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First employment characteristics for the 2011 pediatric surgery fellowship graduates
Journal of Pediatric Surgery (2013) 48, 99–103
www.elsevier.com/locate/jpedsurg
First employment characteristics for the 2011 pediatric surgery fellowship graduates Charles J.H. Stolar, Gudrun Aspelund ⁎ Columbia University, Division of Pediatric Surgery, College of Physicians and Surgeons, Morgan Stanley Children's Hospital/ Columbia University Medical Center, New York City, NY 10032, USA Received 25 September 2012; accepted 13 October 2012
Key words: Pediatric surgery; Contract negotiations; Benefit package; Compensation; Career choice; Employment
Abstract Purpose: Information regarding initial employment of graduating pediatric surgery fellows is limited. More complete data could yield benchmarks of initial career environment. Methods: An anonymous survey was distributed in 2011 to 41 pediatric surgery graduates from all ACGME training programs interrogating details of initial positions and demographics. Results: Thirty-seven of 41 (90%) fellows responded. Male to female ratio was equal. Graduates carried a median debt of $220,000 (range: $0–$850,000). The majority of fellows were married with children. 70% were university/hospital employees, and 68% were unaware of a business plan. Median starting compensation was $354,500 (range: $140,000–$506,000). Starting salary was greatest for N90% clinical obligation appointments (median $427,500 vs. $310,000; p = 0.002), independent of geographic location. Compensation had no relationship to private practice vs. hospital/university/military position, coastal vs. inland location, and practice sites number. Median clinical time was 75% and research time 10%. 49% identified a formal mentor. Graduates covered 1–5 different offices (median 1) and 1–5 surgery sites (median 2). 60% were satisfied with their compensation. Conclusion: Recent pediatric surgery graduates are engaged mainly in clinical care. Research is not incentivized. Compensation is driven by clinical obligations. Graduates have limited knowledge of the business plan supporting their compensation, nature of malpractice coverage, and commitments to resources including research. Graduates have important fiscal and parenting obligations. © 2013 Elsevier Inc. All rights reserved.
Because graduating pediatric surgery fellows are a scarce commodity whose demand exceeds supply, intense efforts are made to fashion attractive recruitment packages. These ⁎ Corresponding author. Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA. Tel.: +1 212 342 8585; fax: +1 212 305 9270. E-mail address: [email protected] (G. Aspelund). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.10.024
discussions are often uninformed negotiations between the graduating fellows and a prospective employer. Importantly, little is known, in aggregate, about the nature of the initial positions accepted. Limited information is available in data bases that are generally devoid of validation or audit and therefore possibly biased by employers' selfreporting. These data bases offer no information other than total compensation but are often used for guidelines for initial and subsequent compensation.
100
C.J.H. Stolar, G. Aspelund
Scant information is published regarding what an initial employment agreement entails beyond salary. There is similarly scant information regarding the circumstances under which graduating fellows enter their first employment as practicing pediatric surgeons. Consequently, we asked if a more comprehensive observational data set collected from the graduating pediatric surgery fellows in a single year could offer testable measures of the initial career negotiations and if these measures could offer generalizable characterization of initial career opportunities for graduating fellows.
An anonymous 31 element questionnaire was developed interrogating demographics, business plan details, compensation, fringe benefits, malpractice coverage, laboratory/ clinical research resource commitments, mentoring, time allocation, quality of work life, satisfaction with business plan, parenting obligations, and debt load on completion of fellowship. We also queried expectations regarding time allotment for clinical and non-clinical activities. The questionnaire was offered to all 41 fellows graduating 6/ 30/2011 and returned without identifiers of any sort. The graduating fellows were identified from the master roster of trainees maintained by the Association of Pediatric Surgery Program Directors. Data points were collated through Microsoft Excel (Microsoft, Redmond, WA) and analyzed for significance. Results are reported as a median and range.
Demographics (N=37).
Gender Male, n (%) Female, n (%) No answer, n (%) Marital status Married, n (%) Single, n (%) “Coupled”, n (%) No answer, n (%) Children Yes, n (%) No, n (%) No answer, n (%) Number, median (range) Race/Ethnicity Caucasian, n (%) Asian, n (%) Hispanic, n (%) Middle Eastern, n (%) African-American, n (%) Other, n (%) No answer, n (%)
Type of position (N=37).
University employee Hospital employee HMO employee Private practice group Military obligation Other No answer
n (%) 15 (40) 11 (30) 0 4 (11) 3 (8) 2 (5) 2 (5)
Descriptive analysis and nonparametric tests were performed with PASW Statistics 18.0 (IBM Corporation, Armonk, NY) and pb0.05 was considered significant.
1. Methods
Table 1
Table 2
2. Results Thirty-seven of 41 graduating fellows (90%) returned completed questionnaires. Despite reminders 4 did not respond. The demographics of the group are reported in Table 1. Seventy percent were university or hospital employed, 11% were in private practice (Table 2). Graduates carried a median total debt load of $220,000 (range $0– $850,000). There was no correlation between starting salary and total debt load at completion of fellowship (Spearman's rho, r=0.064). Sixty eight percent (68%) were either unaware (15/37) of or denied (10/37) that a business plan had been developed unique to their employment (2/37 did not answer). Of the 10 that acknowledged familiarity with a business plan, 8 actually had a copy of the plan. Duration of initial agreement was a median of 3 years (range: 1–8 years) with a median starting total compensation of $354,500 (range: $140,000–$506,000). At 3 years
18 (49) 17 (46) 2 (5) 26 (70) 8 (22) 2 (5) 1 (3) 22 (59) 12 (32) 3 (8) 2 (0-4) 23 (62) 8 (22) 2 (5) 1 (3) 0 1 (3%) 2 (5)
Fig. 1 Median salary for appointments with more or less than 90% clinical obligations.
Employment characteristics of pediatric surgery graduates
101 difference between compensation in hospital/university setting (n=24) vs. private practice (n=5) ($359,000 range: $250,000–506,000 vs. $380,000 range: $180,000–495,000). Fringe benefits negotiated are shown in Table 3; expenses of health, life and disability insurance were often shared however for over 90% (34/37) employers paid for malpractice insurance. Most graduates (19/37, 51%) were not aware of type of their malpractice coverage but 16% (n=6) had “occurrence-made” benefits and 24% (n=9) had “claimsmade” with tail; 3 did not answer. Responsibility for the tail coverage was not queried. The majority (33/37, 89%) did not know their annual malpractice premium. Only 6 graduates completely detailed resource commitments, suggesting limited understanding, and making any meaningful interpretation impossible. A formal mentor was identified for 49% (n=18) of graduates. Only 60% thought they had negotiated a satisfactory compensation package.
Fig. 2
Distribution of total starting salary.
total annual salary should increase to a median $375,000 (range: $148,198–$600,000) according to the initial agreement. Starting salary was greatest for N90% clinical obligation appointments (median $427,500, range: $366,000–$506,000 vs. $310,000, range: $140,000– $445,000; p = 0.001) (Fig. 1). Starting salary was not significantly higher on the coasts (salary on coasts median $365,500, range: $140,000–$506,000 vs. in-land $325,000, range: $240,000–$450,000; p = 0.7). Three respondents did not know their total starting salary, 2 did not reveal salary and 1 did not give location of appointment. Fig. 2 shows distribution of initial total compensation. Median professional time allocated to clinical practice was 75% (range: 0%–100%). Median professional time allocated to research was 10% (range: 0%–80%). Graduates covered range of 1–5 different office sites (median 1) and 1– 5 surgery sites (median 2) independent of geographic location, on a coast or in-land. There was no significant
Table 3
3. Discussion Fellowship training programs and prospective employers inconsistently, if at all, educate their trainees/employees regarding the business structure of the employment opportunities. Most graduates have a limited understanding and are uneducated regarding how their compensation is generated, their responsibilities in this regard, the supporting business plan, their job description, the nature of their malpractice insurance, and commitments to mentoring and investigative support. Current pediatric surgery curricula as adopted by the Association of Pediatric Surgery Training Program Directors and the Residency Review Commission of the American Council on Graduate Medical Education make no mandate for education in these domains. The American Board of Surgery does not consider this an area of core knowledge or competency in its certifying and qualifying process. Recent graduates generally enter their first employment with substantial debt load, spousal/partner obligations,
Fringe benefits (N=37).
Health insurance Disability insurance Life insurance Malpractice insurance Tuition support Retirement account Rent (office, clinic) Auto expenses Secretary/Staff Travel Dues, subscriptions
Self-pay n (%)
Employer pays n (%)
Shared expense n (%)
Don't know n (%)
No answer n (%)
2 (5) 2 (16) 2 (5) 0 5 (14) 3 (8) 0 25 (68) 0 3 (8) 3 (8)
18 (49) 15 (40) 14 (38) 34 (92) 12 (32) 9 (24) 36 (97) 3 (8) 36 (97) 24 (65) 23 (62)
17 (46) 14 (38) 14 (38) 2 (5) 6 (16) 21 (57) 0 4 (11) 0 8 (22) 7 (19)
0 1 (3) 7 (19) 1 (3) 10 (27) 4 (11) 1 (3) 4 (11) 1 (3) 2 (5) 4 (11)
0 1 (3) 0 0 4 (11) 0 0 1 (3) 0 0 0
102 and parenting responsibilities. Debt load reported in the current survey is consistent with accelerating trends reported by the AAMC published in 2009 for all recent medical school graduates regardless of specialty intentions [1]. The current fellows' debt load of median $220,000 (mean $246,055) is worrisome compared to the mean debt load of $51,200 reported for recent graduates in 2003 by Geiger et al. [2]. The details of the aggregate debt load and time-line to retirement of that load are unknown. Similarly it is not understood if employers are cognizant of the graduates' financial pressures. Graduating fellows seem generally unaware and uneducated in negotiating and understanding the terms of their initial employment. Employers may have a goal in mind for new employees and it should be incumbent on prospective employers, in order to establish a successful employee and secure return on investment that the employers understand and be sensitive to these obligations. This survey suggests the only motivation for enhanced compensation is the extent of clinical activity, especially if in excess of 90% of work time. Geographic location and number of practice sites did not seem to be associated with compensation. Despite the conventional wisdom that successful pediatric surgery fellowship applicants are required to engage in some sort of investigative activity before application, this is not rewarded or encouraged by compensation schemes on first employment. Moreover, it is not clear that renewable resources and reasonable clinical obligations are regularly encumbered to allow young faculty an environment in which to succeed. This view is enhanced by the data from Stolar et al. which indicated b10% of all revenues accruing to university pediatric surgery sections was spent on the direct expenses of laboratory investigation by faculty members [3]. Said another way, the spoken desire to develop new knowledge is overwhelmed by the imperative to generate new revenue and limit costs. The very limited data sets from the American Association of Medical Colleges (2010–2011) Report on Medical School Faculty Salary, unique to pediatric surgery for young faculty at the assistant professor rank (n=135) report a median total compensation of $345,000 with 25%tle= $283,000 and 75%tle = $422,000 [4]. The 2011 summary reports for pediatric surgery from the Medical Group Management Association reported all academic ranks as a single cohort (n=42) with 67% defined clinical activity and no expenses deducted from compensation as a mean compensation of $342,000±$80,000 as compared to private practice compensation (n=55) with 100% clinical activity and unknown expenses deducted from compensation as mean $468,000± $172,000 [5]. The median compensation reported in this cohort for university/hospital employed young pediatric surgeons at entry ranks ($337,500) was similar to the mean compensation reported by AAMC ($345,000) and MGMA for all ranks ($342,000). The median compensation for recent graduates in this cohort entering private practice was $380,000 but few
C.J.H. Stolar, G. Aspelund graduates in our cohort entered private practice; the median private practice compensation reported by MGMA was $468,000 but this value did not consider years of experience or seniority or expenses against compensation. It remains unclear whether the conventional wisdom that private practice is more lucrative than university/hospital practice is valid. Going forward it will be of value to obtain serial data sets on this cohort as they mature in their pediatric surgery careers.
References [1] AAMC graduate questionnaire, 2009. [2] Geiger JD, Drogowski RA, Coran AG. The market for pediatric surgeons: an updated survey of recent graduates. J Pediatr Surg 2003;38:397-405. [3] Stolar CJ, Alapan AA, Torres SA. Pediatric surgery—benchmarking performance. J Pediatr Surg 2010;45:265-8. [4] American Association of Medical Colleges. Report on medical school faculty salary/summary reports, 2010–2011. [5] Medical group management association, summary report, 2011.
Discussion “First Employment Characteristics for the 2011 Pediatric Surgery Fellowship Graduates.” Presented by Charles H. Stolar, M.D., New York, NY. Discussant: Arnold Coran, M.D., (Ann Arbor, MI): I would like to thank Dr. Stolar for asking me to discuss this paper and congratulate him on presenting this important data and interesting data. The study is actually a followup of the report by Jim Geiger in 2003 and presented before this organization. Most of the information presented is not surprising. Of interest is the fact that the salaries significantly increased from the 2003 report in spite of the fact that we have gone through a significant recession in this country in 2008 and have not yet recovered from this economic disaster. I wonder if Dr. Stolar has any insight into the significant fiscal discrepancy. Is it driven solely by demand? My observations over the past many years have been that finishing pediatric surgery residents pursuing their first job usually consider two aspects of a new position, both being of equal importance. First lifestyle which includes location in the country, its implications such as schools, cost of living, intellectual environment for themselves and their families, and second professional issues such as work hours, salary, professional colleagues, and last but not least professional growth in the new position. This last point includes research opportunities but for most finishing residents it revolves around the development enhancement of their clinical and surgical skills by being exposed to and involved in a significant variety and volume of index
Employment characteristics of pediatric surgery graduates cases. In the 2003 survey, the fact that 79% of the finishing residents wanted a job in a university children’s hospital supported this premise because the perception has always been that the best exposure to this volume of complex clinical activity is at a university children’s hospital. I believe this has been the case until recently, specifically until the last 5-10 years during which time the paradigm has continued to significantly change resulting in the fact that at the university hospitals significant subspecialization with the development of silos of excellence has changed the opportunity to be exposed to a wide variety of complex cases. Thus, the opportunity to be a broad-based pediatric surgeon - “the true general surgeon” – may be gone. In your manuscript you mention that you measured the quality of work life. In the return surveys, did you receive any comments relating to this important issue? Response: DR. STOLAR: Your first question was about why salaries are increasing despite the economic times. This of course is multifactorial. Partly because we are increasingly recognizing the leverage we as a scarce commodity are able to exercise. You may remember the paper we presented in 2010 where we learned that one FTE of a pediatric surgeon’s worth is about $7.5 million in collectibles to a children’s hospital per FTE. Understanding our central role in the lifeblood of a children’s hospital is a chance to exercise that leverage and I suspect that has some role in the enhancement of how pediatric surgeons are compensated. The other factor in play is the increasing awareness that – I always like to think this is a business, we sell what we can do with our head and our hands and that is our commodity and hospitals sell beds and a children’s hospital realizes that the most lucrative bed they have is a newborn bed and you cannot have a highend newborn facility without several pediatric surgeons. For the hospital to get return on investment they need to have people like us. This may be related to the dilution of the experience in less regionalized environments perhaps but certainly hospitals are realizing that children’s surgery is essential to their lifeblood and children’s surgeons are now learning to exercise that leverage. In regard to the quality of life issue, one thing I really hope to do is to continue to follow this cohort on an
103 annual basis and report back to the association in another 2-3 years of what that quality of life has actually turned out to be because what you think your life as a pediatric surgeon is going to be bears probably zero relationship to what it turns out to be. I look forward to sharing that information about what that quality turns out to be. In the manuscript we asked “are you satisfied or unsatisfied with the package that you negotiated” and only 60% were satisfied before day one of their job, so that is disconcerting. Discussant: Mary Brandt, M.D., (Houston, Texas): First of all, thank you,there is nothing like data to dispel myths and I think that is very important. I have a question and a comment.The question is are you planning to repeat this with new graduates in the future as well? Are you going to continue the study? Response: DR. STOLAR: The answer is, assuming that David Powell invites me back to Washington this year, I can get away from my new kind of job for that 48 hours, and that is another discussion. The answer is yes. As I said, I would like to follow this cohort on an annual basis and report back. Discussant: DR. BRANDT: The other brief comment is something that has happened at this meeting that we have started working on which is the annual residents meeting which is at the AAP but sponsored by the program directors institutions. We have started discussing a curriculum for that meeting, and I think you basically just outlined our curriculum of what needs to happen, so Marjorie Arca is going to be leading that effort through one of the new committees we created in the AAP along with Max Langham and the program directors. That is really more informational but perhaps also a group that could help you with the future study as well. Response: DR. STOLAR: I want to thank you for that comment because one of my rants is that we as surgical educators fail to educate our trainees in how to look for a job. We generally fail, and these kinds of data –and their lack of sophistication is our failing in teaching them what to look for.
www.elsevier.com/locate/jpedsurg
First employment characteristics for the 2011 pediatric surgery fellowship graduates Charles J.H. Stolar, Gudrun Aspelund ⁎ Columbia University, Division of Pediatric Surgery, College of Physicians and Surgeons, Morgan Stanley Children's Hospital/ Columbia University Medical Center, New York City, NY 10032, USA Received 25 September 2012; accepted 13 October 2012
Key words: Pediatric surgery; Contract negotiations; Benefit package; Compensation; Career choice; Employment
Abstract Purpose: Information regarding initial employment of graduating pediatric surgery fellows is limited. More complete data could yield benchmarks of initial career environment. Methods: An anonymous survey was distributed in 2011 to 41 pediatric surgery graduates from all ACGME training programs interrogating details of initial positions and demographics. Results: Thirty-seven of 41 (90%) fellows responded. Male to female ratio was equal. Graduates carried a median debt of $220,000 (range: $0–$850,000). The majority of fellows were married with children. 70% were university/hospital employees, and 68% were unaware of a business plan. Median starting compensation was $354,500 (range: $140,000–$506,000). Starting salary was greatest for N90% clinical obligation appointments (median $427,500 vs. $310,000; p = 0.002), independent of geographic location. Compensation had no relationship to private practice vs. hospital/university/military position, coastal vs. inland location, and practice sites number. Median clinical time was 75% and research time 10%. 49% identified a formal mentor. Graduates covered 1–5 different offices (median 1) and 1–5 surgery sites (median 2). 60% were satisfied with their compensation. Conclusion: Recent pediatric surgery graduates are engaged mainly in clinical care. Research is not incentivized. Compensation is driven by clinical obligations. Graduates have limited knowledge of the business plan supporting their compensation, nature of malpractice coverage, and commitments to resources including research. Graduates have important fiscal and parenting obligations. © 2013 Elsevier Inc. All rights reserved.
Because graduating pediatric surgery fellows are a scarce commodity whose demand exceeds supply, intense efforts are made to fashion attractive recruitment packages. These ⁎ Corresponding author. Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA. Tel.: +1 212 342 8585; fax: +1 212 305 9270. E-mail address: [email protected] (G. Aspelund). 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.10.024
discussions are often uninformed negotiations between the graduating fellows and a prospective employer. Importantly, little is known, in aggregate, about the nature of the initial positions accepted. Limited information is available in data bases that are generally devoid of validation or audit and therefore possibly biased by employers' selfreporting. These data bases offer no information other than total compensation but are often used for guidelines for initial and subsequent compensation.
100
C.J.H. Stolar, G. Aspelund
Scant information is published regarding what an initial employment agreement entails beyond salary. There is similarly scant information regarding the circumstances under which graduating fellows enter their first employment as practicing pediatric surgeons. Consequently, we asked if a more comprehensive observational data set collected from the graduating pediatric surgery fellows in a single year could offer testable measures of the initial career negotiations and if these measures could offer generalizable characterization of initial career opportunities for graduating fellows.
An anonymous 31 element questionnaire was developed interrogating demographics, business plan details, compensation, fringe benefits, malpractice coverage, laboratory/ clinical research resource commitments, mentoring, time allocation, quality of work life, satisfaction with business plan, parenting obligations, and debt load on completion of fellowship. We also queried expectations regarding time allotment for clinical and non-clinical activities. The questionnaire was offered to all 41 fellows graduating 6/ 30/2011 and returned without identifiers of any sort. The graduating fellows were identified from the master roster of trainees maintained by the Association of Pediatric Surgery Program Directors. Data points were collated through Microsoft Excel (Microsoft, Redmond, WA) and analyzed for significance. Results are reported as a median and range.
Demographics (N=37).
Gender Male, n (%) Female, n (%) No answer, n (%) Marital status Married, n (%) Single, n (%) “Coupled”, n (%) No answer, n (%) Children Yes, n (%) No, n (%) No answer, n (%) Number, median (range) Race/Ethnicity Caucasian, n (%) Asian, n (%) Hispanic, n (%) Middle Eastern, n (%) African-American, n (%) Other, n (%) No answer, n (%)
Type of position (N=37).
University employee Hospital employee HMO employee Private practice group Military obligation Other No answer
n (%) 15 (40) 11 (30) 0 4 (11) 3 (8) 2 (5) 2 (5)
Descriptive analysis and nonparametric tests were performed with PASW Statistics 18.0 (IBM Corporation, Armonk, NY) and pb0.05 was considered significant.
1. Methods
Table 1
Table 2
2. Results Thirty-seven of 41 graduating fellows (90%) returned completed questionnaires. Despite reminders 4 did not respond. The demographics of the group are reported in Table 1. Seventy percent were university or hospital employed, 11% were in private practice (Table 2). Graduates carried a median total debt load of $220,000 (range $0– $850,000). There was no correlation between starting salary and total debt load at completion of fellowship (Spearman's rho, r=0.064). Sixty eight percent (68%) were either unaware (15/37) of or denied (10/37) that a business plan had been developed unique to their employment (2/37 did not answer). Of the 10 that acknowledged familiarity with a business plan, 8 actually had a copy of the plan. Duration of initial agreement was a median of 3 years (range: 1–8 years) with a median starting total compensation of $354,500 (range: $140,000–$506,000). At 3 years
18 (49) 17 (46) 2 (5) 26 (70) 8 (22) 2 (5) 1 (3) 22 (59) 12 (32) 3 (8) 2 (0-4) 23 (62) 8 (22) 2 (5) 1 (3) 0 1 (3%) 2 (5)
Fig. 1 Median salary for appointments with more or less than 90% clinical obligations.
Employment characteristics of pediatric surgery graduates
101 difference between compensation in hospital/university setting (n=24) vs. private practice (n=5) ($359,000 range: $250,000–506,000 vs. $380,000 range: $180,000–495,000). Fringe benefits negotiated are shown in Table 3; expenses of health, life and disability insurance were often shared however for over 90% (34/37) employers paid for malpractice insurance. Most graduates (19/37, 51%) were not aware of type of their malpractice coverage but 16% (n=6) had “occurrence-made” benefits and 24% (n=9) had “claimsmade” with tail; 3 did not answer. Responsibility for the tail coverage was not queried. The majority (33/37, 89%) did not know their annual malpractice premium. Only 6 graduates completely detailed resource commitments, suggesting limited understanding, and making any meaningful interpretation impossible. A formal mentor was identified for 49% (n=18) of graduates. Only 60% thought they had negotiated a satisfactory compensation package.
Fig. 2
Distribution of total starting salary.
total annual salary should increase to a median $375,000 (range: $148,198–$600,000) according to the initial agreement. Starting salary was greatest for N90% clinical obligation appointments (median $427,500, range: $366,000–$506,000 vs. $310,000, range: $140,000– $445,000; p = 0.001) (Fig. 1). Starting salary was not significantly higher on the coasts (salary on coasts median $365,500, range: $140,000–$506,000 vs. in-land $325,000, range: $240,000–$450,000; p = 0.7). Three respondents did not know their total starting salary, 2 did not reveal salary and 1 did not give location of appointment. Fig. 2 shows distribution of initial total compensation. Median professional time allocated to clinical practice was 75% (range: 0%–100%). Median professional time allocated to research was 10% (range: 0%–80%). Graduates covered range of 1–5 different office sites (median 1) and 1– 5 surgery sites (median 2) independent of geographic location, on a coast or in-land. There was no significant
Table 3
3. Discussion Fellowship training programs and prospective employers inconsistently, if at all, educate their trainees/employees regarding the business structure of the employment opportunities. Most graduates have a limited understanding and are uneducated regarding how their compensation is generated, their responsibilities in this regard, the supporting business plan, their job description, the nature of their malpractice insurance, and commitments to mentoring and investigative support. Current pediatric surgery curricula as adopted by the Association of Pediatric Surgery Training Program Directors and the Residency Review Commission of the American Council on Graduate Medical Education make no mandate for education in these domains. The American Board of Surgery does not consider this an area of core knowledge or competency in its certifying and qualifying process. Recent graduates generally enter their first employment with substantial debt load, spousal/partner obligations,
Fringe benefits (N=37).
Health insurance Disability insurance Life insurance Malpractice insurance Tuition support Retirement account Rent (office, clinic) Auto expenses Secretary/Staff Travel Dues, subscriptions
Self-pay n (%)
Employer pays n (%)
Shared expense n (%)
Don't know n (%)
No answer n (%)
2 (5) 2 (16) 2 (5) 0 5 (14) 3 (8) 0 25 (68) 0 3 (8) 3 (8)
18 (49) 15 (40) 14 (38) 34 (92) 12 (32) 9 (24) 36 (97) 3 (8) 36 (97) 24 (65) 23 (62)
17 (46) 14 (38) 14 (38) 2 (5) 6 (16) 21 (57) 0 4 (11) 0 8 (22) 7 (19)
0 1 (3) 7 (19) 1 (3) 10 (27) 4 (11) 1 (3) 4 (11) 1 (3) 2 (5) 4 (11)
0 1 (3) 0 0 4 (11) 0 0 1 (3) 0 0 0
102 and parenting responsibilities. Debt load reported in the current survey is consistent with accelerating trends reported by the AAMC published in 2009 for all recent medical school graduates regardless of specialty intentions [1]. The current fellows' debt load of median $220,000 (mean $246,055) is worrisome compared to the mean debt load of $51,200 reported for recent graduates in 2003 by Geiger et al. [2]. The details of the aggregate debt load and time-line to retirement of that load are unknown. Similarly it is not understood if employers are cognizant of the graduates' financial pressures. Graduating fellows seem generally unaware and uneducated in negotiating and understanding the terms of their initial employment. Employers may have a goal in mind for new employees and it should be incumbent on prospective employers, in order to establish a successful employee and secure return on investment that the employers understand and be sensitive to these obligations. This survey suggests the only motivation for enhanced compensation is the extent of clinical activity, especially if in excess of 90% of work time. Geographic location and number of practice sites did not seem to be associated with compensation. Despite the conventional wisdom that successful pediatric surgery fellowship applicants are required to engage in some sort of investigative activity before application, this is not rewarded or encouraged by compensation schemes on first employment. Moreover, it is not clear that renewable resources and reasonable clinical obligations are regularly encumbered to allow young faculty an environment in which to succeed. This view is enhanced by the data from Stolar et al. which indicated b10% of all revenues accruing to university pediatric surgery sections was spent on the direct expenses of laboratory investigation by faculty members [3]. Said another way, the spoken desire to develop new knowledge is overwhelmed by the imperative to generate new revenue and limit costs. The very limited data sets from the American Association of Medical Colleges (2010–2011) Report on Medical School Faculty Salary, unique to pediatric surgery for young faculty at the assistant professor rank (n=135) report a median total compensation of $345,000 with 25%tle= $283,000 and 75%tle = $422,000 [4]. The 2011 summary reports for pediatric surgery from the Medical Group Management Association reported all academic ranks as a single cohort (n=42) with 67% defined clinical activity and no expenses deducted from compensation as a mean compensation of $342,000±$80,000 as compared to private practice compensation (n=55) with 100% clinical activity and unknown expenses deducted from compensation as mean $468,000± $172,000 [5]. The median compensation reported in this cohort for university/hospital employed young pediatric surgeons at entry ranks ($337,500) was similar to the mean compensation reported by AAMC ($345,000) and MGMA for all ranks ($342,000). The median compensation for recent graduates in this cohort entering private practice was $380,000 but few
C.J.H. Stolar, G. Aspelund graduates in our cohort entered private practice; the median private practice compensation reported by MGMA was $468,000 but this value did not consider years of experience or seniority or expenses against compensation. It remains unclear whether the conventional wisdom that private practice is more lucrative than university/hospital practice is valid. Going forward it will be of value to obtain serial data sets on this cohort as they mature in their pediatric surgery careers.
References [1] AAMC graduate questionnaire, 2009. [2] Geiger JD, Drogowski RA, Coran AG. The market for pediatric surgeons: an updated survey of recent graduates. J Pediatr Surg 2003;38:397-405. [3] Stolar CJ, Alapan AA, Torres SA. Pediatric surgery—benchmarking performance. J Pediatr Surg 2010;45:265-8. [4] American Association of Medical Colleges. Report on medical school faculty salary/summary reports, 2010–2011. [5] Medical group management association, summary report, 2011.
Discussion “First Employment Characteristics for the 2011 Pediatric Surgery Fellowship Graduates.” Presented by Charles H. Stolar, M.D., New York, NY. Discussant: Arnold Coran, M.D., (Ann Arbor, MI): I would like to thank Dr. Stolar for asking me to discuss this paper and congratulate him on presenting this important data and interesting data. The study is actually a followup of the report by Jim Geiger in 2003 and presented before this organization. Most of the information presented is not surprising. Of interest is the fact that the salaries significantly increased from the 2003 report in spite of the fact that we have gone through a significant recession in this country in 2008 and have not yet recovered from this economic disaster. I wonder if Dr. Stolar has any insight into the significant fiscal discrepancy. Is it driven solely by demand? My observations over the past many years have been that finishing pediatric surgery residents pursuing their first job usually consider two aspects of a new position, both being of equal importance. First lifestyle which includes location in the country, its implications such as schools, cost of living, intellectual environment for themselves and their families, and second professional issues such as work hours, salary, professional colleagues, and last but not least professional growth in the new position. This last point includes research opportunities but for most finishing residents it revolves around the development enhancement of their clinical and surgical skills by being exposed to and involved in a significant variety and volume of index
Employment characteristics of pediatric surgery graduates cases. In the 2003 survey, the fact that 79% of the finishing residents wanted a job in a university children’s hospital supported this premise because the perception has always been that the best exposure to this volume of complex clinical activity is at a university children’s hospital. I believe this has been the case until recently, specifically until the last 5-10 years during which time the paradigm has continued to significantly change resulting in the fact that at the university hospitals significant subspecialization with the development of silos of excellence has changed the opportunity to be exposed to a wide variety of complex cases. Thus, the opportunity to be a broad-based pediatric surgeon - “the true general surgeon” – may be gone. In your manuscript you mention that you measured the quality of work life. In the return surveys, did you receive any comments relating to this important issue? Response: DR. STOLAR: Your first question was about why salaries are increasing despite the economic times. This of course is multifactorial. Partly because we are increasingly recognizing the leverage we as a scarce commodity are able to exercise. You may remember the paper we presented in 2010 where we learned that one FTE of a pediatric surgeon’s worth is about $7.5 million in collectibles to a children’s hospital per FTE. Understanding our central role in the lifeblood of a children’s hospital is a chance to exercise that leverage and I suspect that has some role in the enhancement of how pediatric surgeons are compensated. The other factor in play is the increasing awareness that – I always like to think this is a business, we sell what we can do with our head and our hands and that is our commodity and hospitals sell beds and a children’s hospital realizes that the most lucrative bed they have is a newborn bed and you cannot have a highend newborn facility without several pediatric surgeons. For the hospital to get return on investment they need to have people like us. This may be related to the dilution of the experience in less regionalized environments perhaps but certainly hospitals are realizing that children’s surgery is essential to their lifeblood and children’s surgeons are now learning to exercise that leverage. In regard to the quality of life issue, one thing I really hope to do is to continue to follow this cohort on an
103 annual basis and report back to the association in another 2-3 years of what that quality of life has actually turned out to be because what you think your life as a pediatric surgeon is going to be bears probably zero relationship to what it turns out to be. I look forward to sharing that information about what that quality turns out to be. In the manuscript we asked “are you satisfied or unsatisfied with the package that you negotiated” and only 60% were satisfied before day one of their job, so that is disconcerting. Discussant: Mary Brandt, M.D., (Houston, Texas): First of all, thank you,there is nothing like data to dispel myths and I think that is very important. I have a question and a comment.The question is are you planning to repeat this with new graduates in the future as well? Are you going to continue the study? Response: DR. STOLAR: The answer is, assuming that David Powell invites me back to Washington this year, I can get away from my new kind of job for that 48 hours, and that is another discussion. The answer is yes. As I said, I would like to follow this cohort on an annual basis and report back. Discussant: DR. BRANDT: The other brief comment is something that has happened at this meeting that we have started working on which is the annual residents meeting which is at the AAP but sponsored by the program directors institutions. We have started discussing a curriculum for that meeting, and I think you basically just outlined our curriculum of what needs to happen, so Marjorie Arca is going to be leading that effort through one of the new committees we created in the AAP along with Max Langham and the program directors. That is really more informational but perhaps also a group that could help you with the future study as well. Response: DR. STOLAR: I want to thank you for that comment because one of my rants is that we as surgical educators fail to educate our trainees in how to look for a job. We generally fail, and these kinds of data –and their lack of sophistication is our failing in teaching them what to look for.