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ORIGINAL RESEARCH |
From the 1Department of Obstetrics and Gynecology and the Brigham and Women's Hospital Physician Organization, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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ABSTRACT |
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Methods: Data from the 2004 National Resident Matching Program were used to estimate the percentage of residency positions filled by U.S. medical graduates in 15 major specialties. Data from the Medical Group Management Association, American Medical Association, and a major Massachusetts liability insurer were used to estimate the mean and median physician income, work hours, and the relative cost of professional liability insurance.
Results: The percentage of residency positions filled by United States medical graduates varied by specialty. In 2004, U.S. graduates filled more than 90% of the residency positions in orthopedics, plastic surgery, and neurosurgery. In contrast, U.S. graduates filled fewer than 60% of the residency positions in internal medicine and family medicine. A positive correlation between mean annual income and the percentage of residency positions filled by U.S. medical graduates (r = 0.78, P < .001) was observed across the 15 specialties studied. In a multivariate analysis, professional liability costs were not associated with the percentage of residency positions filled by U.S. graduates after controlling for annual income (P = .46).
Conclusion: Economic factors are associated with the percentage of specialty positions filled by U.S. medical graduates. Procedure-based and hospital-based specialties with an above-average annual income are most likely to have their residency positions filled by U.S. medical graduates.
Level of Evidence: III
During the past decade there has been a significant decrease in the number of U.S. medical students applying to obstetrics and gynecology residency programs. Many leaders are concerned that this change may indicate a decrease in the relative attractiveness of the specialty. The purpose of this article was to study the association between economic factors and the percentage of residency positions filled by U.S. graduates in 15 major specialties to better understand the potential role of these factors in student career choices.
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MATERIALS AND METHODS |
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The average number of hours dedicated to professional activities per week by specialty for 2001 was obtained from Physician Socioeconomic Statistics published by the American Medical Association (AMA).11 In the AMA report neurologic surgery and plastic surgery are combined in the same category.
The median and mean annual income by specialty was obtained from both the Medical Group Management Association survey for 200312 and the AMA survey of 2001.11 In these surveys, income is reported after payment of practice-associated expenses. The Medical Group Management Association data indicate that the mean annual income of physicians tends to be slightly higher than the median annual income.
The relative cost of professional liability insurance for 2005 was obtained from a major insurer in Massachusetts, the Controlled Risk Insurance Company. Controlled Risk Insurance Company is a captive insurer, which is not for profit and affiliated with Harvard University. Controlled Risk Insurance Company assigns liability premiums to a specialty based on actual and predicted losses in the specialty using both closed and open claims.
The Pearson correlation coefficient was used to analyze relationships between variables. The relation between mean annual income, professional liability cost, work hours per week, and the percentage of residency positions filled by U.S. medical graduates was also explored using a multivariate analytic model. Linear regression was used modeling the percentage (p) of residency positions filled by U.S. medical graduates as a linear function log [p/(1 – p)] of mean annual income, professional liability cost, and work hours per week. A weight of [p/(1 – p)] was applied. Statistical interaction between any 2 predictors and all 3 predictors was tested. All tests were 2-tailed.
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RESULTS |
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The hours devoted to professional activities per week varied widely by specialty. Specialists in obstetrics and gynecology, anesthesiology, general surgery, neurosurgery, plastic surgery, orthopedics, and internal medicine reported working more than 60 hours per week. Specialists in dermatology, psychiatry, and pathology reported working 48 hours or less per week. The correlation between hours worked per week and the percentage of residency positions filled by U.S. graduates was 0.35, P = .20.
As reported by the Medical Group Management Association and AMA, the mean and median annual income varied widely by specialty. Using the mean annual income reported by the Medical Group Management Association, specialists in neurosurgery, orthopedics, radiology, and radiation oncology reported earning more than $400,000. Using the Medical Group Management Association data, specialists in psychiatry, family medicine, internal medicine, and pediatrics reported mean annual income below $180,000. The mean annual income reported for obstetrician–gynecologists was $261,000. Using the Medical Group Management Association data, the correlation between mean and median annual income and percentage of residency positions filled by U.S. graduates was 0.78, P < .001 and 0.77, P = .0008, respectively. Using the AMA data, the correlation between mean annual income and the percentage of residency positions filled by U.S. graduates was 0.82, P < .001.
The relative cost of professional liability insurance varied widely by specialty. For example, using Controlled Risk Insurance Company data, neurosurgeons, obstetrician–gynecologists, and orthopedic surgeons paid greater than 5 times more for their professional liability insurance than internal medicine specialists. Internal medicine specialists, psychiatrists, and pediatricians paid the smallest liability premiums. The correlation between the relative cost of professional liability insurance and the percentage of residency positions filled by U.S. graduates was 0.55, P = .034.
In a multivariate model, only mean annual income remained as a statistically significant predictor (P = .008) of the percentage of residency positions filled by U.S. medical graduates, independent of professional liability cost and work hours per week. Professional liability cost (P = .46) and work hours per week (P = .69) were not significant independent predictors of the percentage of residency positions filled by U.S. medical graduates when controlling for mean annual income. No statistically significant interaction between mean annual income, professional liability cost, and work hours per week in predicting the percentage of residency positions filled by U.S. medical graduates was observed, although the interaction between annual income and the number of work hours per week was of borderline statistical significance (P = .07).
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DISCUSSION |
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Many leaders in obstetrics and gynecology are concerned that relatively large professional liability premiums discourage U.S. medical students from choosing obstetrics and gynecology as their career. However, U.S. medical students do not seem to be absolutely discouraged from choosing other specialties with even larger professional liability expenses, as long as the specialty is procedure- and hospital-based and associated with above-average annual incomes. For example, neurosurgery and orthopedic surgery have very expensive professional liability premiums and above average income. In these fields, U.S. medical students filled more than 90% of the residency positions. In contrast, internal medicine and family medicine have relatively inexpensive professional liability premiums and below average income. In these fields, U.S. medical students filled fewer than 60% of the residency positions. One potential process by which economic factors could influence medical student career choice is that attending physicians in specialties with below-average incomes might directly and indirectly communicate with students that they are dissatisfied with aspects of their practice. For example, they may express dissatisfaction with the excessive cost of liability and office practice costs in relation to annual income.
There are many weaknesses with the idea that economic factors may influence the choice of specialty by medical students. One weakness is that the association between economic factors and the percentage of residency positions filled by U.S. graduates may not be causal. United States students may be attracted to highly compensated procedure-based fields because of the technical challenges and the ability to diagnose and cure a problem in a small number of visits. United States students may be avoiding less well-compensated fields that also have a high degree of continuity of care and chronic care because of the difficulty inherent to the treatment of chronically ill patients, not because of economic factors. Because the procedure-based fields tend to be more highly compensated, the association observed in this report between economic factors and residency choice may be incidental and not causal. United States medical students may choose procedure-based specialties because they are more professionally rewarding and prestigious, not because of the compensation. Another problem of an economic focus is that it may not reflect the important role of controllable life-style8 and the availability of part-time employment opportunities in the selection of specialty training. For example, if U.S. graduates select highly compensated fields such as radiology, dermatology, and anesthesiology because they have controllable work hours, then the relationship between percentage of residency positions filled and income may be incidental. Another weakness of the analysis is that focusing on the percentage of U.S. medical graduates entering a field may be fundamentally irrelevant to the long-term health and attractiveness of a specialty.
More data are needed to understand how medical students choose specialty careers and how specialists assess and report their career satisfaction to students. The decision to choose a specialty is complex. Student values, especially their desire to contribute to the relief of pain and suffering, play a dominant role in the choice of specialty. However, acting as a largely hidden force, economic factors may play some role in the choice of specialty.
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Footnotes |
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doi:10.1097/01.AOG.0000173983.88951.2e
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REFERENCES |
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2. Rosenthal MP, Diamond JJ, Rabinowitz HK, Bauer LC, Jones RL, Kearl G, et al. Influence of income, hours worked, and loan repayment on medical students' decision to pursue a primary care career. JAMA 1994;271:914–7.[Abstract]
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8. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–8.
9. Lind DS, Cendan JC. Two decades of student career choices at the University of Florida increasingly a lifestyle decision. Am Surg 2003;69:53–5.[Medline]
10. Results and data, 2004 match/National Resident Matching Program. Washington (DC): The Program; 2004.
11. Physician socioeconomic statistics. Chicago (IL): American Medical Association, Center for Health Policy Research; 2003.
12. Physician compensation and production survey/Medical Group Management Association. 2004 report based on 2003 data. Englewood (CO): Center for Research in Ambulatory Health Care Administration; 2004.
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