only 13% of men. Furthermore, data also suggest that even women who are full-time work fewer hours each week and see fewer patients than their male colleagues.[8,9] Studies suggest that greater schedule flexibility and fewer hours are key factors in improving female physician satisfaction and preventing burnout.[10-12]
Fewer than half of PCPs (47%) and half of specialists (50%) believe that they are fairly compensated. PCPs have not changed their opinion since the 2011 Medscape compensation survey. On the other hand, fewer specialists feel fairly compensated this year, down from about 52% in 2011.
Although fewer than half of primary care physicians—family physicians at 48% and internists at 45%—believe that they are fairly compensated, they are not the most dissatisfied physicians. Those who feel most underpaid are ophthalmologists (40%) and allergists and general surgeons (both 41%). Those most likely to believe that they are paid fairly are dermatologists (61%) and emergency medicine physicians and pathologists (both 60%). Of interest, the two latter groups reported a 12% rise in compensation this year, which was among the top four increases.
To determine the level of general career satisfaction, Medscape averaged the percentage of physicians who again would choose medicine (slide 29), those who again would choose their specialty (slide 30), and those who thought they were fairly compensated (slide 16). According to the calculation, the most satisfied physicians this year are dermatologists (63%), followed by pathologists and psychiatrists at 57%. The least satisfied, from the bottom up, are internists (47%) and then nephrologists and general surgeons (48% and 49%, respectively). In 2011, the specialties that reported the highest career satisfaction were dermatologists (80%); radiologists (72%), and oncologists (70%). Those who felt the least career satisfaction were primary care physicians (54%).
Despite considerable publicity, cash-only and concierge practices are still not significant payment models.[13,14] In fact, concierge practices stayed level at only 3% since last year, and cash-only even dropped a percentage point. Participation in accountable care organizations, however, has continued to rise dramatically, from 3% in 2011 to 30% in this year's report.
PCPs account for almost the same rate of concierge (4%) and cash-only (5%) practices as the general physician population (3% and 5%, respectively), although interest in direct primary care is still growing among family physician leaders.[15,16] (Direct primary care is not the same as concierge primary care, but it also employs an alternative to fee-for-service insurance billing by charging a retainer for a full range of services.) More PCPs are in or expect to participate in ACOs (43%) this year versus the general population of physicians (37%).
The American Medical Association has warned that the "'regulatory tsunami' facing US physicians could cut Medicare payments by more than 13% by the end of the decade." Nevertheless, 79% of employed and 64% of self-employed physicians said they will continue taking new and current Medicare or Medicaid patients, which is up from their responses last year, when 69% of employed and 57% of self-employed physicians said they would take these patients. Little change was observed in those not taking Medicaid or Medicare. There was, however, a decline among undecided physicians, from 25% of all physicians last year, regardless of employment status, to 14% of employed and 20% of self-employed physicians this year. This decline, coupled with the increase in those taking Medicaid/Medicare patients, suggests that more undecided doctors opted to take these patients.
In a Medscape report on insurers conducted in 2014, well over half (58%) of physicians received less than $100 from private insurers for a new-patient office visit. When asked whether they would drop insurers who pay poorly, 22% of physicians said they would and 35% would not. (The question was not applicable to the remaining survey respondents, most of whom were employed.)
The majority of PCPs (57%) spend 30-45 hours per week seeing patients. Less than a third (31%) spend more than that. A JAMA study of all physicians found that between 1997 and 2007, there was a decrease of nearly 4 hours per week in seeing patients, which may be partly related to the declining fees over that same period. Another reason for the decline is the increasing proportion of women and older physicians, who tend to work shorter hours and fewer weeks.
Paperwork load is heavier among self-employed PCPs: 68% spend 10 or more hours per week on these tasks compared with 61% of their employed peers. In a Medscape 2014 survey on employed physicians, not having to deal with the business of running a practice and not having to deal with insurers and billing were the top two reasons why physicians sought employment (58% and 45%, respectively, cited these two reasons.)
Nearly three quarters (74%) of physicians discuss the cost of treatment with patients, which is an increase from 68% of physicians who answered this way in the 2012 compensation survey. A 2013 editorial in the New England Journal of Medicine stressed the benefits of such discussions, including finding lower-cost alternatives and making trade-offs, and noted that it is "well within physicians' traditional duties to discuss such matters with our patients."
At the top of the list, about one third (31%) of orthopedists offer ancillary services, which can include in-office surgical centers, pain centers, MRI, physical therapy, and orthotics and braces. Anesthesiologists came in second at 30%, with most of their services involving procedures for postoperative pain. (Orthopedists are also the top earners and anesthesiologists are fourth highest.)
Women and men reported slight differences in what they found most rewarding about their jobs. About a third of both (31% of women and 34% of men) cited being very good at their job as a reward, and more women (37%) than men (32%) believe that relationships with patients are a major source of satisfaction. Fewer women (8%) than men (11%) considered making good money a chief benefit.
In the 2011 Medscape report, 69% of physicians said they would choose medicine again and 61% would select their own specialty. This year, 64% would still choose medicine, but only 45% would select their own specialty. Furthermore, in 2011, half said they would choose their own practice setting, but this year only about a quarter (24%) would go that same route.
When looking at all specialties, nearly three quarters of family physicians (73%), 72% of rheumatologists, and 71% of internists would choose medicine again as a career. In the 2014 Medscape survey, internists and family physicians were also within the top three spots, but fewer reported that they would choose medicine again (68% and 67%) than they did this year. The least likely to choose medicine again were radiologists (49%), orthopedists (50%), and plastic surgeons (51%). Compensation levels do not appear to play a significant role in whether physicians would choose this profession again.
Although only 55% of dermatologists said they would choose medicine again, if they did, about three quarters (73%) would choose their own specialty. In second place, about two thirds (67%) of orthopedists would choose their own specialty, although only half of them would be physicians again. And at the bottom of the list, only 25% of internists and 32% of family physicians would want to be primary care doctors again, but both groups were within the top three of re-choosing medicine as a career.