Long-term financial implications of specialty training for physicians

Purpose Given the recent changes in physician reimbursement and managed care penetration, we examined the financial returns that might be anticipated when considering different medical careers. Methods We used survey data from the American Medical Association and standard financial techniques to calculate the return on educational investment (as the discounted, annual hours-adjusted, net present value of additional training) over a working lifetime for six different specialties (family practice, pediatrics, general internal medicine, gastroenterology, cardiology, and general surgery). Results From 1992 to 1998, the annual yield on specialty training (hours-adjusted internal rate of return) declined for all specialty groups, especially for primary care specialties. The difference in the average income between a given specialty and general practice decreased for general internal medicine, from $5400 (95% confidence interval [CI]: $5000 to $5800) in 1992 to $1180 (95% CI: $1160 to $1205) in 1998, and became negative for family practice (from $5200 [95% CI: $1000 to $9500] to −$2500 [95% CI: −$5800 to $800]) and pediatrics (from $4000 [95% CI: $1200 to $6800] to −$6300 [95% CI: −$9700 to −$2900]). Values for surgery decreased from $33,100 (95% CI: $29,400 to $36,400) in 1992 to $27,200 (95% CI: $21,700 to $32,100) in 1998, whereas there were increases for cardiology, from $35,100 (95% CI: $30,000 to $39,700) to $36,700 (95% CI: $26,500 to $45,700), and for gastroenterology, from $30,000 (95% CI: $21,800 to $37,200) to $34,700 (95% CI: $22,700 to $45,300). Conclusion Our analysis suggests that recent efforts to use financial incentives to make primary care fields more attractive have not been effective. Financial returns and the incentives they create should be carefully considered as part of health care reform.