General surgeons who responded to this year's Medscape compensation survey disclosed not only their compensation but also how many hours they work per week, how many minutes they spend with each patient, the most rewarding part of their job, changes to their practice resulting from healthcare reform, and more. (Note: Values in charts have been rounded and may not match the sums described in the captions.)

Physicians were asked to provide their annual 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. Regarding their compensation for patient care, general surgeons ranked above the middle among physicians ($322,000). In last year's report, at $317,000, their ranking was about the same. Orthopedists and cardiologists were numbers one and two this year ($443,000 and $410,000, respectively) and last year as well, at $421,000 and $376,000. Within these specialties there is likely to be a wide range of earnings, as orthopedics and cardiology both include surgical subspecialists, who tend to make significantly more than their generalist counterparts.^[1]

General surgeons reported only a 1% increase in income this year, near the lowest among all physicians. Internists experienced an unexpected 12% increase. When asked about this greater than normal increase, Travis Singleton, senior vice president of national physician search firm Merritt Hawkins, commented that the migration to hospital medicine has shrunk the candidate pool, while at the same time, "over 10,000 baby boomers turn 65 every day, driving demand for internists—and their compensation—higher." Only two specialties, allergy/immunology and pulmonology, experienced a notable decrease in income (-11% and -5%, respectively). Pathologists and plastic surgeons remained stable. The rest of the physicians reported an increase. When asked what they attributed their increases to, most general surgeons responded that they had experienced increase patient volume. Several were working more hours or had seen improvements in efficiency and productivity. Others had simply received raises and/or bonuses or changed jobs or positions.

This year, the highest earnings for general surgeons were reported in the Northwest ($368,000), the North Central region ($366,000), and the Southeast ($329,000), while the lowest were in the Northeast ($305,000) and the Great Lakes ($313,000). Geographic supply and demand continues to play a role in compensation; uneven concentrations of physicians relative to patient population, particularly in primary care, has been a problem for decades in rural and poor communities.^[2] Numerous government policies are aimed at improving access to physicians in these areas, including a program that pays bonuses for working in underserved areas and health professional shortage areas (HPSAs). As a result, surveys indicate that higher incomes are found in these regions.^[3] Nevertheless, according to Travis Singleton of Merritt Hawkins, "While government programs certainly influence compensation, it is largely socioeconomics and competition that drive compensation on a macro scale. We are seeing the compensation gap between rural and urban areas diminish. Where it was once routine to see salaries 10%-15% higher 2-3 hours outside of the metropolitan market, now you see urban markets with large delivery systems raise salaries to level the playing field. In turn, that has caused smaller, more rural markets to add more compensation via salary, signing bonuses, and loan forgiveness."

General surgeons who make the most are in multispecialty group practices ($367,000) and healthcare organizations ($348,000). Last year, earnings were highest for general surgeons in the same two practice settings, though the order was reversed. Those in healthcare organizations earned $390,000, compared with $386,000 for those in multispecialty groups.

This year, as in all previous years of the report, male general surgeons are earning more than their female counterparts. Male general surgeons made $340,000 and their female peers $257,000, a difference of $83,000. When asked about this disparity, Travis Singleton of Merritt Hawkins said, "The persistence of these disparities is puzzling because we see no contractual bias from our clients against female candidates." He observed that disparities may exist in work schedules, "particularly with younger female physicians who are in their peak child-rearing years and require flexible schedules, including part-time." It should be noted, however, that the compensation reported here is based on full-time positions.

Being employed or self-employed does not seem to have a role in the gender disparity in general surgeons' salaries. Earnings for self-employed female general surgeons are $263,000, which is 75% of men's ($353,000), and employed female general surgeons' compensation is $250,000, 74% of their male counterparts' $336,000. (Note: This chart includes full-time workers only but does not control for the number of hours worked.)

In 2010, 48% of medical degrees were earned by women. Given the growing physician shortage, it is interesting that over a quarter of primary care female physicians are part-time. However, among general surgeons, only 8% of female survey respondents work part-time compared with a slightly lower 6% of their male counterparts. Part-time is defined in this survey as working less than 40 hours per week.

Although only 46% of general surgeons believe that they are fairly compensated, they are not the most dissatisfied physicians. Those who feel most underpaid are urologists (42%) and allergists and endocrinologists (both 43%). As in every year's survey since 2012, those who felt most fairly paid are dermatologists (66%), who are also the third highest earners this year. Pathologists (63%) and emergency medicine physicians (60%) followed in satisfaction, even though their earnings were toward the middle range among physicians.

The report this year looked at the difference in earnings of physicians who thought their compensation was fair versus that of their peers who did not. Not surprising is that, regardless of specialty, those who made more were more likely to feel fairly paid than those who made less. General surgeons who believed that they were fairly paid made $81,000 more than their peers who believed that their compensation was unfair. And the more a specialty group earns, the greater the perceived disparity. Orthopedists, for example, are the highest-paid group; those who think that they are fairly paid make $156,000 more than those who find their compensation inadequate.

Nearly two thirds (63%) of employed male general surgeons and 70% of employed female general surgeons believe that they are fairly compensated, compared with only 34% and 26%, respectively, of their self-employed counterparts.

Five years ago, in the 2011 Medscape report, 69% of general surgeons said they would choose medicine again, 60% would select their own specialty, and 49% the same practice setting. This year, percentages were lower across the board. Just over half of general surgeons would choose medicine (54%) or their own specialty (51%), and only one quarter would chose the same practice setting.

To determine the level of general career satisfaction, Medscape averaged the percentage of general surgeons who again would choose medicine, those who would choose their own specialty, and those who thought they were fairly compensated. At 50%, general surgeons ranked toward the bottom among all physicians. In last year's report, at 49%, they ranked slightly lower. According to the calculation, this year the least satisfied physicians are nephrologists (47%) and internists (48%). The most satisfied are dermatologists (65%), followed by oncologists (59%) and psychiatrists and pathologists (both at 58%).

Despite considerable attention, cash-only and concierge practices are still not significant payment models for any physicians, including general surgeons.^[4] This has not changed since last year. This year, only 2% of general surgeons were in concierge practices and 4% in cash-only, down from just 3% and 5% last year. Travis Singleton of Merritt Hawkins observed that in order to avoid the pressure of private practice, the "escape hatch" for many physicians has been employment rather than changing to concierge medicine. However, he has seen a continual increase in the direct pay model and urgent care delivery. General surgeon participation in accountable care organizations (ACOs) had been rising dramatically from year to year, but this year it increased only from 32% to 34%; moreover, only 6% of general surgery respondents expect to join an ACO this year. According to some experts, however, as of late 2015, questions remain about whether meeting quality metrics in ACOs translates into meaningful improvement.^[5]

Twenty-eight percent of general surgeons have seen an influx of patients due to the Affordable Care Act (ACA). A 2015 report analyzed how physicians viewed their ability to provide high-quality care a year after the implementation of the ACA.^[6] It found no association with lower- or higher-quality care whether or not patient load had increased. Among those who said quality had worsened, 21% had a higher patient load and 18% reported no increase. Over three quarters (78%) of physicians whose patient load increased said that quality had stayed the same or improved; 82% of those who experienced no increase reported the same experience.

This year, 73% of self-employed and 95% of employed general surgeons say they are continuing to take new and current Medicare and Medicaid patients. In both groups, these percentages are higher than in the 2015 report (67% and 87%, respectively). In the current report, 13% of self-employed and 2% of employed general surgeons have stopped seeing existing Medicare and Medicaid patients or are not taking new ones, similar to last year's percentages (14% and 3%, respectively).

In a Medscape report on insurers conducted in 2014, well over half (58%) of all physicians received less than $100 from private insurers for a new-patient office visit. In the current compensation report, when general surgeons were asked whether they would drop insurers that pay poorly, 7% said they would and nearly half (45%) said they would not. (The question was not applicable to 48% of general surgeon respondents, most likely because many are employed.)

The authors of a 2013 editorial in the New England Journal of Medicine wrote, "Because treatments can be 'financially toxic,' physicians need to disclose the financial consequences of treatment alternatives just as they inform patients about treatments' side effects."^[7] In Medscape's current compensation report, 81% of general surgeons say they discuss the cost of treatment with patients, though only 18% do so regularly. Thirteen percent don't discuss the costs of their treatments because they don't know them, and only 6% of general surgeons feel that such discussions are inappropriate.

Forty-three percent of general surgeons spend 30-45 hours per week seeing patients, while 45% spend more than that. According to a government analysis, middle-aged physicians work harder than both their younger and older peers.^[8] In fact, in the analysis, those between ages 46 and 55 work more hours now than they did in previous years, while younger doctors (36-45) work fewer hours than previously, perhaps because of the increase in women in those age groups, many of whom are working part-time.

Bureaucratic tasks were the prime cause of physician burnout, according to this year's Medscape Lifestyle Report (and in previous ones as well). Second was spending too many hours at work. Among general surgeons responding to this year's survey, 70% of those who are self-employed and 71% of their employed peers spend 10 hours or more per week on paperwork and administrative tasks.

Some research has found that female physicians spend more time with patients.^[9] In Medscape's report, among all physicians, 41% of men spent 17 minutes or more with their patients compared with 49% of women. However, among general surgeons, 49% of men and 47% of women reported that they spend 17 minutes or more with patients. Note: This slide applies to office-based physicians only.

Among general surgeons, 40% believe that relationships with patients are the major source of satisfaction in their job, and 34% named being good at what they do; these answer choices garnered the most votes by far. Only 8% cited making good money, 7% making the world a better place, and 5% pride in being a doctor. Three percent found nothing rewarding about their work. In the comments section included with this survey question, general surgeons mentioned teaching and helping others.

As of February 2016, 12.7 million Americans selected plans through the Health Insurance Marketplace, about 4% of the US population.^[10] Data are limited on the number of physicians who are participating, however. Often they have no choice, and many may be locked out of networks.^[11] This year, 19% of general surgeons said they plan to participate in the exchanges. In the past, 84% of general surgeons indicated that they did not plan to participate, but this year only 26% do not. The remaining 55% are still unsure.

It is not yet clear how the ACA affects physician income. Many variables will play a role in the ultimate results.^[12] One study from the Robert Wood Johnson Foundation reported a 3% increase in reimbursement in states that expanded Medicaid eligibility and an increase of 3.3% in nonexpansion states.^[13] When general surgeons who participated in health insurance exchanges last year were asked whether their income had been affected, 63% reported no change and only 3% said it had increased. Just over one third (34%) experienced a decrease.