US Residency Competitiveness, Future Salary, and Burnout in Primary Care vs Specialty Fields

We previously found a strong association between the competitiveness of a specialty (as measured by the “fill rate,” the percentage of residency spots filled by US graduates) and physician salary.^1,2 These findings, along with others, underlie efforts to encourage medical students into primary care specialties (family medicine, general internal medicine, and general pediatrics), which tend to be less rewarding financially. At the same time, physician burnout has risen in recent years, with more than half of US physicians now experiencing at least 1 symptom of professional burnout.³ In this study, we sought to identify the recent trends in the association between specialty competitiveness and salaries in 2015, and to also examine the association between lifestyle factors and selection of a primary care field.

Residency data, including the number of available positions, number of US and foreign applicants, and number of spots filled, was gathered from the National Residency Match Program for 2014.⁴ Median specialty salary data was obtained from the Medical Group Management Association for 2015.⁵ Burnout and lifestyle factor data were obtained from the Medscape Lifestyle Report³ 2016, which collected 15 800 physician responses to questions regarding burnout and bias in their respective fields; and the Careers in Medicine webpage from the American Association of Medical Colleges.⁶ Correlation coefficients (r) were calculated using SPSS Statistics software (SPSS Inc, version 23.0).

We found a strong positive correlation between the competitiveness of US residency spots and median specialty salary (r = 0.71) (Figure). Analyzing the data by salary quartile, to minimize specialty specific variation, increased the strength of the correlation (r = 0.97), which is unchanged from 1989. Primary care specialties had lower mean salaries than nonprimary care specialties ($228 684 vs $413 915) and lower rates of competitiveness (53% vs 73%); the 3 lowest earning specialties were the primary care fields. Of all specialties, family medicine had the lowest median salary ($221 419) and competitiveness (43%); neurosurgery had the highest median salary ($747 066); and otorhinolaryngology had the highest competitiveness (94%), despite a salary near the mean for all physicians. Lifestyle factors were found to have a weak, but positive correlation with specialty competitiveness, as determined by the following measures: severity of burnout (r = 0.13); presence of bias toward patients (r = 0.37); happiness at work (r = 0.19); happiness outside of work (r = 0.45); hours worked per week (r = 0.18); and the sum of happiness at and outside of work (r = 0.34). A negative correlation between presence of burnout and specialty competitiveness was also observed (r = −0.16) (Table).

Since 1989, despite efforts to increase primary care residency applications, the association between specialty competitiveness and salary quartile remains unchanged, suggesting that the general influence of salaries on applicants has remained stable. However, the association between specialty competitiveness and individual salaries has decreased (r = 0.85 [1989], r = 0.82 [2008], r = 0.71 [2015]), perhaps owing to the consideration by applicants of “lifestyle factors” unique to a specialty, as borne out by the associations between burnout/bias and competitiveness. Since our original analysis¹ in 1989, the ratio of specialty to primary care competitiveness has risen from 1.15 to 1.39, while the ratio of average specialty salary to primary care salary has risen from 1.63 to 1.81. The divergence is clear: nonprimary care fields are now nearly 1.5 times as competitive as primary care specialties, while primary care specialties have roughly half as much earning potential. These results may suggest that primary care fields attract fewer US medical students owing to their comparatively low salaries and high rates of burnout and bias. Policy makers would be well served to understand these forces to encourage increased commitment to primary care specialties.

Corresponding Author: David A. Faber, University of Miami Miller School of Medicine, 1600 NW 10 Avenue, Miami, FL 33136 (dfaber@med.miami.edu).

Published Online: August 15, 2016. doi:10.1001/jamainternmed.2016.4642

Author Contributions: Mr Faber had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Faber, Joshi.

Acquisition, analysis, or interpretation of data: Faber, Ebell.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Joshi, Ebell

Statistical analysis: All authors.

Administrative, technical, or material support: Joshi.

Study supervision: Joshi, Ebell.

Conflict of Interest Disclosures: None reported.