There is certainly a diversity of passions and motivations, both intrinsic and extrinsic, which propel surgical careers; ultimately, most have the common thread of developing the skills and abilities to be a healing force for humanity. This noble goal, however, is not without financial challenges, which can come as a surprise to early career surgeons who might assume there will be a significant financial payout once training is complete.
While a surgeon’s income on average typically ranks near the top among career fields in the US, the student debt crisis has significant implications for these individuals. Current surgeon compensation models typically do not account for increasing student debt levels that continue to escalate with no ceiling in sight. This article provides the highlights of research conducted by the authors and our colleagues at The University of Alabama at Birmingham, which recently was published in the Journal of the American College of Surgeons, “Diminishing Returns: An Analysis of Surgeon Compensation in the Setting of Ever-Increasing Student Debt.”
The Evolution of Student Debt
While student debt is increasing exponentially for higher education, in addition to any debt accrued from expenses associated with an undergraduate degree, medical education, in particular, is becoming increasingly expensive.
Notably, funding mechanisms for medical education have evolved drastically during the past 60 years. In the 1960s, many students were able to finance their medical education via family contributions and/or income from a research position or externship.1 By the 1970s, more than half of all students were taking out loans to pay for medical school, and by the mid-1980s, more than 86% of students were graduating with debt.2 Today, the average medical student graduates with approximately $200,000 in student debt.3
Training Obligations and Income Potential
Additional compounding factors that exacerbate the problem of student debt for surgeons include the length of time required for residency training and an income potential that has stalled compared to the rate of debt accumulation. Surgeons, on average, will dedicate 10 or more years to formal professional training, during which there is very little income (particularly during medical school), or they are earning only a fraction of the salary that their peers with professional degrees or those with shorter residency training obligations are earning.4,5
After training is completed, the starting salaries of hospital-employed surgeons are heavily influenced by the overall financial health of the practice environment, which in turn, is dependent on variables such as payer mix, region, and general overhead.6 Productivity compensation, typically based off of work relative value units, is also declining due to diminishing conversion factors that determine reimbursement. For example, the Medicare conversion factor in 2024 was less than it was in 1998 (<50% of inflation-adjusted dollars).7
Surgeon Debt and Income Trajectories
Taking these factors into consideration, our research group examined salary and education debt data from the Medical Group Management Association and the Association of American Medical Colleges datasets. To allow for more direct comparisons of salary and debt over time, inflation adjustments were made using the Consumer Price Index calculator from the US Bureau of Labor Statistics.8 Examining trends of debt and income over time, we found that in 1984, the median surgeon salary was $111,287 annually, and corresponding median medical school debt was $22,000.
In 2019, the median salary and debt were $350,000 and $200,000, respectively. After adjusting the 1984 figures to 2019 dollars (salary of $274,900 and debt of $53,344), the 2019 figures represent increases of 214.5% for salary and 809% for debt. The resulting debt-to-income ratio increased sharply from 0.2 in 1984 to 0.6 in 2012 and has remained relatively constant since. Even after inflation adjustment, medical school debt has increased nearly four times in the past 40 years, while salaries have only increased by 25%.9
Potential Solutions
From a debt alleviation perspective, there are programs available for student loan forgiveness, usually contingent upon an agreement to practice in a nonprofit and/or underserved setting after training. Most notably, the Public Service Loan Forgiveness Program, which requires 10 years of qualifying payments, calculated as a function of current salary while practicing in the aforementioned settings, after which the remaining loan balance is forgiven.10
This is an attractive option for surgeons given the length of time required in a relatively low-paying residency. However, with ever-changing legislation surrounding student debt, it is unclear whether this option will be a reliable path in the future.
In terms of improving compensation models to favor surgeon productivity, pay-for-performance models have been proposed, emphasizing value-based metrics and quality care. However, these models disadvantage poor and low-resourced patients and hospital systems.11 Lastly, there is a large portion of uncompensated work that surgeons undertake, including care coordination, quality improvement efforts, mentoring, research, and advocacy. Future compensation models should consider these factors in hiring packages, as their benefits to the healthcare profession overall cannot be overstated.
The growth of student debt has significantly outpaced that of the surgeon’s income and is poised to have increasingly detrimental effects on the financial standing of surgeons. This problem requires innovative input from surgeons to develop sustainable financial models that alleviate the debt burden and continue to improve equity and quality in care delivery.
Disclaimer
The thoughts and opinions expressed in this column are solely those of the author and do not necessarily reflect those of the ACS.
Dr. Angela Sickels is an integrated vascular surgery resident at The University of Alabama at Birmingham.
Dr. Bart Rose is the section chief of hepatopancreatobiliary surgery at The University of Alabama at Birmingham (UAB) and director of the UAB Pancreatobiliary Disease Center.
References
- Lambdin JA. Survey of how medical students finance their education, 1974-1975. Available at: https://files.eric.ed.gov/fulltext/ED121215.pdf. Accessed January 17, 2025.
- Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med. 2011 Jul;86(7):840–845.
- Association of American Medical Colleges. AAMC Faculty Salary Report FY 2019. Washington, DC; 2019. Available at: https://www.aamc.org/data-reports/workforce/report/aamc-faculty-salary-report. Accessed January 17, 2025.
- Stortz SK, Foglia LM, Thagard AS, et al. Comparing compensation of US military physicians and civilian physicians in residency training and beyond. Cureus. 2021;13(1):e12931.
- US Bureau of Labor Statistics. Occupational Outlook Handbook. Available at: https://www.bls.gov/ooh/architecture-and-engineering.htm. Accessed January 27, 2025.
- Resnick AS, Corrigan D, Mullen JL, et al. Surgeon contribution to hospital bottom line: Not all are created equal. Ann Surg. 2005;242(4):530-7; discussion 7-9.
- Centers for Medicare and Medicaid. Physician Fee Schedule. Available at: https://www.cms.gov/medicare/payment/fee-schedules/physician. Accessed January 17, 2025.
- US Bureau of Labor Statistics. Available at: https://www.bls.gov/data/inflation_calculator.htm. Accessed January 17, 2025.
- Sickels AD, McElroy K, Robinson J, et al. Diminishing Rreturns: An analysis of surgeon compensation in the setting of ever-increasing student debt. J Am Coll Surg. December 11, 2024.
- Public Service Loan Forgiveness Program. Available at: https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service. Accessed January 17, 2025.
- NEJM Catalyst. What Is Pay for Performance in Healthcare? Catalyst Carryover. Massachusetts Medical Society. 2018;4(2). Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0245. Accessed January 17, 2025.
