how important is salary?

Although I think this poll is interesting and all, the results should be taken with a grain of salt. What would be equally interesting is to poll the same question to a group of PRACTICING orthopods. I would suspect the results would be a bit different. I may sound like a cynic, but while $125K per year seems like a decent living to most med students (living on next to nothing), most active practicing orthopods, regardless of how much they "love" what they do would find it difficult to accept the current number of hours they devote, the stress they incur, the liability they accept (both financial and personal) and the accumulated cost of training (from both loans and deferred salary compared to their cohorts) for $125K per year. I would be willing to bet that if somehow overnight, the average orthopod could only earn $125K per year, the already increasing deficit of orthopaedic surgeons would skyrocket. There are many other fields which require less training and deal with much less liability and stress on a daily basis which can earn as much or more.

The whole point of this rant is that while the question is a hypothetical one, the situation of decreasing reimbursement and increasing overhead is very real and threatens healthcare daily. While medicare (and thus private payers) continue to eek down physician reimbursement, employees essential to running a practice continue to demand increases in salary at least consistent with the cost of living. When is the last time you heard of a nurse or transcriptionist taking a CUT in pay to continue to work. The cost of paper, lights, and electricity don't routinely drop either. On the surface it is easy for an idealist to consider salary concerns selfish and superficial, but unless orthopaedists and physicians in general begin to demand their value in society like every other segment of the working class does, we will continue to accept less and less for doing the same job. Eventually there will be no financial incentive to pursue medicine, and while there are certainly other reasons to go into orthopaedics and medicine in general, most qualified candidates will seek out other professions.

Sorry for the book, but I find this a very important issue for orthopaedics and medicinein general in the next ten years.

-ED

Anyone else want to discuss orthopod compensation more extensively (i.e. academic vs private, regional differences, subspecialty differences, etc... ) or point us to a thread where this has been done?

I think this is probably a topic on many minds, and also one well suited for an "anonymous" forum...

If all medical fields paid 125K and had same work hours, I'd do ortho.

Here's a link to the 2006 Medical Group Management Association physician income report, you can scroll down to orthopedic surgery and see results by region, subspecialty, etc. According to this, the average orthopod makes about 400k, which sounds right....anyone have any comments?



The biggest problem with any of these salary surveys is that each one is inherently biased by having a skewed sample; for instance, I think AMGA surveys large practice management organizations and probably misses all the 2-3 person private practices...what that does to the numbers is anyone's guess.

As for the subspecialty numbers, no surprises there....spine and joints make significantly more than average, and peds makes significantly less.

what is consensus on sports medicine orthopod salaries?

I think the salary definitely matters... its just like what you can say about give and take... If you are putting extra efforts, taking extra stress, less vacations, less time with family.. then you ought to be paid good... It doesn't mean I am doing orthopaedics just for money... I love being an Orthopod but if I am not getting enough for what I am doing, then I ain't gonna do it.
I would rather do something like PMR and just enjoy with my family and outside the hospital then.

you all make me sad ....

if money was the issue, you should have gone into business. it is a sad state of our youth today and the new generation Y.

if you are really concerned about money, medicine in general will really disappoint and frustrate you.

the business side of medicine takes away the heart of medicine. remember you should feel privileged when a patient accepts you as their physician.

love what you do ... the money will follow ... if you are concerned about money ... go into radiology or anesthesia ... where u have little patient meaningful contact

The way I think of it is about VALUE not necessarily money or salary. We, as physicians, are at the center of this health care industrial complex. Things dont move or happen unless there is a physician to sign on to it... I mean everything. Thinking of it that way, physicians are grossly under-compensated for the value-add, they bring into the system. Even taking a look at the negative part of our system, malpractice, requires a physician on both sides. No one can bring a malpractice case to court without a physician beside them. Yet even in these cases, physicans are usually paid a nominal fee (like 10-20K), not a percentage of the award which is how the lawyers are paid. At some point, it's not even about the salaries- they are only representative of how much power we are losing in this system.

One concept that gets lost in thinking about salaries is the time value of money. 300K in 1990 is not the same as 300K in 2010, in real and nominal terms. So for an entering orthopod to expect making 300k in 2010 baffles me. I am not saying it is not enough to live by but our compensation is going down, not staying the same. Our salaries don't even account for inflation.

Lagbaja, brings some very important issues to the table.

Staff, I am moved by your, "you should feel privileged when a patient accepts you as their physician" speech. But it is not unreasonable for orthopods and physicians in general to care about falling reimbursement and the business side of medicine. Too often, fellow "hollier than thou" physicians and society in general make the medical community feel somehow guilty about caring even an ounce about money. To address financial issues within medicine does not mean one doesn't love their job, is less devoted, or cares any less about their patients. To assume that "generation Y" has their priorities screwed up because they (we, although I am well beyond generation Y) discuss VERY REAL financial concerns is conceited and judgemental. While not always the case, usually those who chastise younger physicians who discuss financial issues are older orthopods and physicians who practiced in the "golden age" of medicine, have made their retirement, put their kids through college (or at least have a good start) and have paid off their virtually non-existent med school loans. In these cases, it makes the one criticizing appear at best hypocritical. It is easy to criticize others for caring about money when you are financially set yourself.

Let's look at a basic FACT. Physician reimbursement as a whole in 2006 was DOWN 17% from 2002 and continually merging insurance companies posted record PROFITS during this time, all the while health insurance premiums have increased. While orthopods are still earning a decent living, look at our colleagues in FP and Peds who spend nearly as long in post-undergraguate training and earn less than some of the drug reps bringing them donoughts and certainly less than the guys opening boxes of implants in the OR. That is the real "sad state" of affairs in our society, and not the "Youth" or "Generation Y's" attitude as "Staff" would imply. I am not knocking those people for their ability to earn a living. They certainly have the right to earn whatever the free market can bear. But so do physicians. But if we continue to IGNORE financial concerns because of some unspoken sentiment that it is somehow wrong, the situation will only worsen, ultimately leading to an increasing shortage of those physicians, and ultimately adversely affect patient access to health care. Physicians should not be criticized for efforts to take back some of the pie from the government and insurance companies, because just like every other sector of society, no one outside of the physician community will care enough to make any effort to protect physican income other than physicians themselves. Politicians aren't going to do it. Nurses aren't going to do it. Insurance company execs aren't going to do it, etc.

Orthopedics is not immune to the phenomenon. In our institution, a level one trauma center, we have been looking for YEARS with futility to add trauma trained orthopedists to cover difficult cases. Because of the government regulated STARK laws, our hospital is not allowed to offer an orthopedic traumatologist any more than what any busy general orthopedist could earn in a small community. This is happening nationwide as many centers struggle to find trauma coverage. If the government would relax the restrictions, hospitals could then pay whatever the market could bear for a traumatoligist. Of course, at first it would be an obscene amount of money, but eventually as salaries rise, more residents would pursue trauma fellowships and the shortage corrected, with salaries eventally correcting to reflect the supply. That is how every other profession is allowed to operate in a free market system, but not medicine, and not orthopedics. As a result, more patients suffer from a lack of access to trauma trained orthopedists. This example could easily be applied to physicians as a whole.

So, although I apologize for the rant and the long winded post, in summary, I will NOT apologize to "Staff" and others like him or her who stand on their throne and cast stones at younger physicians who look to preserve their livelihood. Ultimately, it is patient care that is at stake.

That is all.

-ED

i guess i must respond to earthdawg's "hollier than thou" physicians, discuss VERY REAL financial concerns, and the grey haired comment.

i would like to just put out there i personally was not around in the golden era and i would appreciate some grey hair it would make me look older, but i appreciate that you putting me in the class of the grey hairs.

i guess i have to do the 1 2 3 thing ...

1. my point of criticizing the younger generation for looking at the dollars and cents is that medicine itself regardless of specialty has taken a hit financially. so, that as a primary factor or one of the factor in having someone chose a specialty sadden me.

2. the shortage that we in orthopaedic surgery are having in the areas of trauma and my area pediatrics; and the large amount of people now going into spine and sports really speaks to people following the dollar. there is a glut of sports physicians, yet in trauma and pediatrics there is a great need. can it be only money, most certainly not. but, i am sure if the income was same more people would consider the currently needed subspecialties.

3. most physicians now are not "salaried" unless they are in the old academic system, or an employee of a hospital. most physicians are in a system which is incentive based, meaning you get a percentage of your collections; or a straight, you pay your overhead with you collections and the rest is yours. so, going into a specialty for a specific salary is kinda misleading, because there is now salary; the quotes you may read about usually it has to do with the initial salary with incentive based on performance and collections. most of the money discussions depend on the practice, the location, our payer mix, etc..

4. money should always be a concern. i would agree with everyone. but, i would like to say that if money was a primary concern, business is probably an easier way of going about it.

5. as far as throne, i personally don't own one or choose to. i did not intend to cast stones at young physicians. but, it does disappoint me that so many would choose not to be in a specialty because of money.

as for me, i will continue to do my menial "job" as a lowly pedipod. dealing with out 60% medicaid population (0%medicare which is actually a good payer) and truely loving what i do. i will continue to pay my medical school loans on time.
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... and one day i too will be financially set as my fellow classmates in there sports practices with their surgery centers.

i will continue to try try to inspire my students and residents to love the field of orthopaedics. and encourage them to challenge the status quo.

Don't you love how people learn to provide very long arguments on a WIDE range of topics, and then conveniently back them ALL up with a quote about patient care.

Has anyone considered that we, as physicians, aren't providing as much "value" to society as we used to? Patients ARE getting more resourceful and aware that the MD doesn't always know best. Paternalism is decreasing, and patients trust their doctors less, and rightfully so much of the time. Physicians in the United States over the past 50 years have benefited from overcompensation! I believe this is society's way of finally telling us that they know we aren't worth as much as we would like to think. When we finally figure out a good way to align patients decisions in pursuing healthcare with the actual value they place in it, then it might just blow your socks off.

If you really believe all you say, and if you REALLY HAVE PATIENT CARE AS YOUR PRIORITY, then it is quite clear that we need you lobbying on capitol hill to save the healthcare system. Hell, you could make a lot more money doing that as well, and according to your logic, you would improve the health of patients in our country. Get paid more and do more to benefit patients than you will as a practicing orthopod?

I would be interested in learning why your healthcare organization hasn't figured out how to deal with the provisions of the STARK law(s), whereas so many others across the country have modified their arrangements with physicians in the community successfully. It is fitting that you bring up the STARK law, being so concerned about money. You sound like exactly the type of physician that got us in so much trouble to begin with. Come on, let's hear about how you can complete your decision making without considering how it will affect you financially???

Well, maybe there will be room for another boutique surgery center for you to open, and you can leave the complete care for society's health to us. After all, it would be best for the patients in the end if you weren't involved.

md007,

You seem simply to want to pick a fight, so I'll resist the urge to spiral this one down with insults.

The point of my post was simply to respond to "Staff's" assertion that the youth of medicine is in a "sad state" and care nothing about money simply because they (we I guess, although I don't consider myself youth) are CONCERNED about declining reimbursement.

As a whole (obviously excluding myself - you seem to have my motivations pegged based on a single post) my contention is that physicians DO put patient care above reimbursement. Please, I beg, name ONE other profession which has even seen their earning power not keep up with inflation, much less DROP year after year. I doubt very few teachers, nurses, policemen, etc, all of which provide for the public good, would continue to work in a job if they were told tomorrow they would get a pay CUT next year. Physicians continue to do the same job for less money year after year. Were physicians overpaid in the past? Perhaps. Are they appropriately compensated now? Probably, depending on the specialty. Will they at some point be underpaid in the future and lead to shortages in certain fields? Well, it has already happened in my opionion - which despite what you would suggest, ultimately DOES affect patient care and access to health care. There are some areas of my state where the closest OB/GYN is three hours away. It wasn't always the case and I can't help but blame at least SOME of that on the decreasing reimbursement coupled with the increasing cost of running a practice.

You can insult me all you want on an anonymous message board, but it doesn't change the fact that ignoring financial issues in medicine is not only appropriate, but necessary.

Oh, and by the way, I don't own even a part of a surgery center.

now now gentleman ... let's not fight ... although some may say i should be upset with someone trying to incite me with remarks directed directly at me ... no apologies need ... my feelings are not easily hurt

Earthdawg brings up points ... all of which have merrit ...

that being said, salaries and stark laws are not related and therefore really should not be discussed in the sam setting ... stark laws are in relation to the buisness of medicine (what you own or have relationships with ... MRI, PT/OT)

patient care and salaries/reimbursement it discussed together you really tread on thin ice ... understand there are a lot of physician practices that limit their patient practice based on your insurance ... i.e. will not take medicaid, or lesser insurances ... is this done in the patients best intrest? .... patients with treatable condition by any competent orthopaedic surgeon that are refered away because of insurance ...

insurance payments ... well that is a discussion unto itself ...

well i got to run ... another knee pain patient to see ...

now everyone play nice

I think my biggest problem is with the "gen Y" comment. I feel it is the older physicians who have sold out the younger ones by chosing to have PAs and NPs in their practices instead of hiring a new partner in order to keep their salary high. This has occurred in all fields and now these groups are saying "we don't need physician supervision because we have been doing it by ourselves for a while." Physicians are about to lose all primary care and soon I am sure other groups will start encroaching on surgery. The respect of the physician has steadily been decreasing and this cannot be blamed on those that are just now coming into the field.

Staff,

I am not trying to encite you. I don't know anything about you. You may work 27 hours a day, eat Ramon noodles for dinner and live in a cardboard box for all I know. My comments about "holier than thou" physicians were about older physicians in general who criticize younger physicians about caring about money (hence the phrase, "while not always the case") and not necessarily about you.

It is my understanding that STARK laws also apply to how much a hospital is allowed to offer a physician in relation to standard income. Even if a hospital has a tremendous need for a physician, they are not allowed to offer over 75th percentile or 90th percentile, etc without raising STARK violation concerns. IE, if the hospital pays an unreasonbly high salary, they are guilty of offering a "kick back" in return for the physician's cases, and are therefore in violation. I am far from an expert, but I believe it does apply at least for employed physicians.

In response to your assertion that refusal of patients with medicaid is not in the patient's best interest - of COURSE it is not in the patient's best interest. But with whom does the fault lie? Is it with the physician, who in some cases doesn't even break even after paying their overhead when seeing those cases, or with those in control of deciding how much to reimburse for those cases. I personally accept any patient coming through my door, refuse no medicaid, and see a large number of uninsured in my practice, but at some point, let's say medicaid cuts reimbursement to the point that they are 50% or even 25% of what they are now, then it will be impossible to continue to see those patients and even earn a living. Even fewer physicians will be able (or willing, whatever the case) to accept medicaid. Why is it always the "greedy physician" who is to blame and not the insurance companies or politicians. The amount of the total Medicare budget spent on physician reimbursement is about 5%. So even if Medicare decided that physicians should work for free, only 5% would be saved. So why do physician reimburesent rates for Medicare continue to fall? Because physicians have allowed it.

I agree with most of what you say. It IS sad that specialties and subspecialties are chosen with financial concerns in mind, but I believe that is a result of declining reimbursement across the board, rendering pediatrics and FP less desireable. Physicians, like other sectors of society, are human, and are driven by incentive. It is unrealistic to expect them to behave otherwise. Is it ideal? No. Are there exceptions? Yes, and you sound like one of them, but most physicians have at least one eye on the bottom line, and that doesn't make them any less devoted to patient care.

By the way, my last post should have ended with, "You can insult me all you want on an anonymous message board, but it doesn't change the fact that CONSIDERING financial issues in medicine is not only appropriate, but necessary."

So I have been reading this post for a while and decided to ask the simple question....does anyone really know just how much a successful orthopod takes home? How about an average orthopod?

I have only heard rumors....and trust me, if money was the #1 reason I was going into ortho, then I would feel awful stupid right about now....do the math people......not too many stock brokers are getting up at 430 am everyday to work a 16 hour day for 5 years at about $8/hour.....you gotta love it to do it.....

oh i love a good debate ...

first i would like to put out there that i am of the opinion (i know and everyone has one) tha money is always a factor in a practice ... i feel tha medicine in general has taken a huge hit ... now most of you in the forum are in madicine, so you come into it understanding that ... therefore your chioce of practice then should be based on what you feel best suites you ... the money side initially should not be as much a factor ... other specialties that do well are derm, radiology, anethesia (an great life style and income), cardiology .... question is will these ultimately make you proud of what you do .... or do you feel like trump working for the dollar ... this is a personal issue ....

second to give Doctor Sawbonz some information

there are diferent practice agreements (single specialty group, multi-specialty group, solo practice, hospitalist, academic) .... depending on location, specialty, and incentive the average is between 200-400 ... the thing that is hard to figure in is it will go up or down based on your practice payor mix, how hard you work, and the bonus structure with in your group .... i will speak for most practices (private) .... when you are going into a practice this is a system of determining your overhead (either on a percentage or flat fee) ..... your overead includes clinic/office space, malpractice, supplies, nurse, pa/np, secratary .... therefore depending on your practice these number may very ... i will put numbers on this .... my sports friends overhead ranges from $20-30,000/month on average .... he also has a nice office with all the trimmings ....

third to dr. eathdawg ... the enciting comment just comes because you put the "I will NOT apologize to "Staff" and others like him or her" ... that's all ... i got much love for you brother ...

stark laws ... hmmmm

The Stark statute applies only to physicians who refer Medicare and Medicaid patients for specific services ("designated health services," or DHS) to entities with which they (or an immediate family member) have a "financial relationship." The lists of designated health services and financial relationships addressed by the statute are extraordinarily broad. To ensure you're not violating Stark, you must evaluate any economic benefits you receive from entities to which you refer Medicare and Medicaid patients to determine whether they meet any of the almost 20 detailed and complicated "exceptions" described in the statute.

THE EXCEPTIONS
The almost 20 exceptions to the Stark statute address many different types of referrals, including the following:

- To other physicians in the group,
- For in-office ancillary services,
- Within prepaid health plans,
- To entities in which the physician is invested (including publicly traded entities, hospitals in Puerto Rico, rural providers and a hospital itself).

The statute also describes some other exceptions, such as when financial relationships include the following:

- Rental of office space and equipment,
- Bona fide employment relationships,
- Personal services arrangements,
- Physician recruitment.


i am not sure why you have problems recruiting a trama doc ... we are fortunate ... we have 7 in our group ...

as far as the reimbusement issue, that is anothere subject that we can speek at length about .... i would whole heartedly agree with the problems with reimbursement the system medicaid (state) and medicare (federal) ... we as physicians need to be more vocal ... the AAOS has been very vocal in the recent years .... more needs to be done ...

you all rock ... orthopods rule ... thanks for putting up with my statement against Gen Y ... i am Gen X ... may be i'm just jealous ... i didn't get my PS3 for christmas ... so now i am saving up (i am a lowly pedipod)

Good, I think we are starting to find some common middle ground here.

We all have to understand your organizational structure before knowing how STARK applies to you in particular. So let's move on from that, hopefully with the common ground that it is a good thing that physicians are no longer able (theoretically) to increase their incomes by modifying their referral patterns. I think we can all agree that what is truly sad here is that this was required in the first place! But as you say, humans respond to incentives. It is unfortunate that the AMA, among others, tried to perpetuate the idea of the infallible physician for so long.

On the topic of Medicare expenditures decreasing...this is such a monster of an issue, with so many factors to consider it isn't funny. By the way, I believe teachers also often face decreases in their earning power (I believe 40 of the 50 states last year didn't keep up with inflation). None of us are smart enough to completely understand Medicare (if that were even possible). But many of its modifications over the years have been targeted at physicians who (consciously or not) game the system in their favor. They had to create DRGs and Fraud and Abuse programs to name a couple. Again, hopefully we can agree that it is sad that as "professional" "scientists", we created a "product" that simply hasn't fared that well in retrospect. Albeit there are some great examples of healthcare improving the lives of its patients, there are just as many examples of it failing to do what it intended. Much has been written about variations in practice patterns based on geography and the density of physician services in a given area. Yet more and more justification for society to view physicians not as god-like infallible "professionals", but, just as EarthDawg indicated, humans responding to incentives. I believe that in the big picture of the history of medicare, it makes sense that they are reducing the money going to physicians simply because they are realizing that they have been overcompensated in the past (or at least took advantage of the system).

Now, the challenge, as you suggested and I agree, is to find the correct levels, of both physician reimbursement and the number of physicians. Many well-educated, decent individuals believe there is no shortage whatsoever of any kind of physicians. Perhaps you don't need an OB-GYN doctor within 3 hours? You might think that statement is ridiculous, but just bear with me in my hypothetical scenario. Consider, society is in many ways making that decision by allowing it to happen. Midwives can fill the gap and manage the overwhelming majority of uncomplicated pregnancies for a much lower cost. Perhaps rather than interpreting this with emotional outrage, we can see that society is telling us something. Namely, I interpret this that society is saying it is better off to pay less and to have the overwhelming majority of pregnancies handled just fine, while making those unfortunate ones who need an OB doctor travel 3 hours. At some point in the continuum, we (society) have to make a choice, we must weigh the costs and benefits.

So why shouldn't it be like this. PAs and NPs? If they can provide services with equivalent outcomes to that of an FP trained doc, then who cares about their education? Isn't it BETTER OFF FOR THE PATIENTS, because now more money can be spent elsewhere, whether on a new hip for grandpa, better education for little susie, or a 3rd SUV for the family?

We are brushing on what I consider to be some very complex issues. If we truly hope to learn anything and educate others in this forum, then we need to reduce the emotion in our posts and try to boil the arguments down to what we are really saying (rather than tackling multiple topics in one post and claiming patient care as the ends that any means must achieve). So I am trying that now (with the caveat that I am open to modifications of my arguments for the sake of my own education).

I certainly agree that financial concerns are worth considering, I'm pretty sure that is a given. However, I also know relatively where I stand on the supply and demand curve for orthopods. I know that we are far, far from a level where I would pack my bags for D.C., but that point will come at different times for us all. If you feel the value of your services is greater than what you are being compensated, then you can:

A. Reconsider your analysis by realizing the positive externalities of being an orthopaedist are just as important, if not more so, than the wages you earn.
B. Lobby for higher wages (or try to push to unionize orthopods so that we can collectively demand higher wages)
C. Take your valuable self elsewhere (other country?, other industry?)

If you consider yourself more valuable than the "average" orthopaedist does, then you will be frustrated by a lack of effort by your colleagues on this topic. Not until the "average" orthopod is undervalued will we, as a whole, create and see changes in our "favor". If no one can hire a traumatologist at your place (or say, the entire country), then supply will rise, prices will fall, and dynamic equilibrium will be achieved.

OK, I am done for today. This is kinda fun, but for the amount of energy we are putting into some of our posts, we should try to at least get something out and recognize when we are wasting energy in some of our arguments.

I am also stuck needing to upgrade from my Super Nintendo. Any suggestions? I hear those last few months of 4th year are a great time to get your gaming back on.

you must have a freakin huge group then, since only about 25-35 people in the whole country do trauma fellowships each year in the US. Compare that to deluge of spine and sports people each year and it is easy to see why some places just cant find a trauma guy. Peds guys are just or more uncommon these days too...

our group isn't that large but we do have an excellent trauma service ... known by some as the "Detroit Mafia" ... although we are not in detroit ...

ahhh .... i got a slow scoli clinic ... it is the slow season ...