What was it about endocrinology that enticed you into this subspecialty? Was it the challenge of making the diagnosis of a difficult metabolic problem? Or the satisfaction of helping patients with chronic medical conditions live a better life? What it probably wasn't was the financial remuneration. In April, Medscape published its annual Physician Compensation Report, which included average salaries from a survey of full-time practicing physicians. Not surprisingly, endocrinologists were nowhere near the top. That designation belonged to orthopedists. In fact, endocrinologists were almost at the bottom, reporting an average salary about half that of orthopedists. And this "honor" of earning almost the lowest salary among 29 medical specialties has been held for some years. Are We Being Compensated Fairly? So why are we at the low end of physician salaries? The most obvious answer is that it is a cognitive subspecialty, with procedures being limited to ones that are outpatient—done in a clinic instead of a hospital or stand-alone surgical unit, where administrative overhead needs are quite different. Limited to thyroid ultrasound; thyroid fine-needle aspiration; and, more recently, subcutaneous insertion of a continuous glucose sensor, most of endocrinology is diagnostic and interpretive and involves the management of chronic conditions. Forty-four percent of respondents stated that they spend 20 or more hours per week on paperwork and administrative duties. What was not asked about was the time spent on charting alone. Endocrinologists spend time on other activities too, such as downloading data from insulin pumps, meters, or continuous sensors—all of which take time and are typically not associated with a fee. One practice reported about 647 hours of face-to-face patient time and 1461 hours of non–face-to-face time per full-time healthcare professional that went unreimbursed each year. Of this unreimbursed time, 57% was for a nurse, 22% for a dietitian, 12% for a pharmacist, and 8% for a medical assistant. Using the mean salaries for each of these healthcare providers, the yearly nonbillable cost was estimated to be $97,498. This nonbillable time was felt to be grossly underestimated because administrative time was not captured. And although interpretation of sensor data has, as an example, gained attention as a recognized compensatory activity, it is a standardized fee, not based on the complexity of interpretation or the management and treatment advice discussed with the patient. Yet, endocrinologists are of direct benefit to other subspecialties through referrals. Patients with diabetes need dilated pupil eye exams. They may need podiatry, cardiology, nephrology, or psychiatry services. And yes, even orthopedic intervention, such as in the case of adhesive capsulitis, which is frequently seen in individuals with diabetes. And this is just a short list of downstream revenue generation that systems have tried to quantify. Blame the Gender Pay Gap? Another contributing factor to endocrinologists' low compensation may be the increasing trend of women entering this specialty. Since 2014, female applicants to endocrinology fellowship training positions have outnumbered male applicants by almost 3 to 1. A 2016 report in the Journal of Clinical Endocrinology and Metabolismnoted that 72% of those entering an endocrine fellowship in 2013 and 75% of applicants to fellowship in 2014 were female. Clearly, endocrinology is becoming a female-dominated subspecialty—and women are typically paid less than men. In 2018, Medscape reported that male endocrinologists earned on average $233,000, whereas female endocrinologists earned $184,000 that same year. Some have argued that this is not due to initial job salary offers but what has been termed "alternative factors"—the family responsibilities that are typically assumed by women, such as child care, elder care, and home care, which in turn can affect hours available for patient care. But women are also known to be poor negotiators for better salaries and professional advancement recognition. Gender discrimination continues to be an issue that is receiving more attention, but we have yet to see real outcomes. The Joy of Practice So what does this mean for the future of endocrinology? Well, it will be predominantly female. Practices will be more and more likely to have physician extenders, with the 2019 Medscape Compensation Report indicating that 51% of endocrinologists have associated nurse practitioners and 26% have physician assistants. The gradual movement of salary equity between men and women sounds promising for the future, but whether that could have an impact on overall salaries in endocrinology remains unclear. But one aspect predicts that endocrinology will survive, and that is the joy of practice. Despite the low compensation, 73% of responding endocrinologists indicated that they would go into medicine again, and 78% would choose endocrinology again, even though only 42% felt that they were fairly compensated. When endocrinologists were asked what the most rewarding aspect of their profession is, relationships with and gratitude from patients came out on top, at 28%, and knowing that they are making a difference in the world was a close second, at 26%—a promising future for endocrinology! Source
