Obstetrician Incomes – Who says professional life is fair? (part 2 of 3)

Who Says Professional Life Is Fair?

When asked whether they believe themselves to be fairly compensated, more than one half of ob/gyns — 55% — said no, a small increase from last year’s 50%. Their view is not particularly different from the general physician population; 51% of all surveyed specialists felt fairly compensated.

Ob/gyns are certainly not the most disgruntled group. Plastic surgeons, whose mean salary ranked 9th of 25 participating specialties, were the least likely to feel that they were fairly compensated, with only 37% responding to the question with a “yes.”

Similarly, just 38% of endocrinologists, who ranked 22nd salary-wise, thought they were fairly compensated. Dermatologists, who held the 8th spot, were the most likely to be satisfied with their incomes: 71% said they were fairly compensated.

Radiologists — who, along with orthopedists, were the top earners — and pathologists, who occupied 15th place, were next: 62% and 63%, respectively, felt that they were reasonably paid. Sixty-one percent of emergency medicine practitioners, who ranked 14th in yearly salary, also said they were justly paid.

Clearly, something aside from yearly income must color physicians’ responses. Otherwise, why would 40% of urologists, who are fifth from the top of the pay range with an average annual salary of $309,000, say they were fairly compensated, while 59% of psychiatrists, whose yearly pay of $170,000 is fifth from the bottom, feel that they were adequately rewarded? One half of orthopedists, the highest-paid specialists along with radiologists, said they were fairly compensated; 50% of pediatricians, the lowest-paid specialists, said the same.

That’s Rich

If you think physicians are flush, you are not likely to be practicing medicine. Most specialists do not believe themselves to be wealthy. Among ob/gyns, only 9% thought they could accurately be described as rich. As for the rest, 46% said that their income was no better than that of many nonphysicians, and 45% pointed out that although their income might rightly categorize them as wealthy, accumulated debts and expenses prevent them from feeling especially well-to-do.

Which specialists were most likely to deem their finances to be rather robust? A mere 15% of pathologists thought of themselves as rich, along with 14% of radiologists, oncologists, and gastroenterologists. Rheumatologists and plastic surgeons had the smallest proportion of physicians disposed to a sense of prosperity — just 6%.

Of Patients and Paperwork

Office Hours Declining?

Might ob/gyns be spending a little less time seeing patients? Roughly one third of practitioners taking part in the 2012 report said they devoted 30-40 hours a week to seeing patients in the preceding year, compared with about 25% of those responding to the 2011 survey. Whereas 25% of ob/gyns said they spent 41-50 hours attending to patients each week in 2011, 31% said the same 1 year earlier. About 20% logged fewer than 30 hours per week seeing patients in 2011, compared with 12% in 2010. Twelve percent reported 51-60 hours of patient visits per week in the 2012 report, compared with 18% the year before. Some 9% of 2012 participants said that patient visits consumed more than 60 hours a week in 2011. In contrast, 13% of ob/gyns responding to the 2011 survey kept that schedule.

Job-sharing might account, at least in part, for the ostensible reduction in hours spent attending to patients in the office. “As more women — mothers — enter the ob/gyn workforce, it is likely that more are employed part-time in job-sharing arrangements,” remarks Andrew Kaunitz, MD, Professor and Associate Chair, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville. “This is one likely partial explanation. Could another reason be the economy?” He points to an October 2011 report from the Pew Research Center,^[1] which noted that the birth rate in the United States has been declining since 2008, when the nation’s economic outlook began to deteriorate. Similar observations have been made during other difficult financial times: notably, the Great Depression. “In addition,” Kaunitz adds, “concerns about copays and missing work may make women more reluctant to attend office visits or arrange elective surgery.”

Among all specialists surveyed in 2012, approximately 9% dedicate more than 60 hours per week to patients’ office visits. That 9% does not represent all specialties equally. For example, 5% of ob/gyns said they spend more than 65 hours per week attending to patients. In contrast, one quarter of critical care physicians spend more than 65 hours per week seeing patients, as do 11% of cardiologists and general surgeons and 10% of internists and nephrologists.

Patient Visits per Week

According to the 2012 report, ob/gyns’ patient volume per week in 2011 was as follows:

• < 25: 10%;
• 25-49: 16%;
• 50-75: 22%;
• 76-99: 21%;
• 100-124: 19%;
• 125-149: 6%;
• 150-174: 3%;
• 175-200: 1.5%; and
• > 200: 0.5%.

Ob/gyns saw similar numbers of women per week in 2011 and 2010. Of those responding to the 2011 survey, about 46% said they attended to 50-99 women each week in 2010, 20% saw 100-124 patients, and 13% saw 125 women or more. About 7% of ob/gyns examined fewer than 25 patients per week; 2% saw more than 200 women.

Among all specialists who responded to the 2012 report, the largest proportions saw 25-49 patients (22%) and 50-75 patients (17%) weekly. Combining categories indicated that some 26% of all doctors, vs 40% of ob/gyns, examined 76-124 patients each week. Finally, 2% of all physicians attend to more than 200 patients per week. No doubt, radiologists contributed heavily to that 2%: About 34% said that they see more than 200 patients weekly.

The average duration of these patient visits and the percentage of ob/gyns reporting these durations in the 2012 report were as follows:

• < 9 minutes: 7%;
• 9-12 minutes: 26%;
• 13-16 minutes: 35%;
• 17-20 minutes: 17%;
• 21-24 minutes: 7%; and
• ≥ 25 minutes: 8%.

As in 2010, more than one half of ob/gyns in 2011 spent 9-16 minutes with their patients during each visit (55% in 2010; 61% in 2011). Among all specialists, 44% allotted 9-16 minutes per visit in 2011, and 31% allotted 17-24 minutes.

Of course, length of visit varies by specialty. According to the 2012 report, visits lasted 9-16 minutes for 30% of endocrinologists, 31% of radiologists, 42% of internists, 44% of cardiologists, 51% of family medicine practitioners, 57% of pediatricians, 63% of ophthalmologists, and 66% of dermatologists.

At the extreme ends of the range, an average of less than 9 minutes per visit was reported by 1% of endocrinologists, 3% of family practitioners, 3% of internists, 4% of cardiologists, 4% of pediatricians, 12% of dermatologists, 15% of ophthalmologists, and 48% of radiologists. Among those who spend an average of 25 minutes or more with patients are 4% of dermatologists, 4% of ophthalmologists, 10% of radiologists, 11% of family practitioners, 13% of pediatricians, 14% of cardiologists, 17% of internists, and 20% of endocrinologists.

Executive Privilege?

Many of the hours not reserved for attending to patients are given over to paperwork and administrative duties. These activities occupied the following number of hours per week for ob/gyns participating in the 2012 report:

• 1-4: 17%;
• 5-9: 28%;
• 10-14: 28%;
• 15-19: 11%;
• 20-24: 7%; and
• > 25: 10%.

Practitioners are expending much energy on such tasks as documentation, preauthorization, and the myriad components of practice management. The paper stream has been steady for ob/gyns — they spent similar amounts of time on these endeavors in both 2011 and 2010, although the percentage enduring 25 hours per week or more has begun to creep up. When ob/gyns in the 2011 survey were asked how many hours per week they allotted to responsibilities other than direct patient care, the responses were as follows:

• 0-4: 18%;
• 5-9: 30%;
• 10-14: 27%;
• 15-19: 11%;
• 20-24: 8%; and
• ≥ 25: 7%.

When the 2012 report responses from all specialists were tallied, the general picture was far different. More than one half (53%) spent only 1-4 hours on paperwork and administrative responsibilities; 13% devoted more than 25 hours. Similar to ob/gyns, 10% of other primary care physicians — internists, family medicine practitioners, and pediatricians — also needed more than 25 hours per week to complete these tasks.

Still, other specialists spend the maximum amount of time hiking the paper trail. For example, in 2011, 33% of pathologists spent 25 hours or more per week on paperwork and administrative activities, along with 27% of specialists in infectious diseases and HIV/AIDS, 18% of oncologists, and 15% of endocrinologists and critical care specialists.

Statistically, the particularly heavy burden of paperwork and administrative chores shouldered by some physicians is offset by the relatively small percentages of other specialists who spend as much time on duties that do not involve direct patient care. For example, 8% of radiologists and urologists, 6% of emergency medicine practitioners, and 5% of ophthalmologists and plastic surgeons devoted 25 hours or more per week to these functions in 2011.

Major Change Is in Ob/Gyns’ Mood

Now that you have the advantage of experience, would you choose the same career? According to the 2012 Medscape report, a minority of ob/gyns, 37%, said they would select the same specialty; merely 23% would pick the same practice setting. Moreover, just 55% would become physicians if they could choose to do it over again.

Unhappiness with medicine, and with obstetrics and gynecology in particular, has sharply increased. One year ago, 53% of respondents said they would practice obstetrics and gynecology, and 69% would pursue medicine again. And more than twice as many — 48% — said they would select the same practice setting.

Frustration was not limited to ob/gyns. Among the 2012 report participants from all specialties, 41% said they would choose the same specialty, 54% would select medicine as a career, and 23% would elect to work in the same practice setting. When questioned in 2011, 61% of all participating physicians said they would practice the same specialty, 69% would pursue a medical career, and 50% would opt for the same practice setting.

To get a sense of general contentment — or discontentment — among survey participants in each field, the responses to the 3 questions measuring satisfaction with medicine, specialty, and compensation were averaged. The 2012 report estimate of total satisfaction for ob/gyns, calculated to be 46%, was the same as that for general surgeons, nephrologists, neurologists, and urologists. Only endocrinologists (45%), internists (44%), and plastic surgeons (41%) were less satisfied. Dermatologists had the highest scores (64%) of the 25 represented specialists, followed by psychiatrists (56%) and emergency medicine practitioners (54%). Next, at 53%, were gastroenterologists, infectious disease/HIV specialists, ophthalmologists, and pathologists.

Oddly enough, ob/gyns responding to the 2011 survey had a higher degree of global satisfaction — 57%, a figure matched by nephrologists and pulmonologists — but only primary care physicians (54%) had a lower percentage. Dermatologists (80%), the leaders of the 2012 report, also proved to be the most satisfied lot in the 2011 report, followed by radiologists (72%), oncologists (70%), and gastroenterologists (69%). In fact, although a particular type of specialist might have a higher or lower rank than in 2011, members of every specialty had a lower satisfaction score in 2012.

“I think the overall economy might have an effect on physicians’ perception of medicine and job satisfaction,” says Shelly Holmström, MD, Associate Professor of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa. “Many physicians have seen their incomes or benefits diminishing in recent years, while the cost to practice is the same or greater each year. Some physicians may be worried about the enactment of the Patient Protection and Affordable Care Act.”

Holmström, who also serves as President-Elect of the Florida Obstetric and Gynecologic Society, notes that a lot of young physicians, after graduating from medical school and completing a residency, may then struggle to pay off loans while trying to start new practices — and perhaps, new families. Also distressing are the litigious proclivities of the patient population. “The average ob/gyn is named in 2.6 lawsuits during his or her career,” she remarks. “These lawsuits are often settled, or they may even find for the defense when a verdict is rendered, but the process causes months or years of stress for the physician.”

The Future Is Now

“Change is inevitable in a progressive country,” said British politician and prime minister Benjamin Disraeli. “Change is constant.” Although the politician probably didn’t have medicine on his mind when he addressed listeners in Edinburgh, Scotland, in 1867, the words aptly describe the state of affairs physicians are facing today. Also unavoidable are the uncertainty and anxiety that change brings when your livelihood is involved.

Asked whether they participated in alternative patient care or payment models, 7% of ob/gyns responded affirmatively. One percent said they have concierge practices, and 3% have cash-only practices, which perhaps aren’t so much new as they are reinvented. Three percent are involved in Accountable Care Organizations (ACOs), and another 5% plan to take part in an ACO in the coming year. These percentages exactly reflect what is happening among all specialists participating in the 2012 Medscape report.

The last model, the ACO, is a component of the Medicare Shared Savings Program, which is authorized by the Affordable Care Act. Designed to attain better health outcomes, an ACO links primary care practices, specialty practices, and hospitals, and these entities work together to provide care for a certain patient population; Medicare recipients are an obvious case in point. Reimbursement is associated with the quality of care, as determined by specific indicators, and reductions in the entire cost of providing that care. For example, if providers manage to curtail expenditures, the ACO receives some percentage of the savings. However, depending on the payment model selected, the ACO also could be accountable for higher-than-anticipated costs, absorbing a portion of the resulting loss.

Some 29% of ob/gyns believed that joining an ACO would trigger a large drop in income, 26% anticipated a minor decline, and 12% expected little or no effect on income. One third, 33%, said it was too soon to know what might occur. These views were analogous to those of the entire pool of specialists: 28% expected a sizeable decline in income, 24% predicted a small decrease, 12% expected little or no change, and 36% said it was too soon to tell. Shelly Holmström suggested that aside from concerns over loss of income, physicians might believe that participation in an ACO would also mean less autonomy in the way they practice.

Little Enthusiasm for Treatment Guidelines

Treatment guidelines and quality measures drawn up by Medicare and other insurers will be used to steer shared savings programs toward particular goals. One half of surveyed ob/gyns said that such directives would have a negative effect on patient care; 27% predicted that they will have no influence on the quality of patient care; and 23% were upbeat, noting that treatment guidelines and quality measures will bring about improved care. This is not all that different from the general opinion of all specialists questioned. Among all respondents, 47% said that treatment guidelines and quality measures would have a negative effect on patient care, 29% envisaged no effect on quality of care, and 25% believed that guidance would bring about improvements in care.

“Physicians could fear that they will be penalized — receive less reimbursement — if they do not follow the guidelines exactly,” Holmström says. “Also, physicians frequently do not like to be told exactly how to practice medicine because every patient is different, and we do not practice ‘cookbook’ medicine. For example, physicians in Florida are now mandated to perform certain imaging tests before a woman can undergo an elective abortion. These may be unnecessary clinically but are necessary according to Florida law. Physicians might resent being told what to order when the test is unnecessary or not indicated.”

Nearly two thirds of ob/gyns said that they have no intention of trimming costs by ordering fewer tests. Of these, 39% — similar to 43% of all specialists — said that quality guidelines and cost-containment measures are not in the patients’ best interests. Another 25% of ob/gyns will not reduce testing because they feel that they need to practice defensive medicine; 24% of all physicians agreed. Nine percent of ob/gyns, and 7% of all survey respondents, are willing to curb testing because this tactic will affect their income. Three times as many ob/gyns, or 27%, will do so because they think the guidelines are good. Similarly, 27% of all practitioners said they would cut back on diagnostic efforts because the guidelines are beneficial.

Again, the public’s penchant for litigation probably influences physicians’ responses. Shelly Holmström points out that in Tampa, Florida, plentiful commercials and billboards advertise the services of personal injury lawyers. What if not checking a laboratory result leads to a missed diagnosis or delayed treatment? “Ob/gyns might be more amenable if the testing recommendations are founded on evidence-based research and not purely on cost-cutting,” she remarks.

Speaking of Money

Whereas ob/gyns are generally willing to discuss the cost of treatment with patients, only 41% regularly do so. Another 48% occasionally talk about the price of care if the patient introduces the subject first. Seven percent never talk about charges because they don’t know the fees for treatments, and 4% said they do not talk about cost with patients because it is inappropriate to do so. Again, these percentages more or less reflect the outlook of all specialists surveyed: 38% regularly talk about fees, 46% discuss treatment cost if the patient starts the conversation, 9% won’t because they don’t know what treatments cost, and 7% felt that such discussion was unsuitable

“The practice of obstetrics and gynecology is ever-evolving,” Holmström says. For example, more hospitals are hiring or forming laborist groups, so that specific physicians are dedicated to the inpatient care of pregnant women. With that service in place, physicians in the community can choose to offer only office-based obstetrics and gynecology. Satisfaction with career choice undoubtedly changes over time as well.

In offering an opinion, Peter Bernstein, MD, MPH, Professor of Clinical Obstetrics & Gynecology and Women’s Health, Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, New York, New York, stresses that he is not the typical practitioner. “I work as a full-time member of an academic faculty at a medical school,” he says. “I only see patients 1-2 days each week — the rest of my time is devoted to research, administration, and teaching. From my perspective, largely taking care of the uninsured and patients receiving government assistance, this is an exciting time to be a physician. Healthcare reform is long overdue, and I am cautiously optimistic that what is coming down the pike will make things much better for us. I think it is a great time to be a doctor.”

Sidebar: Survey Methodology and Demographics

Between February 1, 2012, and February 17, 2012, Medscape gathered compensation data from 24,216 physicians in the United States, a group representing 25 specialties. Their responses were captured through a third-party online survey collection site. Six percent of participants — 1453 doctors — were ob/gyns. Fifty-three percent of ob/gyns were male, 47% were female. Most ob/gyns (93%) were MDs, and most were board-certified (87%).

Participants’ ages were well distributed. Twenty-two percent of ob/gyns were aged 28-39 years, 26% were 40-49 years, 27% were 50-59 years, and 25% were 60 years of age or older.

In some cases, percentages in this survey do not add up to 100%, owing to rounding.