I don’t know what a reasonable income is for physicians. They are among the highest paid workers in the United States, but they also spend more time in training after undergraduate school (at least seven years, often more) and have heavy responsibility in making critical decisions and performing procedures that affect peoples’ very mortality. Working off hours is expected and being on-call 24 hours a day is a common duty. The average debt for medical school graduates in 2021 was $216,000, exclusive of debt incurred in undergraduate studies. Surely some degree of income realization over the norm is fair.
The Data
Of course, no physician is lining up at the soup kitchen, and US doctors enjoy higher incomes than those of doctors in any other country–by a lot. The average yearly net income for all physicians in America was $316,000 in 2021. Here are average net incomes by specialty:
- Plastic Surgery: $471K.
- Otolaryngology: $461K.
- Cardiology: $430K.
- Dermatology: $419K.
- Radiology: $419K.
- Gastroenterology: $417K.
- Urology: $408K.
- Orthopedics: $482K
- Plastic Surgery: $471K
- Otolaryngology: $461K
- Cardiology: $430K
- Dermatology: $419K
- Radiology: $419K
- Gastroenterology: $417K
- Urology: $408K
- Anesthesiology: $392K
- Ophthalmology: $366K
- Surgery, General: $362K
- Oncology: $359K
- Emergency Medicine: $353K
- Critical Care: $349K
- Pulmonary Medicine: $331K
- Pathology: $308K
- Physical Medicine & Rehab.: $306K
- Nephrology: $305K
- Ob/Gyn: $303K
- Allergy & Immunology: $275K
- Neurology: $267K
- Psychiatry: $260K
- Rheumatology: $259K
- Internal Medicine: $243K
- Infectious Diseases: $239K
- Diabetes & Endocrinology: $236K
- Family Medicine: $231K
- Pediatrics: $225K
- Public Health/Preventative Med.: $209K
The correlation between lower pay for primary care doctors (so-called “cognitive” doctors, i.e., those who provide first contact and follow patients over time–mainly general internists, family medicine specialists, and pediatricians) versus specialists is notable. On average, primary care doctors’ incomes are 69% of specialists’. And the key for specialists is the performance of lucrative procedures, which primary care doctors rarely do. Clearly, our reimbursement policies are heavily weighted in favor of paying handsomely for procedures.
Ramifications
So, while I may not know what just compensation is for doctors in general, I do know the gap in incomes between primary care doctors and specialists is remarkable.* How does this play out? A study published in the Journal of the American Medical Association in 2013 is telling. The researchers looked at two common procedures, colonoscopy and cataract extraction. They found that specialists earned, for colonoscopy and cataract surgery, 368% and 486%, respectively, of the revenue primary care doctors realize in their work for the same amount of time spent. Practice expenses for proceduralists are greater (especially malpractice), and proceduralists do spend more time in training, but these factors are not close to a justification for the majestically greater compensation.
Here is an example to illustrate the gap. When I was a hospice physician, I was called upon to see patients for “recertification,” that is, I was required every three months to see a patient getting hospice care to certify continued eligibility for hospice services. The patient might be 30 miles from my home, and I might often drive an hour each way. I could spend about one half hour with the patient and the family, for which I would receive $85 dollars from my company if the patient lived in a facility, and $100 for a patient living at home. I was not compensated for the time spent driving, but I did receive mileage at about 43 cents per mile after the first 20 miles (there are arcane rules regarding mileage that are not worth going into). If traffic was light and the visit was not complicated, I would earn about $34 an hour for my efforts. I was also on-call 24 hours a day, being compensated only for the actual time spent on phone calls.
I am not complaining–I loved my hospice work. But I present the vignette to show the remarkable contrasting compensation for doing procedures compared to cognitive work. Gastroenterologists, for instance, currently get about $300 from Medicare (private insurance pays more) for a screening colonoscopy, which costs the colonoscopist anywhere from 15 to 60 minutes. In uncomplicated cases, the doctor can easily realize about $1,000 an hour.**
Disclosure and Opinion
Full disclosure: I am a general internist (retired), and am in the bin of “cognitive” physicians, who do not do highly compensated procedures. Hospice doctors occupy the same category. In presenting the above examples, I have obviously stacked the narrative of the relative lack of reimbursement for primary care doctors, my goal being to illustrate the staggering difference that is possible in compensation for cognitive work versus procedural work.
No doctor is poor, so the question is whether this discrepancy matters. If so, what should be done about it? And how did we get such a system? Stay tuned.
*Another major gap in compensation practices involves women and minorities…..But that is subject for another time.
** The colonoscopist’s fee is typically 20 to 25% of the overall bill for the procedure–the rest is a facility fee and a fee for anesthesia; if tissue is to be analyzed, that is another cost.
A partial explanation for non-American doctors being compensated less is that frequently their undergraduate and even medical education is paid for by the state thus incurring less overall debt upon graduation than the majority of their American peers. Also, at least in the English system, the majority of night duty is handled by hospital “registrars”, roughly equivalent to our House Staff.
Jim – I imagine medical schools teach that “analytical” doctored make much less than “procedure “ doctors. It’s a wonder anyone chooses to be an internist. Good job.
I wasn’t surprised that specialists earn considerably more that primary care doctors and that part of the reason is the cost of their insurance. It seems to me that we need to start from the beginning…the cost of medical education at our Universities. I understand that if doctors agree to serve in underserved communities for a year or two, just as some programs for teachers do, that some or all of their loans are cancelled. That is something that could be expanded,
I’m not an insurance specialist, but I would bet that the insurance companies are making hugh profits and also that the courts are awarding gigantic settlements. Both of these areas need to be examined. People are so litigious, there should be limits on settlements.