Business of Medicine

A majority of internal medicine physicians report feeling underpaid, but approximately half say that potential pay was not a factor in their decision to choose the specialty, based on data from Medscape’s annual Internist Compensation Report.

Data from the Mercer consulting firm cited in the Medscape report showed an increase of 3% in 2023 over 2022 earnings for physicians in the United States overall. However, on a list of 29 specialties included in the report, internal medicine ranked near the bottom for annual compensation.

The report, based on data from 7000 physicians across the United States, showed that 58% of internal medicine physicians think physicians in general are underpaid, while 33% said that “most physicians are paid about right,” and 8% said that physicians are overpaid. Similarly, when asked about their personal compensation, 55% said that internists are not fairly paid, given their work demands.

Despite concerns about pay, 65% of the internists surveyed said that they were not taking on extra work to boost their incomes. Although less than half (45%) reported being happy with their current pay, 49% said that pay was not a factor in their choice of internal medicine.

Among internists, 60% reported opportunities for bonuses, but the average primary care provider bonus in 2023 was $27,000, compared with an average of $51,000 for bonus pay among specialists.

Money was relatively low on the list as being the most rewarding part of the job for an internist, according to the report. While 34% of respondents cited being good at their jobs and finding answers and diagnoses as the most rewarding part of their jobs, only 9% said “making good money at a job I like” was the most rewarding. The most commonly cited most challenging part of the job was “having so many rules and regulations (22%).”

In addition, approximately two thirds of respondents said other medical businesses (such as telemedicine, retailer clinics, and nonphysician healthcare providers) had no impact on their income, nor did competing physician practices.

More than half (58%) of the respondents were women and the most common age group (based on 5-year increments) was 50-54 years (15%).
 

Regular Pay Assessment Increases Awareness

Assessing physician compensation annually or at regular intervals allows organizations and physicians to know their financial situation and compensation/benefits compared with other professionals, said Noel Deep, MD, an internal medicine physician in group practice in Antigo, Wisconsin, in an interview. “During the COVID-19 pandemic, many individual practices and employed physicians saw a decline in their revenue due to decrease in routine patient visits to the clinician offices, and decrease in routine and preventative procedures,” he noted.

“The findings from the current report were not unexpected, as certain specialties are more lucrative than primary care,” Dr. Deep said. “Specialties such as orthopedics, plastic surgery, and cardiology have the potential not only to generate more income for those specialist physicians, but also for the healthcare organizations that employ them,” he said.
 

Job Satisfaction Remains Important

As a practicing internist, Dr. Deep agreed that many internal medicine physicians would state that the satisfaction that their job and caring for patients brings to them is more important than the financial aspect of their practice.

“I am asked on occasion if I had an opportunity to go back to medical school and make a choice, whether I would have picked a different specialty. My answer is no,” Dr. Deep said.

“I would have picked internal medicine because of the satisfaction that it brings me,” he said.

Dr. Deep shared some potential strategies for employers to recruit and retain internal medicine physicians. If employers could incentivize internal medicine and other primary care specialties with higher signing bonuses and try to make their annual bonuses comparable to surgical specialties, that would help ensure that internal medicine specialists feel they are being paid fairly for their work, he said. “Decreasing the bureaucratic burden and involving physicians in decision-making and determination of compensation would also help,” he said.

Dr. Deep had no financial conflicts to disclose, and serves on the Editorial Advisory Board of Internal Medicine News.

A majority of internal medicine physicians report feeling underpaid, but approximately half say that potential pay was not a factor in their decision to choose the specialty, based on data from Medscape’s annual Internist Compensation Report.

Data from the Mercer consulting firm cited in the Medscape report showed an increase of 3% in 2023 over 2022 earnings for physicians in the United States overall. However, on a list of 29 specialties included in the report, internal medicine ranked near the bottom for annual compensation.

The report, based on data from 7000 physicians across the United States, showed that 58% of internal medicine physicians think physicians in general are underpaid, while 33% said that “most physicians are paid about right,” and 8% said that physicians are overpaid. Similarly, when asked about their personal compensation, 55% said that internists are not fairly paid, given their work demands.

Despite concerns about pay, 65% of the internists surveyed said that they were not taking on extra work to boost their incomes. Although less than half (45%) reported being happy with their current pay, 49% said that pay was not a factor in their choice of internal medicine.

Among internists, 60% reported opportunities for bonuses, but the average primary care provider bonus in 2023 was $27,000, compared with an average of $51,000 for bonus pay among specialists.

Money was relatively low on the list as being the most rewarding part of the job for an internist, according to the report. While 34% of respondents cited being good at their jobs and finding answers and diagnoses as the most rewarding part of their jobs, only 9% said “making good money at a job I like” was the most rewarding. The most commonly cited most challenging part of the job was “having so many rules and regulations (22%).”

In addition, approximately two thirds of respondents said other medical businesses (such as telemedicine, retailer clinics, and nonphysician healthcare providers) had no impact on their income, nor did competing physician practices.

More than half (58%) of the respondents were women and the most common age group (based on 5-year increments) was 50-54 years (15%).
 

Regular Pay Assessment Increases Awareness

Assessing physician compensation annually or at regular intervals allows organizations and physicians to know their financial situation and compensation/benefits compared with other professionals, said Noel Deep, MD, an internal medicine physician in group practice in Antigo, Wisconsin, in an interview. “During the COVID-19 pandemic, many individual practices and employed physicians saw a decline in their revenue due to decrease in routine patient visits to the clinician offices, and decrease in routine and preventative procedures,” he noted.

“The findings from the current report were not unexpected, as certain specialties are more lucrative than primary care,” Dr. Deep said. “Specialties such as orthopedics, plastic surgery, and cardiology have the potential not only to generate more income for those specialist physicians, but also for the healthcare organizations that employ them,” he said.
 

Job Satisfaction Remains Important

As a practicing internist, Dr. Deep agreed that many internal medicine physicians would state that the satisfaction that their job and caring for patients brings to them is more important than the financial aspect of their practice.

“I am asked on occasion if I had an opportunity to go back to medical school and make a choice, whether I would have picked a different specialty. My answer is no,” Dr. Deep said.

“I would have picked internal medicine because of the satisfaction that it brings me,” he said.

Dr. Deep shared some potential strategies for employers to recruit and retain internal medicine physicians. If employers could incentivize internal medicine and other primary care specialties with higher signing bonuses and try to make their annual bonuses comparable to surgical specialties, that would help ensure that internal medicine specialists feel they are being paid fairly for their work, he said. “Decreasing the bureaucratic burden and involving physicians in decision-making and determination of compensation would also help,” he said.

Dr. Deep had no financial conflicts to disclose, and serves on the Editorial Advisory Board of Internal Medicine News.

A majority of internal medicine physicians report feeling underpaid, but approximately half say that potential pay was not a factor in their decision to choose the specialty, based on data from Medscape’s annual Internist Compensation Report.

Data from the Mercer consulting firm cited in the Medscape report showed an increase of 3% in 2023 over 2022 earnings for physicians in the United States overall. However, on a list of 29 specialties included in the report, internal medicine ranked near the bottom for annual compensation.

The report, based on data from 7000 physicians across the United States, showed that 58% of internal medicine physicians think physicians in general are underpaid, while 33% said that “most physicians are paid about right,” and 8% said that physicians are overpaid. Similarly, when asked about their personal compensation, 55% said that internists are not fairly paid, given their work demands.

Despite concerns about pay, 65% of the internists surveyed said that they were not taking on extra work to boost their incomes. Although less than half (45%) reported being happy with their current pay, 49% said that pay was not a factor in their choice of internal medicine.

Among internists, 60% reported opportunities for bonuses, but the average primary care provider bonus in 2023 was $27,000, compared with an average of $51,000 for bonus pay among specialists.

Money was relatively low on the list as being the most rewarding part of the job for an internist, according to the report. While 34% of respondents cited being good at their jobs and finding answers and diagnoses as the most rewarding part of their jobs, only 9% said “making good money at a job I like” was the most rewarding. The most commonly cited most challenging part of the job was “having so many rules and regulations (22%).”

In addition, approximately two thirds of respondents said other medical businesses (such as telemedicine, retailer clinics, and nonphysician healthcare providers) had no impact on their income, nor did competing physician practices.

More than half (58%) of the respondents were women and the most common age group (based on 5-year increments) was 50-54 years (15%).
 

Regular Pay Assessment Increases Awareness

Assessing physician compensation annually or at regular intervals allows organizations and physicians to know their financial situation and compensation/benefits compared with other professionals, said Noel Deep, MD, an internal medicine physician in group practice in Antigo, Wisconsin, in an interview. “During the COVID-19 pandemic, many individual practices and employed physicians saw a decline in their revenue due to decrease in routine patient visits to the clinician offices, and decrease in routine and preventative procedures,” he noted.

“The findings from the current report were not unexpected, as certain specialties are more lucrative than primary care,” Dr. Deep said. “Specialties such as orthopedics, plastic surgery, and cardiology have the potential not only to generate more income for those specialist physicians, but also for the healthcare organizations that employ them,” he said.
 

Job Satisfaction Remains Important

As a practicing internist, Dr. Deep agreed that many internal medicine physicians would state that the satisfaction that their job and caring for patients brings to them is more important than the financial aspect of their practice.

“I am asked on occasion if I had an opportunity to go back to medical school and make a choice, whether I would have picked a different specialty. My answer is no,” Dr. Deep said.

“I would have picked internal medicine because of the satisfaction that it brings me,” he said.

Dr. Deep shared some potential strategies for employers to recruit and retain internal medicine physicians. If employers could incentivize internal medicine and other primary care specialties with higher signing bonuses and try to make their annual bonuses comparable to surgical specialties, that would help ensure that internal medicine specialists feel they are being paid fairly for their work, he said. “Decreasing the bureaucratic burden and involving physicians in decision-making and determination of compensation would also help,” he said.

Dr. Deep had no financial conflicts to disclose, and serves on the Editorial Advisory Board of Internal Medicine News.

Recently, “low field” MRIs have been in the news, with the promise that they’ll be safer and easier. People can go in them with their cell phones, car keys in pockets, no ear plugs needed for the noise, etc. They’re cheaper to build and can be plugged into a standard outlet.

That’s all well and good, but what about accuracy and image quality?

That’s a big question. Even proponents of the technology say it’s not as good as what we see with 3T MRI, so they’re trying to compensate by using AI and other software protocols to enhance the pictures. Allegedly it looks good, but so far only healthy volunteers have been scanned. How will it do with a small low-grade glioma or other subtle (but important) findings? We don’t know yet.

Personally, I think having to give up your iPhone and car keys for an hour, and put in foam ear plugs, are small trade-offs to get an accurate diagnosis.

Of course, I’m also approaching this as someone who deals with brain imaging. Maybe for other structures, like a knee, that kind of detail isn’t as necessary (or maybe it is. I’m definitely not in that field).

So, as with so many things that make it into the popular press, they likely have potential, but are still not ready for prime time.

This sort of stuff always gets my office phones ringing. Patients see a blurb about it on the news or Facebook and assume it’s available now, so they want one. They seem to think the new MRI is like Bones McCoy’s tricorder. I take the scanner off my belt, wave it over them, and the answer comes up on the screen. The fact that the unit still weighs over a ton is hidden at the bottom of the blurb, if it’s even mentioned at all.

There’s also the likelihood that this sort of thing is going to be taken to the public, in the same way carotid Dopplers have been. Marketed to the worried well with celebrity endorsements and taglines like “see what your doctor won’t look for.” Of course, MRIs are chock full of things like nonspecific white matter changes, disc bulges, tiny meningiomas, and a host of other incidental findings that cause panic in cyberchondriacs. Who then call us.

But that’s another story.

I understand that for some parts of the world a comparatively inexpensive, transportable, MRI that requires less shielding and power is a HUGE deal. Its availability can make the difference between life and death.

I’m not knocking the technology. I’m sure it will be useful. But, like so much in medicine, it’s not here yet.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Recently, “low field” MRIs have been in the news, with the promise that they’ll be safer and easier. People can go in them with their cell phones, car keys in pockets, no ear plugs needed for the noise, etc. They’re cheaper to build and can be plugged into a standard outlet.

That’s all well and good, but what about accuracy and image quality?

That’s a big question. Even proponents of the technology say it’s not as good as what we see with 3T MRI, so they’re trying to compensate by using AI and other software protocols to enhance the pictures. Allegedly it looks good, but so far only healthy volunteers have been scanned. How will it do with a small low-grade glioma or other subtle (but important) findings? We don’t know yet.

Personally, I think having to give up your iPhone and car keys for an hour, and put in foam ear plugs, are small trade-offs to get an accurate diagnosis.

Of course, I’m also approaching this as someone who deals with brain imaging. Maybe for other structures, like a knee, that kind of detail isn’t as necessary (or maybe it is. I’m definitely not in that field).

So, as with so many things that make it into the popular press, they likely have potential, but are still not ready for prime time.

This sort of stuff always gets my office phones ringing. Patients see a blurb about it on the news or Facebook and assume it’s available now, so they want one. They seem to think the new MRI is like Bones McCoy’s tricorder. I take the scanner off my belt, wave it over them, and the answer comes up on the screen. The fact that the unit still weighs over a ton is hidden at the bottom of the blurb, if it’s even mentioned at all.

There’s also the likelihood that this sort of thing is going to be taken to the public, in the same way carotid Dopplers have been. Marketed to the worried well with celebrity endorsements and taglines like “see what your doctor won’t look for.” Of course, MRIs are chock full of things like nonspecific white matter changes, disc bulges, tiny meningiomas, and a host of other incidental findings that cause panic in cyberchondriacs. Who then call us.

But that’s another story.

I understand that for some parts of the world a comparatively inexpensive, transportable, MRI that requires less shielding and power is a HUGE deal. Its availability can make the difference between life and death.

I’m not knocking the technology. I’m sure it will be useful. But, like so much in medicine, it’s not here yet.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Recently, “low field” MRIs have been in the news, with the promise that they’ll be safer and easier. People can go in them with their cell phones, car keys in pockets, no ear plugs needed for the noise, etc. They’re cheaper to build and can be plugged into a standard outlet.

That’s all well and good, but what about accuracy and image quality?

That’s a big question. Even proponents of the technology say it’s not as good as what we see with 3T MRI, so they’re trying to compensate by using AI and other software protocols to enhance the pictures. Allegedly it looks good, but so far only healthy volunteers have been scanned. How will it do with a small low-grade glioma or other subtle (but important) findings? We don’t know yet.

Personally, I think having to give up your iPhone and car keys for an hour, and put in foam ear plugs, are small trade-offs to get an accurate diagnosis.

Of course, I’m also approaching this as someone who deals with brain imaging. Maybe for other structures, like a knee, that kind of detail isn’t as necessary (or maybe it is. I’m definitely not in that field).

So, as with so many things that make it into the popular press, they likely have potential, but are still not ready for prime time.

This sort of stuff always gets my office phones ringing. Patients see a blurb about it on the news or Facebook and assume it’s available now, so they want one. They seem to think the new MRI is like Bones McCoy’s tricorder. I take the scanner off my belt, wave it over them, and the answer comes up on the screen. The fact that the unit still weighs over a ton is hidden at the bottom of the blurb, if it’s even mentioned at all.

There’s also the likelihood that this sort of thing is going to be taken to the public, in the same way carotid Dopplers have been. Marketed to the worried well with celebrity endorsements and taglines like “see what your doctor won’t look for.” Of course, MRIs are chock full of things like nonspecific white matter changes, disc bulges, tiny meningiomas, and a host of other incidental findings that cause panic in cyberchondriacs. Who then call us.

But that’s another story.

I understand that for some parts of the world a comparatively inexpensive, transportable, MRI that requires less shielding and power is a HUGE deal. Its availability can make the difference between life and death.

I’m not knocking the technology. I’m sure it will be useful. But, like so much in medicine, it’s not here yet.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

While rheumatologists reported small pay gains this year, more than half said the specialty was underpaid.

In the Medscape Rheumatologist Compensation Report 2024, 53% said that they did not feel fairly paid given their work demands. Rheumatologist respondents reported earning an average of $286,000 annually, ranking them as the seventh lowest earners out of a total of 29 specialties surveyed. Orthopedics was the highest earning specialty, with $558,000 in annual income, and diabetes & endocrinology was the lowest earning specialty, with $256,000 in annual compensation.

In last year’s report, a rheumatologist’s average income was $281,000.

This new report was compiled from an online survey including more than 7000 physicians from 29 specialties, of whom 1% of respondents were rheumatologists. Most respondents (58%) were women, and 39% were men. The survey was available from October 2, 2023, to January 16, 2024.

Rheumatologists reported a 2% increase in pay compared with that cited in the previous year’s report. Physical medicine and rehabilitation had the largest bump in pay at 11%. A total of 29% of rheumatologists said their pay had increased from that in the previous year, and 18% reported fewer earnings. About half (53%) reported that their income remained the same.

When asked about physician pay in the United States, 61% of rheumatologists said most physicians were underpaid, 34% said physicians were paid fairly, and only 4% said most physicians were overpaid.

“Most physicians who take care of chronic illnesses in long-term patients are underpaid. Not all doctors are,” said one survey respondent.

Another 41% of rheumatologists said they supplemented income with additional work, including other medical-related work (30%), nonmedical-related work (5%), adding more hours to their primary job (5%), and medical moonlighting (4%). (Respondents could choose more than one option in the survey.) This is slightly lower than last year’s survey, where 46% of rheumatologist respondents said they took on additional work.

About three out of four rheumatologists said that other medical businesses or competing physician practices did not affect their income, and only 5% said these competitors considerably affected income.

Rheumatologists listed being good at their job/diagnosing (36%) as the most rewarding part of their profession, followed by gratitude from/relationships with patients (26%) and making the world a better place/helping others (19%). Difficulties with insurance and receiving fair reimbursement (22%), dealing with difficult patients (20%), having many rules and regulations (18%), and working with an electronic health record system (15%) were the most commonly reported challenges for rheumatologists.

A version of this article appeared on Medscape.com.

While rheumatologists reported small pay gains this year, more than half said the specialty was underpaid.

In the Medscape Rheumatologist Compensation Report 2024, 53% said that they did not feel fairly paid given their work demands. Rheumatologist respondents reported earning an average of $286,000 annually, ranking them as the seventh lowest earners out of a total of 29 specialties surveyed. Orthopedics was the highest earning specialty, with $558,000 in annual income, and diabetes & endocrinology was the lowest earning specialty, with $256,000 in annual compensation.

In last year’s report, a rheumatologist’s average income was $281,000.

This new report was compiled from an online survey including more than 7000 physicians from 29 specialties, of whom 1% of respondents were rheumatologists. Most respondents (58%) were women, and 39% were men. The survey was available from October 2, 2023, to January 16, 2024.

Rheumatologists reported a 2% increase in pay compared with that cited in the previous year’s report. Physical medicine and rehabilitation had the largest bump in pay at 11%. A total of 29% of rheumatologists said their pay had increased from that in the previous year, and 18% reported fewer earnings. About half (53%) reported that their income remained the same.

When asked about physician pay in the United States, 61% of rheumatologists said most physicians were underpaid, 34% said physicians were paid fairly, and only 4% said most physicians were overpaid.

“Most physicians who take care of chronic illnesses in long-term patients are underpaid. Not all doctors are,” said one survey respondent.

Another 41% of rheumatologists said they supplemented income with additional work, including other medical-related work (30%), nonmedical-related work (5%), adding more hours to their primary job (5%), and medical moonlighting (4%). (Respondents could choose more than one option in the survey.) This is slightly lower than last year’s survey, where 46% of rheumatologist respondents said they took on additional work.

About three out of four rheumatologists said that other medical businesses or competing physician practices did not affect their income, and only 5% said these competitors considerably affected income.

Rheumatologists listed being good at their job/diagnosing (36%) as the most rewarding part of their profession, followed by gratitude from/relationships with patients (26%) and making the world a better place/helping others (19%). Difficulties with insurance and receiving fair reimbursement (22%), dealing with difficult patients (20%), having many rules and regulations (18%), and working with an electronic health record system (15%) were the most commonly reported challenges for rheumatologists.

A version of this article appeared on Medscape.com.

While rheumatologists reported small pay gains this year, more than half said the specialty was underpaid.

In the Medscape Rheumatologist Compensation Report 2024, 53% said that they did not feel fairly paid given their work demands. Rheumatologist respondents reported earning an average of $286,000 annually, ranking them as the seventh lowest earners out of a total of 29 specialties surveyed. Orthopedics was the highest earning specialty, with $558,000 in annual income, and diabetes & endocrinology was the lowest earning specialty, with $256,000 in annual compensation.

In last year’s report, a rheumatologist’s average income was $281,000.

This new report was compiled from an online survey including more than 7000 physicians from 29 specialties, of whom 1% of respondents were rheumatologists. Most respondents (58%) were women, and 39% were men. The survey was available from October 2, 2023, to January 16, 2024.

Rheumatologists reported a 2% increase in pay compared with that cited in the previous year’s report. Physical medicine and rehabilitation had the largest bump in pay at 11%. A total of 29% of rheumatologists said their pay had increased from that in the previous year, and 18% reported fewer earnings. About half (53%) reported that their income remained the same.

When asked about physician pay in the United States, 61% of rheumatologists said most physicians were underpaid, 34% said physicians were paid fairly, and only 4% said most physicians were overpaid.

“Most physicians who take care of chronic illnesses in long-term patients are underpaid. Not all doctors are,” said one survey respondent.

Another 41% of rheumatologists said they supplemented income with additional work, including other medical-related work (30%), nonmedical-related work (5%), adding more hours to their primary job (5%), and medical moonlighting (4%). (Respondents could choose more than one option in the survey.) This is slightly lower than last year’s survey, where 46% of rheumatologist respondents said they took on additional work.

About three out of four rheumatologists said that other medical businesses or competing physician practices did not affect their income, and only 5% said these competitors considerably affected income.

Rheumatologists listed being good at their job/diagnosing (36%) as the most rewarding part of their profession, followed by gratitude from/relationships with patients (26%) and making the world a better place/helping others (19%). Difficulties with insurance and receiving fair reimbursement (22%), dealing with difficult patients (20%), having many rules and regulations (18%), and working with an electronic health record system (15%) were the most commonly reported challenges for rheumatologists.

A version of this article appeared on Medscape.com.

Fewer than half (42%) of obstetricians/gynecologists in the latest Medscape survey said they were satisfied with their average $352,000/year pay, putting them in the bottom 20% of specialties for pay satisfaction.

The $352,000 listed in the Medscape Ob/Gyn Compensation Report 2024 put the specialty in the middle of physicians overall. Orthopedists made the most at $558,000, followed by plastic surgeons at $536,000. Endocrinologists/diabetes specialists made the least at $256,000.
 

Ob.Gyn. Pay Rose 4%

Ob.gyns.’ pay overall was up 4% this year and the specialty was one of 10 in the survey that saw an increase.

There were contrasts in satisfaction among the specialties: Public health and preventive medicine physicians had the highest rate of satisfaction with pay (65% were satisfied) though they made new the least among physicians ($263,000). Those least satisfied with their pay were infectious disease physicians with only 34% saying they were satisfied.

There was also a contrast between what ob.gyns. thought about all physicians’ pay and what they thought of their own pay. While 68% said they thought physicians were underpaid, only 58% said that about their own specialty.

Elizabeth Woodcock, a healthcare consultant with Woodcock and Associates in Atlanta, Georgia, said this may be a mindset of self-deprecation, where pay is concerned.

“I think their response is a function of their lens — ‘I feel fortunate to have a job, to care for my patients, to be paid for this work,’ ” Ms. Woodcock said in the survey report.
 

Most Billings, Most Pay

“As a rule of thumb, the specialists who generate the most gross billings to commercial payers are more likely to receive the highest compensation,” said Jeff Decker, president of AMN Healthcare’s physician solutions division.

Louise P. King, MD, JD, associate professor of obstetrics and gynecology at Harvard Medical School in Boston, said lower reimbursement for procedures drives her reimbursement as a gynecological surgeon.

“Ob.gyns. — who are primarily surgical and have the highest malpractice risks and costs of almost the entire profession — earn far less than other surgeons,” she said.

The reasons for that are complex, she said, but she explained in a commentary in Obstetrics and Gynecology that “insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity.”

She says that doubly affects female gynecological surgeons, who make up a disproportionately high number of surgeons in the field and serve mostly female patients.
 

Implications for Patient Care

Lower reimbursement also has implications for patient care, she says. Lower reimbursement for gynecological surgeries pushes many obstetrics and gynecological surgeons to perform fewer surgeries and more obstetric services, “resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates,” said Dr. King.

She added that as a gynecological surgeon, because of the lower reimbursement for services, “I have less access to [operating room] time and supports like midlevel clinicians.”

Fifty-three percent of ob.gyns. reported they have a chance for an incentive bonus and the average was $40,000; this is compared with the highest bonuses — $142,000, which were for dermatologists, followed by orthopedists at $102,000.

Ob.gyns. were also asked about whether they supplemented their income with additional work and 39% this year, about the same percentage as last year, said they did. The percentage is similar to the number of physicians who say they supplement their income. In most cases, for all physicians, the outside work is usually within the medical field.

Ms. Woodcock, Mr. Decker, and Dr. King report no relevant financial disclosures.

Fewer than half (42%) of obstetricians/gynecologists in the latest Medscape survey said they were satisfied with their average $352,000/year pay, putting them in the bottom 20% of specialties for pay satisfaction.

The $352,000 listed in the Medscape Ob/Gyn Compensation Report 2024 put the specialty in the middle of physicians overall. Orthopedists made the most at $558,000, followed by plastic surgeons at $536,000. Endocrinologists/diabetes specialists made the least at $256,000.
 

Ob.Gyn. Pay Rose 4%

Ob.gyns.’ pay overall was up 4% this year and the specialty was one of 10 in the survey that saw an increase.

There were contrasts in satisfaction among the specialties: Public health and preventive medicine physicians had the highest rate of satisfaction with pay (65% were satisfied) though they made new the least among physicians ($263,000). Those least satisfied with their pay were infectious disease physicians with only 34% saying they were satisfied.

There was also a contrast between what ob.gyns. thought about all physicians’ pay and what they thought of their own pay. While 68% said they thought physicians were underpaid, only 58% said that about their own specialty.

Elizabeth Woodcock, a healthcare consultant with Woodcock and Associates in Atlanta, Georgia, said this may be a mindset of self-deprecation, where pay is concerned.

“I think their response is a function of their lens — ‘I feel fortunate to have a job, to care for my patients, to be paid for this work,’ ” Ms. Woodcock said in the survey report.
 

Most Billings, Most Pay

“As a rule of thumb, the specialists who generate the most gross billings to commercial payers are more likely to receive the highest compensation,” said Jeff Decker, president of AMN Healthcare’s physician solutions division.

Louise P. King, MD, JD, associate professor of obstetrics and gynecology at Harvard Medical School in Boston, said lower reimbursement for procedures drives her reimbursement as a gynecological surgeon.

“Ob.gyns. — who are primarily surgical and have the highest malpractice risks and costs of almost the entire profession — earn far less than other surgeons,” she said.

The reasons for that are complex, she said, but she explained in a commentary in Obstetrics and Gynecology that “insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity.”

She says that doubly affects female gynecological surgeons, who make up a disproportionately high number of surgeons in the field and serve mostly female patients.
 

Implications for Patient Care

Lower reimbursement also has implications for patient care, she says. Lower reimbursement for gynecological surgeries pushes many obstetrics and gynecological surgeons to perform fewer surgeries and more obstetric services, “resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates,” said Dr. King.

She added that as a gynecological surgeon, because of the lower reimbursement for services, “I have less access to [operating room] time and supports like midlevel clinicians.”

Fifty-three percent of ob.gyns. reported they have a chance for an incentive bonus and the average was $40,000; this is compared with the highest bonuses — $142,000, which were for dermatologists, followed by orthopedists at $102,000.

Ob.gyns. were also asked about whether they supplemented their income with additional work and 39% this year, about the same percentage as last year, said they did. The percentage is similar to the number of physicians who say they supplement their income. In most cases, for all physicians, the outside work is usually within the medical field.

Ms. Woodcock, Mr. Decker, and Dr. King report no relevant financial disclosures.

Fewer than half (42%) of obstetricians/gynecologists in the latest Medscape survey said they were satisfied with their average $352,000/year pay, putting them in the bottom 20% of specialties for pay satisfaction.

The $352,000 listed in the Medscape Ob/Gyn Compensation Report 2024 put the specialty in the middle of physicians overall. Orthopedists made the most at $558,000, followed by plastic surgeons at $536,000. Endocrinologists/diabetes specialists made the least at $256,000.
 

Ob.Gyn. Pay Rose 4%

Ob.gyns.’ pay overall was up 4% this year and the specialty was one of 10 in the survey that saw an increase.

There were contrasts in satisfaction among the specialties: Public health and preventive medicine physicians had the highest rate of satisfaction with pay (65% were satisfied) though they made new the least among physicians ($263,000). Those least satisfied with their pay were infectious disease physicians with only 34% saying they were satisfied.

There was also a contrast between what ob.gyns. thought about all physicians’ pay and what they thought of their own pay. While 68% said they thought physicians were underpaid, only 58% said that about their own specialty.

Elizabeth Woodcock, a healthcare consultant with Woodcock and Associates in Atlanta, Georgia, said this may be a mindset of self-deprecation, where pay is concerned.

“I think their response is a function of their lens — ‘I feel fortunate to have a job, to care for my patients, to be paid for this work,’ ” Ms. Woodcock said in the survey report.
 

Most Billings, Most Pay

“As a rule of thumb, the specialists who generate the most gross billings to commercial payers are more likely to receive the highest compensation,” said Jeff Decker, president of AMN Healthcare’s physician solutions division.

Louise P. King, MD, JD, associate professor of obstetrics and gynecology at Harvard Medical School in Boston, said lower reimbursement for procedures drives her reimbursement as a gynecological surgeon.

“Ob.gyns. — who are primarily surgical and have the highest malpractice risks and costs of almost the entire profession — earn far less than other surgeons,” she said.

The reasons for that are complex, she said, but she explained in a commentary in Obstetrics and Gynecology that “insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity.”

She says that doubly affects female gynecological surgeons, who make up a disproportionately high number of surgeons in the field and serve mostly female patients.
 

Implications for Patient Care

Lower reimbursement also has implications for patient care, she says. Lower reimbursement for gynecological surgeries pushes many obstetrics and gynecological surgeons to perform fewer surgeries and more obstetric services, “resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates,” said Dr. King.

She added that as a gynecological surgeon, because of the lower reimbursement for services, “I have less access to [operating room] time and supports like midlevel clinicians.”

Fifty-three percent of ob.gyns. reported they have a chance for an incentive bonus and the average was $40,000; this is compared with the highest bonuses — $142,000, which were for dermatologists, followed by orthopedists at $102,000.

Ob.gyns. were also asked about whether they supplemented their income with additional work and 39% this year, about the same percentage as last year, said they did. The percentage is similar to the number of physicians who say they supplement their income. In most cases, for all physicians, the outside work is usually within the medical field.

Ms. Woodcock, Mr. Decker, and Dr. King report no relevant financial disclosures.

More than half of family physicians think that physicians in general are underpaid, but 50% said that in their own situations, they felt fairly paid given their work demands, based on data from Medscape’s annual Family Physician Compensation Report.

The report, based on data from 7,000 physicians across the United States, showed similarly that 50% of family physicians were happy with their pay, which put them about midway on a list of 29 specialties ranking happiness with pay, above some of the higher paid specialties including orthopedics and plastic surgery.

The report cited data from the Mercer consulting firm showing an increase of 3% in 2023 over 2022 earnings among physicians in the United States overall. The average annual earnings for family medicine physicians were near the bottom of a list of 29 specialties included in the report, but 90% said that potential pay was not a factor or a minor factor in choosing the specialty.

According to the report, 61% of family physicians reported taking no additional work to boost income, but 20% reported taking on additional medical-related work, and 6% reported non-medical-related work.

For most family physicians compensation for patient care remained approximately the same as previous years, and a majority said that neither competing physician practices nor other medical businesses (such as retail clinics or nonphysician practitioners) had an effect on their incomes (70% and 62%, respectively).

Although 54% of family practice physicians reported opportunities for incentive bonuses, these bonuses are generally based on a combination of clinical, economic, and experience factors, and are lower for primary care physicians than for specialists. The average bonus for a primary care physician in 2023 was $27,000 compared with an average bonus of $51,000 for a specialist, according to the report.

Overall, 32% of the family physicians reported gratitude from and relationships with patients as the most satisfying part of their jobs, followed by being good at their jobs by finding answers to medical questions and making diagnoses (24%), and making the world a better place (19%).
 

Why Money Still Matters

The relatively minor increase in earnings is “the minimum necessary to continue to attract talented individuals into family medicine,” Susan Kuchera, MD, associate director of the Family Medicine Residency Program at Jefferson Health, Abington, Pennsylvania, said in an interview.

The current report referenced a 2023 report of interviews with medical residents, and approximately half of residents overall said that potential earnings were influential in their decisions.

However, the current Medscape report does not reflect the debt burden held by most new physicians, said Dr. Kuchera, who was not involved in the report. “The educational debt and long years of training can be a deterrent for some to choose a lower paying specialty like primary care; if we want to continue to provide our communities with primary care specialists, we need to keep pace with other areas of medicine,” she said.

“It takes a minimum of 7 years to train a primary care physician, we can’t lose sight over time of the factors that impact a person’s choice to pursue primary care,” Dr. Kuchera said.
 

More Support Needed for Community-Based Care

The data from the report were not surprising, given that the work of primary care physicians is hard, but “historically undervalued” compared with procedural medicine, Dr. Kuchera said. With more emphasis on the value of healthy communities, “we will realize that the relationship family physicians have with their communities is paramount to creating a healthy society,” she added.

The fact that patient care accounts for more than 75% of what family doctors feel to be most rewarding in their profession reflects that most do this work because longitudinal care of patients and communities is rewarding, Dr. Kuchera said in an interview.

“Employers need to value the special training of family doctors to take care of communities,” Dr. Kuchera said. This includes finding ways to incentivize value-based care and to provide the necessary resources to care for communities with poor social determinants of health, she added.

Dr. Kuchera had no financial conflicts to disclose.

More than half of family physicians think that physicians in general are underpaid, but 50% said that in their own situations, they felt fairly paid given their work demands, based on data from Medscape’s annual Family Physician Compensation Report.

The report, based on data from 7,000 physicians across the United States, showed similarly that 50% of family physicians were happy with their pay, which put them about midway on a list of 29 specialties ranking happiness with pay, above some of the higher paid specialties including orthopedics and plastic surgery.

The report cited data from the Mercer consulting firm showing an increase of 3% in 2023 over 2022 earnings among physicians in the United States overall. The average annual earnings for family medicine physicians were near the bottom of a list of 29 specialties included in the report, but 90% said that potential pay was not a factor or a minor factor in choosing the specialty.

According to the report, 61% of family physicians reported taking no additional work to boost income, but 20% reported taking on additional medical-related work, and 6% reported non-medical-related work.

For most family physicians compensation for patient care remained approximately the same as previous years, and a majority said that neither competing physician practices nor other medical businesses (such as retail clinics or nonphysician practitioners) had an effect on their incomes (70% and 62%, respectively).

Although 54% of family practice physicians reported opportunities for incentive bonuses, these bonuses are generally based on a combination of clinical, economic, and experience factors, and are lower for primary care physicians than for specialists. The average bonus for a primary care physician in 2023 was $27,000 compared with an average bonus of $51,000 for a specialist, according to the report.

Overall, 32% of the family physicians reported gratitude from and relationships with patients as the most satisfying part of their jobs, followed by being good at their jobs by finding answers to medical questions and making diagnoses (24%), and making the world a better place (19%).
 

Why Money Still Matters

The relatively minor increase in earnings is “the minimum necessary to continue to attract talented individuals into family medicine,” Susan Kuchera, MD, associate director of the Family Medicine Residency Program at Jefferson Health, Abington, Pennsylvania, said in an interview.

The current report referenced a 2023 report of interviews with medical residents, and approximately half of residents overall said that potential earnings were influential in their decisions.

However, the current Medscape report does not reflect the debt burden held by most new physicians, said Dr. Kuchera, who was not involved in the report. “The educational debt and long years of training can be a deterrent for some to choose a lower paying specialty like primary care; if we want to continue to provide our communities with primary care specialists, we need to keep pace with other areas of medicine,” she said.

“It takes a minimum of 7 years to train a primary care physician, we can’t lose sight over time of the factors that impact a person’s choice to pursue primary care,” Dr. Kuchera said.
 

More Support Needed for Community-Based Care

The data from the report were not surprising, given that the work of primary care physicians is hard, but “historically undervalued” compared with procedural medicine, Dr. Kuchera said. With more emphasis on the value of healthy communities, “we will realize that the relationship family physicians have with their communities is paramount to creating a healthy society,” she added.

The fact that patient care accounts for more than 75% of what family doctors feel to be most rewarding in their profession reflects that most do this work because longitudinal care of patients and communities is rewarding, Dr. Kuchera said in an interview.

“Employers need to value the special training of family doctors to take care of communities,” Dr. Kuchera said. This includes finding ways to incentivize value-based care and to provide the necessary resources to care for communities with poor social determinants of health, she added.

Dr. Kuchera had no financial conflicts to disclose.

More than half of family physicians think that physicians in general are underpaid, but 50% said that in their own situations, they felt fairly paid given their work demands, based on data from Medscape’s annual Family Physician Compensation Report.

The report, based on data from 7,000 physicians across the United States, showed similarly that 50% of family physicians were happy with their pay, which put them about midway on a list of 29 specialties ranking happiness with pay, above some of the higher paid specialties including orthopedics and plastic surgery.

The report cited data from the Mercer consulting firm showing an increase of 3% in 2023 over 2022 earnings among physicians in the United States overall. The average annual earnings for family medicine physicians were near the bottom of a list of 29 specialties included in the report, but 90% said that potential pay was not a factor or a minor factor in choosing the specialty.

According to the report, 61% of family physicians reported taking no additional work to boost income, but 20% reported taking on additional medical-related work, and 6% reported non-medical-related work.

For most family physicians compensation for patient care remained approximately the same as previous years, and a majority said that neither competing physician practices nor other medical businesses (such as retail clinics or nonphysician practitioners) had an effect on their incomes (70% and 62%, respectively).

Although 54% of family practice physicians reported opportunities for incentive bonuses, these bonuses are generally based on a combination of clinical, economic, and experience factors, and are lower for primary care physicians than for specialists. The average bonus for a primary care physician in 2023 was $27,000 compared with an average bonus of $51,000 for a specialist, according to the report.

Overall, 32% of the family physicians reported gratitude from and relationships with patients as the most satisfying part of their jobs, followed by being good at their jobs by finding answers to medical questions and making diagnoses (24%), and making the world a better place (19%).
 

Why Money Still Matters

The relatively minor increase in earnings is “the minimum necessary to continue to attract talented individuals into family medicine,” Susan Kuchera, MD, associate director of the Family Medicine Residency Program at Jefferson Health, Abington, Pennsylvania, said in an interview.

The current report referenced a 2023 report of interviews with medical residents, and approximately half of residents overall said that potential earnings were influential in their decisions.

However, the current Medscape report does not reflect the debt burden held by most new physicians, said Dr. Kuchera, who was not involved in the report. “The educational debt and long years of training can be a deterrent for some to choose a lower paying specialty like primary care; if we want to continue to provide our communities with primary care specialists, we need to keep pace with other areas of medicine,” she said.

“It takes a minimum of 7 years to train a primary care physician, we can’t lose sight over time of the factors that impact a person’s choice to pursue primary care,” Dr. Kuchera said.
 

More Support Needed for Community-Based Care

The data from the report were not surprising, given that the work of primary care physicians is hard, but “historically undervalued” compared with procedural medicine, Dr. Kuchera said. With more emphasis on the value of healthy communities, “we will realize that the relationship family physicians have with their communities is paramount to creating a healthy society,” she added.

The fact that patient care accounts for more than 75% of what family doctors feel to be most rewarding in their profession reflects that most do this work because longitudinal care of patients and communities is rewarding, Dr. Kuchera said in an interview.

“Employers need to value the special training of family doctors to take care of communities,” Dr. Kuchera said. This includes finding ways to incentivize value-based care and to provide the necessary resources to care for communities with poor social determinants of health, she added.

Dr. Kuchera had no financial conflicts to disclose.

Florida has become the first state to allow doctors to perform cesarean sections outside of hospitals, siding with a private equity-owned physicians group that says the change will lower costs and give pregnant women the homier birthing atmosphere that many desire.

But the hospital industry and the nation’s leading obstetricians’ association say that even though some Florida hospitals have closed their maternity wards in recent years, performing C-sections in doctor-run clinics will increase the risks for women and babies when complications arise.

“A pregnant patient that is considered low-risk in one moment can suddenly need lifesaving care in the next,” Cole Greves, an Orlando perinatologist who chairs the Florida chapter of the American College of Obstetricians and Gynecologists, said in an email to KFF Health News. The new birth clinics, “even with increased regulation, cannot guarantee the level of safety patients would receive within a hospital.”

This spring, a law was enacted allowing “advanced birth centers,” where physicians can deliver babies vaginally or by C-section to women deemed at low risk of complications. Women would be able to stay overnight at the clinics.

Women’s Care Enterprises, a private equity-owned physicians group with locations mostly in Florida along with California and Kentucky, lobbied the state legislature to make the change. BC Partners, a London-based investment firm, bought Women’s Care in 2020.

“We have patients who don’t want to deliver in a hospital, and that breaks our heart,” said Stephen Snow, who recently retired as an ob.gyn. with Women’s Care and testified before the Florida Legislature advocating for the change in 2018.

Brittany Miller, vice president of strategic initiatives with Women’s Care, said the group would not comment on the issue.

Health experts are leery.

“What this looks like is a poor substitute for quality obstetrical care effectively being billed as something that gives people more choices,” said Alice Abernathy, an assistant professor of obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “This feels like a bad band-aid on a chronic issue that will make outcomes worse rather than better,” Abernathy said.

Nearly one-third of U.S. births occur via C-section, the surgical delivery of a baby through an incision in the mother’s abdomen and uterus. Generally, doctors use the procedure when they believe it is safer than vaginal delivery for the parent, the baby, or both. Such medical decisions can take place months before birth, or in an emergency.

Florida state Sen. Gayle Harrell, the Republican who sponsored the birth center bill, said having a C-section outside of a hospital may seem like a radical change, but so was the opening of outpatient surgery centers in the late 1980s.

Harrell, who managed her husband’s ob.gyn. practice, said birth centers will have to meet the same high standards for staffing, infection control, and other aspects as those at outpatient surgery centers.

“Given where we are with the need, and maternity deserts across the state, this is something that will help us and help moms get the best care,” she said.

Seventeen hospitals in the state have closed their maternity units since 2019, with many citing low insurance reimbursement and high malpractice costs, according to the Florida Hospital Association.

Mary Mayhew, CEO of the Florida Hospital Association, said it is wrong to compare birth centers to ambulatory surgery centers because of the many risks associated with C-sections, such as hemorrhaging.

The Florida law requires advanced birth centers to have a transfer agreement with a hospital, but it does not dictate where the facilities can open nor their proximity to a hospital.

“We have serious concerns about the impact this model has on our collective efforts to improve maternal and infant health,” Mayhew said. “Our hospitals do not see this in the best interest of providing quality and safety in labor and delivery.”

Despite its opposition to the new birth centers, the Florida Hospital Association did not fight passage of the overall bill because it also included a major increase in the amount Medicaid pays hospitals for maternity care.

Mayhew said it is unlikely that the birth centers would help address care shortages. Hospitals are already struggling with a shortage of ob.gyns., she said, and it is unrealistic to expect advanced birth centers to open in rural areas with a large proportion of people on Medicaid, which pays the lowest reimbursement for labor and delivery care.

It is unclear whether insurers will cover the advanced birth centers, though most insurers and Medicaid cover care at midwife-run birth centers. The advanced birth centers will not accept emergency walk-ins and will treat only patients whose insurance contracts with the facilities, making them in-network.

Snow, the retired ob.gyn. with Women’s Care, said the group plans to open an advanced birth center in the Tampa or Orlando area.

The advanced birth center concept is an improvement on midwife care that enables deliveries outside of hospitals, he said, as the centers allow women to stay overnight and, if necessary, offer anesthesia and C-sections.

Snow acknowledged that, with a private equity firm invested in Women’s Care, the birth center idea is also about making money. But he said hospitals have the same profit incentive and, like midwives, likely oppose the idea of centers that can provide C-sections because they could cut into hospital revenue.

“We are trying to reduce the cost of medicine, and this would be more cost-effective and more pleasant for patients,” he said.

Kate Bauer, executive director of the American Association of Birth Centers, said patients could confuse advanced birth centers with the existing, free-standing birth centers for low-risk births that have been run by midwives for decades. There are currently 31 licensed birth centers in Florida and 411 free-standing birth centers in the United States, she said.

“This is a radical departure from the standard of care,” Bauer said. “It’s a bad idea,” she said, because it could increase risks to mom and baby.

No other state allows C-sections outside of hospitals. The only facility that offers similar care is a birth clinic in Wichita, Kansas, which is connected by a short walkway to a hospital, Wesley Medical Center.

The clinic provides “hotel-like” maternity suites where staffers deliver about 100 babies a month, compared with 500 per month in the hospital itself.

Morgan Tracy, a maternity nurse navigator at the center, said the concept works largely because the hospital and birthing suites can share staff and pharmacy access, plus patients can be quickly transferred to the main hospital if complications arise.

“The beauty is there are team members on both sides of the street,” Tracy said.
 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Florida has become the first state to allow doctors to perform cesarean sections outside of hospitals, siding with a private equity-owned physicians group that says the change will lower costs and give pregnant women the homier birthing atmosphere that many desire.

But the hospital industry and the nation’s leading obstetricians’ association say that even though some Florida hospitals have closed their maternity wards in recent years, performing C-sections in doctor-run clinics will increase the risks for women and babies when complications arise.

“A pregnant patient that is considered low-risk in one moment can suddenly need lifesaving care in the next,” Cole Greves, an Orlando perinatologist who chairs the Florida chapter of the American College of Obstetricians and Gynecologists, said in an email to KFF Health News. The new birth clinics, “even with increased regulation, cannot guarantee the level of safety patients would receive within a hospital.”

This spring, a law was enacted allowing “advanced birth centers,” where physicians can deliver babies vaginally or by C-section to women deemed at low risk of complications. Women would be able to stay overnight at the clinics.

Women’s Care Enterprises, a private equity-owned physicians group with locations mostly in Florida along with California and Kentucky, lobbied the state legislature to make the change. BC Partners, a London-based investment firm, bought Women’s Care in 2020.

“We have patients who don’t want to deliver in a hospital, and that breaks our heart,” said Stephen Snow, who recently retired as an ob.gyn. with Women’s Care and testified before the Florida Legislature advocating for the change in 2018.

Brittany Miller, vice president of strategic initiatives with Women’s Care, said the group would not comment on the issue.

Health experts are leery.

“What this looks like is a poor substitute for quality obstetrical care effectively being billed as something that gives people more choices,” said Alice Abernathy, an assistant professor of obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “This feels like a bad band-aid on a chronic issue that will make outcomes worse rather than better,” Abernathy said.

Nearly one-third of U.S. births occur via C-section, the surgical delivery of a baby through an incision in the mother’s abdomen and uterus. Generally, doctors use the procedure when they believe it is safer than vaginal delivery for the parent, the baby, or both. Such medical decisions can take place months before birth, or in an emergency.

Florida state Sen. Gayle Harrell, the Republican who sponsored the birth center bill, said having a C-section outside of a hospital may seem like a radical change, but so was the opening of outpatient surgery centers in the late 1980s.

Harrell, who managed her husband’s ob.gyn. practice, said birth centers will have to meet the same high standards for staffing, infection control, and other aspects as those at outpatient surgery centers.

“Given where we are with the need, and maternity deserts across the state, this is something that will help us and help moms get the best care,” she said.

Seventeen hospitals in the state have closed their maternity units since 2019, with many citing low insurance reimbursement and high malpractice costs, according to the Florida Hospital Association.

Mary Mayhew, CEO of the Florida Hospital Association, said it is wrong to compare birth centers to ambulatory surgery centers because of the many risks associated with C-sections, such as hemorrhaging.

The Florida law requires advanced birth centers to have a transfer agreement with a hospital, but it does not dictate where the facilities can open nor their proximity to a hospital.

“We have serious concerns about the impact this model has on our collective efforts to improve maternal and infant health,” Mayhew said. “Our hospitals do not see this in the best interest of providing quality and safety in labor and delivery.”

Despite its opposition to the new birth centers, the Florida Hospital Association did not fight passage of the overall bill because it also included a major increase in the amount Medicaid pays hospitals for maternity care.

Mayhew said it is unlikely that the birth centers would help address care shortages. Hospitals are already struggling with a shortage of ob.gyns., she said, and it is unrealistic to expect advanced birth centers to open in rural areas with a large proportion of people on Medicaid, which pays the lowest reimbursement for labor and delivery care.

It is unclear whether insurers will cover the advanced birth centers, though most insurers and Medicaid cover care at midwife-run birth centers. The advanced birth centers will not accept emergency walk-ins and will treat only patients whose insurance contracts with the facilities, making them in-network.

Snow, the retired ob.gyn. with Women’s Care, said the group plans to open an advanced birth center in the Tampa or Orlando area.

The advanced birth center concept is an improvement on midwife care that enables deliveries outside of hospitals, he said, as the centers allow women to stay overnight and, if necessary, offer anesthesia and C-sections.

Snow acknowledged that, with a private equity firm invested in Women’s Care, the birth center idea is also about making money. But he said hospitals have the same profit incentive and, like midwives, likely oppose the idea of centers that can provide C-sections because they could cut into hospital revenue.

“We are trying to reduce the cost of medicine, and this would be more cost-effective and more pleasant for patients,” he said.

Kate Bauer, executive director of the American Association of Birth Centers, said patients could confuse advanced birth centers with the existing, free-standing birth centers for low-risk births that have been run by midwives for decades. There are currently 31 licensed birth centers in Florida and 411 free-standing birth centers in the United States, she said.

“This is a radical departure from the standard of care,” Bauer said. “It’s a bad idea,” she said, because it could increase risks to mom and baby.

No other state allows C-sections outside of hospitals. The only facility that offers similar care is a birth clinic in Wichita, Kansas, which is connected by a short walkway to a hospital, Wesley Medical Center.

The clinic provides “hotel-like” maternity suites where staffers deliver about 100 babies a month, compared with 500 per month in the hospital itself.

Morgan Tracy, a maternity nurse navigator at the center, said the concept works largely because the hospital and birthing suites can share staff and pharmacy access, plus patients can be quickly transferred to the main hospital if complications arise.

“The beauty is there are team members on both sides of the street,” Tracy said.
 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Florida has become the first state to allow doctors to perform cesarean sections outside of hospitals, siding with a private equity-owned physicians group that says the change will lower costs and give pregnant women the homier birthing atmosphere that many desire.

But the hospital industry and the nation’s leading obstetricians’ association say that even though some Florida hospitals have closed their maternity wards in recent years, performing C-sections in doctor-run clinics will increase the risks for women and babies when complications arise.

“A pregnant patient that is considered low-risk in one moment can suddenly need lifesaving care in the next,” Cole Greves, an Orlando perinatologist who chairs the Florida chapter of the American College of Obstetricians and Gynecologists, said in an email to KFF Health News. The new birth clinics, “even with increased regulation, cannot guarantee the level of safety patients would receive within a hospital.”

This spring, a law was enacted allowing “advanced birth centers,” where physicians can deliver babies vaginally or by C-section to women deemed at low risk of complications. Women would be able to stay overnight at the clinics.

Women’s Care Enterprises, a private equity-owned physicians group with locations mostly in Florida along with California and Kentucky, lobbied the state legislature to make the change. BC Partners, a London-based investment firm, bought Women’s Care in 2020.

“We have patients who don’t want to deliver in a hospital, and that breaks our heart,” said Stephen Snow, who recently retired as an ob.gyn. with Women’s Care and testified before the Florida Legislature advocating for the change in 2018.

Brittany Miller, vice president of strategic initiatives with Women’s Care, said the group would not comment on the issue.

Health experts are leery.

“What this looks like is a poor substitute for quality obstetrical care effectively being billed as something that gives people more choices,” said Alice Abernathy, an assistant professor of obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “This feels like a bad band-aid on a chronic issue that will make outcomes worse rather than better,” Abernathy said.

Nearly one-third of U.S. births occur via C-section, the surgical delivery of a baby through an incision in the mother’s abdomen and uterus. Generally, doctors use the procedure when they believe it is safer than vaginal delivery for the parent, the baby, or both. Such medical decisions can take place months before birth, or in an emergency.

Florida state Sen. Gayle Harrell, the Republican who sponsored the birth center bill, said having a C-section outside of a hospital may seem like a radical change, but so was the opening of outpatient surgery centers in the late 1980s.

Harrell, who managed her husband’s ob.gyn. practice, said birth centers will have to meet the same high standards for staffing, infection control, and other aspects as those at outpatient surgery centers.

“Given where we are with the need, and maternity deserts across the state, this is something that will help us and help moms get the best care,” she said.

Seventeen hospitals in the state have closed their maternity units since 2019, with many citing low insurance reimbursement and high malpractice costs, according to the Florida Hospital Association.

Mary Mayhew, CEO of the Florida Hospital Association, said it is wrong to compare birth centers to ambulatory surgery centers because of the many risks associated with C-sections, such as hemorrhaging.

The Florida law requires advanced birth centers to have a transfer agreement with a hospital, but it does not dictate where the facilities can open nor their proximity to a hospital.

“We have serious concerns about the impact this model has on our collective efforts to improve maternal and infant health,” Mayhew said. “Our hospitals do not see this in the best interest of providing quality and safety in labor and delivery.”

Despite its opposition to the new birth centers, the Florida Hospital Association did not fight passage of the overall bill because it also included a major increase in the amount Medicaid pays hospitals for maternity care.

Mayhew said it is unlikely that the birth centers would help address care shortages. Hospitals are already struggling with a shortage of ob.gyns., she said, and it is unrealistic to expect advanced birth centers to open in rural areas with a large proportion of people on Medicaid, which pays the lowest reimbursement for labor and delivery care.

It is unclear whether insurers will cover the advanced birth centers, though most insurers and Medicaid cover care at midwife-run birth centers. The advanced birth centers will not accept emergency walk-ins and will treat only patients whose insurance contracts with the facilities, making them in-network.

Snow, the retired ob.gyn. with Women’s Care, said the group plans to open an advanced birth center in the Tampa or Orlando area.

The advanced birth center concept is an improvement on midwife care that enables deliveries outside of hospitals, he said, as the centers allow women to stay overnight and, if necessary, offer anesthesia and C-sections.

Snow acknowledged that, with a private equity firm invested in Women’s Care, the birth center idea is also about making money. But he said hospitals have the same profit incentive and, like midwives, likely oppose the idea of centers that can provide C-sections because they could cut into hospital revenue.

“We are trying to reduce the cost of medicine, and this would be more cost-effective and more pleasant for patients,” he said.

Kate Bauer, executive director of the American Association of Birth Centers, said patients could confuse advanced birth centers with the existing, free-standing birth centers for low-risk births that have been run by midwives for decades. There are currently 31 licensed birth centers in Florida and 411 free-standing birth centers in the United States, she said.

“This is a radical departure from the standard of care,” Bauer said. “It’s a bad idea,” she said, because it could increase risks to mom and baby.

No other state allows C-sections outside of hospitals. The only facility that offers similar care is a birth clinic in Wichita, Kansas, which is connected by a short walkway to a hospital, Wesley Medical Center.

The clinic provides “hotel-like” maternity suites where staffers deliver about 100 babies a month, compared with 500 per month in the hospital itself.

Morgan Tracy, a maternity nurse navigator at the center, said the concept works largely because the hospital and birthing suites can share staff and pharmacy access, plus patients can be quickly transferred to the main hospital if complications arise.

“The beauty is there are team members on both sides of the street,” Tracy said.
 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Over the past few years, several new, highly effective treatment strategies have improved survival outcomes in patients with early breast cancer.

“We’ve been very fortunate” to see these advances, Sara M. Tolaney, MD, MPH, chief, Division of Breast Oncology, Dana-Farber Cancer Institute, Boston, told attendees at the European Society of Medical Oncology (ESMO) Breast Cancer annual congress.

However, Dr. Tolaney noted, these new treatment approaches can come with big limitations — namely, potential overtreatment of some patients as well as short- and long-term toxicities, some of which can be life-threatening.

These caveats have prompted trials exploring strategies to de-escalate therapy, which essentially means providing the right amount of treatment to the right patient at the right time, said Dr. Tolaney. The goal is to “right-size” or “optimize therapy” to maintain strong outcomes while mitigating side effects.

De-escalation studies are “critical to preserving quality of life” and affect the cost-effectiveness of therapy, she explained.

But, she added, de-escalation trials are “not a very attractive strategy to pharmaceutical companies” and can be challenging for researchers to conduct. These trials may, for instance, lack adequate sample sizes and sufficient statistical power, which can interfere with achieving clinically meaningful findings that may affect practice.

That is why carefully designing de-escalation trials is crucial, Dr. Tolaney said.

In her talk at ESMO Breast, Dr. Tolaney highlighted several strategies for designing these trials.

One strategy is to shorten the duration of therapy, said Dr. Tolaney.

This approach was explored in the PHARE and PERSEPHONE trials, which looked at 6 vs 12 months of trastuzumab in nonmetastatic breast cancer. Other trials, such as GeparNuevo and KEYNOTE-522, explored whether adjuvant checkpoint inhibitor therapy was needed, or could be skipped, following neoadjuvant therapy. This approach requires establishing noninferiority, or similar efficacy, between the standard of care and the shorter duration of therapy.

A second strategy is to remove part of the chemotherapy regimen, typically the most toxic agent, Dr. Tolaney continued.

Conducting a prospective, randomized trial exploring this approach in human epidermal growth factor receptor 2–positive (HER2+) early breast cancer, for example, would be difficult for a range of reasons, such as the need to enroll thousands of patients.

Dr. Tolaney and colleagues, however, designed a nonrandomized prospective study — the APT trial — with just over 400 patients to assess adjuvant paclitaxel plus trastuzumab in patients with node-negative HER2+ disease. The open-label, single-arm, phase 2 APT trial found that adjuvant paclitaxel and trastuzumab led to a 10-year recurrence-free interval of 96.3%, 10-year overall survival of 94.3%, and 10-year breast cancer–specific survival of 98.8%.

Outcomes with this adjuvant regimen were comparable to previous findings in historical controls who received doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab or docetaxel, carboplatin, and trastuzumab.

Dr. Tolaney concluded that given few events, “it’s unlikely we need to escalate therapy to do better for most patients,” and the APT regimen “can be considered a reasonable and appealing approach for the majority of patients” with node-negative HER2+ breast cancer.

“A single-arm design for a de-escalation study can be practice-changing but only if there are very few recurrences,” Dr. Tolaney said.

Substituting chemotherapy with a targeted, potentially less-toxic agent is a third de-escalation approach. The ATEMPT trial compared patients receiving trastuzumab emtansine (T-DM1) with those receiving paclitaxel plus trastuzumab followed by maintenance trastuzumab.

Investigators found that de-escalation with T-DM1 was associated with very few recurrences but similar rates of certain adverse events, including grade 2 or higher neurotoxicity, febrile neutropenia, and grade 4 or higher hematologic toxicity.

However, there are questions about how to define “less toxic,” Dr. Tolaney said. The trial found, for instance, that T-DM1 did have some advantages — patients reported better quality of life and experienced less alopecia and neurotoxicity, as well as a less severe impact on fertility.

Understanding the right endpoint to demonstrate less toxicity is critical, “as we start to think about how to replace standard chemotherapies with better targeted drugs,” she added.

The ATEMPT 2.0 trial, which is currently enrolling, will aim to answer some of these questions about defining and demonstrating less toxicity, she said.

Finally, some researchers are attempting to omit chemotherapy altogether with the help of biomarkers. The TAILORx trial, for instance, aimed to stratify patients with early-stage breast cancer by clinical risk factors combined with a 21-gene expression assay and found that adjuvant chemotherapy was not necessary in a large proportion of these women.

On the biomarker front, oncologists might be able to use ctDNA to guide decision-making and personalize therapy, Tolaney said. The presence of ctDNA is associated with an almost 100% likelihood of having a recurrence, whereas its absence suggests better outcomes, she explained.

Oncologists could use the presence or absence of ctDNA to guide next steps — assign patients to follow-up assessments when ctDNA is not present or to standard or experimental treatment when it is present. It may also be possible to leverage the presence of minimal residual disease to help direct treatment choices.

But ctDNA is currently not as perfect a predictor of outcome as it could be, she cautioned. “We need more sensitive assays [so] I’m not sure we’re quite ready to use lack of ctDNA to de-escalate treatment,” she said.

Dr. Tolaney declared relationships with Novartis, Pfizer, Merck, Lilly, AstraZeneca, Genentech/Roche, Eisai, Sanofi, Bristol Myers Squib, and other companies.

A version of this article appeared on Medscape.com .

Over the past few years, several new, highly effective treatment strategies have improved survival outcomes in patients with early breast cancer.

“We’ve been very fortunate” to see these advances, Sara M. Tolaney, MD, MPH, chief, Division of Breast Oncology, Dana-Farber Cancer Institute, Boston, told attendees at the European Society of Medical Oncology (ESMO) Breast Cancer annual congress.

However, Dr. Tolaney noted, these new treatment approaches can come with big limitations — namely, potential overtreatment of some patients as well as short- and long-term toxicities, some of which can be life-threatening.

These caveats have prompted trials exploring strategies to de-escalate therapy, which essentially means providing the right amount of treatment to the right patient at the right time, said Dr. Tolaney. The goal is to “right-size” or “optimize therapy” to maintain strong outcomes while mitigating side effects.

De-escalation studies are “critical to preserving quality of life” and affect the cost-effectiveness of therapy, she explained.

But, she added, de-escalation trials are “not a very attractive strategy to pharmaceutical companies” and can be challenging for researchers to conduct. These trials may, for instance, lack adequate sample sizes and sufficient statistical power, which can interfere with achieving clinically meaningful findings that may affect practice.

That is why carefully designing de-escalation trials is crucial, Dr. Tolaney said.

In her talk at ESMO Breast, Dr. Tolaney highlighted several strategies for designing these trials.

One strategy is to shorten the duration of therapy, said Dr. Tolaney.

This approach was explored in the PHARE and PERSEPHONE trials, which looked at 6 vs 12 months of trastuzumab in nonmetastatic breast cancer. Other trials, such as GeparNuevo and KEYNOTE-522, explored whether adjuvant checkpoint inhibitor therapy was needed, or could be skipped, following neoadjuvant therapy. This approach requires establishing noninferiority, or similar efficacy, between the standard of care and the shorter duration of therapy.

A second strategy is to remove part of the chemotherapy regimen, typically the most toxic agent, Dr. Tolaney continued.

Conducting a prospective, randomized trial exploring this approach in human epidermal growth factor receptor 2–positive (HER2+) early breast cancer, for example, would be difficult for a range of reasons, such as the need to enroll thousands of patients.

Dr. Tolaney and colleagues, however, designed a nonrandomized prospective study — the APT trial — with just over 400 patients to assess adjuvant paclitaxel plus trastuzumab in patients with node-negative HER2+ disease. The open-label, single-arm, phase 2 APT trial found that adjuvant paclitaxel and trastuzumab led to a 10-year recurrence-free interval of 96.3%, 10-year overall survival of 94.3%, and 10-year breast cancer–specific survival of 98.8%.

Outcomes with this adjuvant regimen were comparable to previous findings in historical controls who received doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab or docetaxel, carboplatin, and trastuzumab.

Dr. Tolaney concluded that given few events, “it’s unlikely we need to escalate therapy to do better for most patients,” and the APT regimen “can be considered a reasonable and appealing approach for the majority of patients” with node-negative HER2+ breast cancer.

“A single-arm design for a de-escalation study can be practice-changing but only if there are very few recurrences,” Dr. Tolaney said.

Substituting chemotherapy with a targeted, potentially less-toxic agent is a third de-escalation approach. The ATEMPT trial compared patients receiving trastuzumab emtansine (T-DM1) with those receiving paclitaxel plus trastuzumab followed by maintenance trastuzumab.

Investigators found that de-escalation with T-DM1 was associated with very few recurrences but similar rates of certain adverse events, including grade 2 or higher neurotoxicity, febrile neutropenia, and grade 4 or higher hematologic toxicity.

However, there are questions about how to define “less toxic,” Dr. Tolaney said. The trial found, for instance, that T-DM1 did have some advantages — patients reported better quality of life and experienced less alopecia and neurotoxicity, as well as a less severe impact on fertility.

Understanding the right endpoint to demonstrate less toxicity is critical, “as we start to think about how to replace standard chemotherapies with better targeted drugs,” she added.

The ATEMPT 2.0 trial, which is currently enrolling, will aim to answer some of these questions about defining and demonstrating less toxicity, she said.

Finally, some researchers are attempting to omit chemotherapy altogether with the help of biomarkers. The TAILORx trial, for instance, aimed to stratify patients with early-stage breast cancer by clinical risk factors combined with a 21-gene expression assay and found that adjuvant chemotherapy was not necessary in a large proportion of these women.

On the biomarker front, oncologists might be able to use ctDNA to guide decision-making and personalize therapy, Tolaney said. The presence of ctDNA is associated with an almost 100% likelihood of having a recurrence, whereas its absence suggests better outcomes, she explained.

Oncologists could use the presence or absence of ctDNA to guide next steps — assign patients to follow-up assessments when ctDNA is not present or to standard or experimental treatment when it is present. It may also be possible to leverage the presence of minimal residual disease to help direct treatment choices.

But ctDNA is currently not as perfect a predictor of outcome as it could be, she cautioned. “We need more sensitive assays [so] I’m not sure we’re quite ready to use lack of ctDNA to de-escalate treatment,” she said.

Dr. Tolaney declared relationships with Novartis, Pfizer, Merck, Lilly, AstraZeneca, Genentech/Roche, Eisai, Sanofi, Bristol Myers Squib, and other companies.

A version of this article appeared on Medscape.com .

Over the past few years, several new, highly effective treatment strategies have improved survival outcomes in patients with early breast cancer.

“We’ve been very fortunate” to see these advances, Sara M. Tolaney, MD, MPH, chief, Division of Breast Oncology, Dana-Farber Cancer Institute, Boston, told attendees at the European Society of Medical Oncology (ESMO) Breast Cancer annual congress.

However, Dr. Tolaney noted, these new treatment approaches can come with big limitations — namely, potential overtreatment of some patients as well as short- and long-term toxicities, some of which can be life-threatening.

These caveats have prompted trials exploring strategies to de-escalate therapy, which essentially means providing the right amount of treatment to the right patient at the right time, said Dr. Tolaney. The goal is to “right-size” or “optimize therapy” to maintain strong outcomes while mitigating side effects.

De-escalation studies are “critical to preserving quality of life” and affect the cost-effectiveness of therapy, she explained.

But, she added, de-escalation trials are “not a very attractive strategy to pharmaceutical companies” and can be challenging for researchers to conduct. These trials may, for instance, lack adequate sample sizes and sufficient statistical power, which can interfere with achieving clinically meaningful findings that may affect practice.

That is why carefully designing de-escalation trials is crucial, Dr. Tolaney said.

In her talk at ESMO Breast, Dr. Tolaney highlighted several strategies for designing these trials.

One strategy is to shorten the duration of therapy, said Dr. Tolaney.

This approach was explored in the PHARE and PERSEPHONE trials, which looked at 6 vs 12 months of trastuzumab in nonmetastatic breast cancer. Other trials, such as GeparNuevo and KEYNOTE-522, explored whether adjuvant checkpoint inhibitor therapy was needed, or could be skipped, following neoadjuvant therapy. This approach requires establishing noninferiority, or similar efficacy, between the standard of care and the shorter duration of therapy.

A second strategy is to remove part of the chemotherapy regimen, typically the most toxic agent, Dr. Tolaney continued.

Conducting a prospective, randomized trial exploring this approach in human epidermal growth factor receptor 2–positive (HER2+) early breast cancer, for example, would be difficult for a range of reasons, such as the need to enroll thousands of patients.

Dr. Tolaney and colleagues, however, designed a nonrandomized prospective study — the APT trial — with just over 400 patients to assess adjuvant paclitaxel plus trastuzumab in patients with node-negative HER2+ disease. The open-label, single-arm, phase 2 APT trial found that adjuvant paclitaxel and trastuzumab led to a 10-year recurrence-free interval of 96.3%, 10-year overall survival of 94.3%, and 10-year breast cancer–specific survival of 98.8%.

Outcomes with this adjuvant regimen were comparable to previous findings in historical controls who received doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab or docetaxel, carboplatin, and trastuzumab.

Dr. Tolaney concluded that given few events, “it’s unlikely we need to escalate therapy to do better for most patients,” and the APT regimen “can be considered a reasonable and appealing approach for the majority of patients” with node-negative HER2+ breast cancer.

“A single-arm design for a de-escalation study can be practice-changing but only if there are very few recurrences,” Dr. Tolaney said.

Substituting chemotherapy with a targeted, potentially less-toxic agent is a third de-escalation approach. The ATEMPT trial compared patients receiving trastuzumab emtansine (T-DM1) with those receiving paclitaxel plus trastuzumab followed by maintenance trastuzumab.

Investigators found that de-escalation with T-DM1 was associated with very few recurrences but similar rates of certain adverse events, including grade 2 or higher neurotoxicity, febrile neutropenia, and grade 4 or higher hematologic toxicity.

However, there are questions about how to define “less toxic,” Dr. Tolaney said. The trial found, for instance, that T-DM1 did have some advantages — patients reported better quality of life and experienced less alopecia and neurotoxicity, as well as a less severe impact on fertility.

Understanding the right endpoint to demonstrate less toxicity is critical, “as we start to think about how to replace standard chemotherapies with better targeted drugs,” she added.

The ATEMPT 2.0 trial, which is currently enrolling, will aim to answer some of these questions about defining and demonstrating less toxicity, she said.

Finally, some researchers are attempting to omit chemotherapy altogether with the help of biomarkers. The TAILORx trial, for instance, aimed to stratify patients with early-stage breast cancer by clinical risk factors combined with a 21-gene expression assay and found that adjuvant chemotherapy was not necessary in a large proportion of these women.

On the biomarker front, oncologists might be able to use ctDNA to guide decision-making and personalize therapy, Tolaney said. The presence of ctDNA is associated with an almost 100% likelihood of having a recurrence, whereas its absence suggests better outcomes, she explained.

Oncologists could use the presence or absence of ctDNA to guide next steps — assign patients to follow-up assessments when ctDNA is not present or to standard or experimental treatment when it is present. It may also be possible to leverage the presence of minimal residual disease to help direct treatment choices.

But ctDNA is currently not as perfect a predictor of outcome as it could be, she cautioned. “We need more sensitive assays [so] I’m not sure we’re quite ready to use lack of ctDNA to de-escalate treatment,” she said.

Dr. Tolaney declared relationships with Novartis, Pfizer, Merck, Lilly, AstraZeneca, Genentech/Roche, Eisai, Sanofi, Bristol Myers Squib, and other companies.

A version of this article appeared on Medscape.com .

The envelope was a small one, with a handwritten address. Of course, there were other things in the mail to sort through: insurance payments, bills, correspondence. So I attended to those while I made coffee and started my computer.

After a few minutes I came back to the small envelope.

Inside was a card from a recently widowed lady, thanking me for my care of her husband and telling me I was very kind.

I’d only seem him once, about a year ago, and then had a follow-up phone call to go over the results.

In medicine you develop, as I’ve previously written, “Spidey Sense.” Things alert you that something bad is going on, even when you can’t quite put your finger on it yet. His story set off several of my alarms, and I sent him off for tests.

A few days later the electromyography and nerve conduction velocity (EMG/NCV) specialist I’d referred him to called to confirm the gentleman had ALS. He’d given him the diagnosis and started him on riluzole.

I called the patient and his wife that night to discuss things in more detail. My colleague, since neuromuscular disease is his field, had already started the process (this isn’t patient poaching, he and I have worked together long enough that he knows I’d rather he take over the case). I explained things further. They didn’t have any questions.

I didn’t hear from them again until the card came. On the flip side was a picture of them and their extended family. I have no idea how they vote, or what their religion is, or how much money they have. None of that matters.

They’re nice people, and a patient, who came to me for help. I was touched by her appreciation for the little I could do, and that she took time to express that to me.

None of us cures anyone in the long run. We can put off the inevitable, do our best to relieve suffering, and try to bring comfort — even when the last is all we can do.

Here in 2024, with all of our medications and computers and tests it’s hard to believe that we still come up short — very short – against so many diseases. Yet we do.

All of us can only do our best, even when the best we can do is to be kind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

The envelope was a small one, with a handwritten address. Of course, there were other things in the mail to sort through: insurance payments, bills, correspondence. So I attended to those while I made coffee and started my computer.

After a few minutes I came back to the small envelope.

Inside was a card from a recently widowed lady, thanking me for my care of her husband and telling me I was very kind.

I’d only seem him once, about a year ago, and then had a follow-up phone call to go over the results.

In medicine you develop, as I’ve previously written, “Spidey Sense.” Things alert you that something bad is going on, even when you can’t quite put your finger on it yet. His story set off several of my alarms, and I sent him off for tests.

A few days later the electromyography and nerve conduction velocity (EMG/NCV) specialist I’d referred him to called to confirm the gentleman had ALS. He’d given him the diagnosis and started him on riluzole.

I called the patient and his wife that night to discuss things in more detail. My colleague, since neuromuscular disease is his field, had already started the process (this isn’t patient poaching, he and I have worked together long enough that he knows I’d rather he take over the case). I explained things further. They didn’t have any questions.

I didn’t hear from them again until the card came. On the flip side was a picture of them and their extended family. I have no idea how they vote, or what their religion is, or how much money they have. None of that matters.

They’re nice people, and a patient, who came to me for help. I was touched by her appreciation for the little I could do, and that she took time to express that to me.

None of us cures anyone in the long run. We can put off the inevitable, do our best to relieve suffering, and try to bring comfort — even when the last is all we can do.

Here in 2024, with all of our medications and computers and tests it’s hard to believe that we still come up short — very short – against so many diseases. Yet we do.

All of us can only do our best, even when the best we can do is to be kind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

The envelope was a small one, with a handwritten address. Of course, there were other things in the mail to sort through: insurance payments, bills, correspondence. So I attended to those while I made coffee and started my computer.

After a few minutes I came back to the small envelope.

Inside was a card from a recently widowed lady, thanking me for my care of her husband and telling me I was very kind.

I’d only seem him once, about a year ago, and then had a follow-up phone call to go over the results.

In medicine you develop, as I’ve previously written, “Spidey Sense.” Things alert you that something bad is going on, even when you can’t quite put your finger on it yet. His story set off several of my alarms, and I sent him off for tests.

A few days later the electromyography and nerve conduction velocity (EMG/NCV) specialist I’d referred him to called to confirm the gentleman had ALS. He’d given him the diagnosis and started him on riluzole.

I called the patient and his wife that night to discuss things in more detail. My colleague, since neuromuscular disease is his field, had already started the process (this isn’t patient poaching, he and I have worked together long enough that he knows I’d rather he take over the case). I explained things further. They didn’t have any questions.

I didn’t hear from them again until the card came. On the flip side was a picture of them and their extended family. I have no idea how they vote, or what their religion is, or how much money they have. None of that matters.

They’re nice people, and a patient, who came to me for help. I was touched by her appreciation for the little I could do, and that she took time to express that to me.

None of us cures anyone in the long run. We can put off the inevitable, do our best to relieve suffering, and try to bring comfort — even when the last is all we can do.

Here in 2024, with all of our medications and computers and tests it’s hard to believe that we still come up short — very short – against so many diseases. Yet we do.

All of us can only do our best, even when the best we can do is to be kind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

About 45,000 people will descend on Chicago for the American Society of Clinical Oncology (ASCO) annual meeting, starting May 31.

From its origins in 1964, ASCO’s annual event has grown to become the world’s largest clinical oncology meeting, drawing attendees from across the globe.

More than 7000 abstracts were submitted for this year’s meeting a new record — and over 5000 were selected for presentation.

This year’s chair of the Annual Meeting Education Committee, Thomas William LeBlanc, MD, told us he has been attending the meeting since his training days more than a decade ago.

The event is “just incredibly empowering and energizing,” Dr. LeBlanc said, with opportunities to catch up with old colleagues and meet new ones, learn how far oncology has come and where it’s headed, and hear clinical pearls to take back the clinic.

This year’s theme, selected by ASCO President Lynn M. Schuchter, MD, is “The Art and Science of Cancer Care: From Comfort to Cure.” 

Dr. LeBlanc, a blood cancer specialist at Duke University, Durham, North Carolina, said the theme has been woven throughout the abstract and educational sessions. Most sessions will have at least one presentation related to how we support people — not only “when we cure them but also when we can’t cure them,” he said.

Topics will include patient well-being, comfort measures, and survivorship. And for the first time the plenary session will include a palliative care abstract that addresses whether or not palliative care can be delivered effectively through telemedicine. The session is on Sunday, June 2. 

Other potentially practice changing plenary abstracts tackle immunotherapy combinations for resectable melanoma, perioperative chemotherapy vs neoadjuvant chemoradiation for esophageal cancer, and osimertinib after definitive chemoradiotherapy for unresectable non–small cell lung cancer.

ASCO is piloting a slightly different format for research presentations this year. Instead of starting with context and background, speakers have been asked to present study results upfront as well as repeat them at the end of the talk. The reason behind the tweak is that engagement and retention tend to be better when results are presented upfront, instead of just at the end of a talk.

A popular session — ASCO Voices — has also been given a more central position in the conference: Friday, May 31. In this session, speakers will give short presentations about their personal experiences as providers, researchers, or patients.

ASCO Voices is a relatively recent addition to the meeting that has grown and gotten better. The talks are usually “very powerful narratives” that remind clinicians about “the importance of what they’re doing each day,” Dr. LeBlanc said.

Snippets of the talks will be played while people wait for sessions to begin at the meeting, so attendees who miss the Friday talks can still hear them.

In terms of educational sessions, Dr. LeBlanc highlighted two that might be of general interest to practicing oncologists: A joint ASCO/American Association for Cancer Research session entitled “Drugging the ‘Undruggable’ Target: Successes, Challenges, and the Road Ahead,” on Sunday morning and “Common Sense Oncology: Equity, Value, and Outcomes That Matter” on Monday morning.

As a blood cancer specialist, he said he is particularly interested in the topline results from the ASC4FIRST trial of asciminib, a newer kinase inhibitor, in newly diagnosed chronic myeloid leukemia, presented on Friday.

As in past years, this news organization will be on hand providing coverage with a dedicated team of reporters, editors, and videographers. Stop by our exhibit hall booth — number 26030 — to learn about the tools we offer to support your practice.
 

A version of this article appeared on Medscape.com .

About 45,000 people will descend on Chicago for the American Society of Clinical Oncology (ASCO) annual meeting, starting May 31.

From its origins in 1964, ASCO’s annual event has grown to become the world’s largest clinical oncology meeting, drawing attendees from across the globe.

More than 7000 abstracts were submitted for this year’s meeting a new record — and over 5000 were selected for presentation.

This year’s chair of the Annual Meeting Education Committee, Thomas William LeBlanc, MD, told us he has been attending the meeting since his training days more than a decade ago.

The event is “just incredibly empowering and energizing,” Dr. LeBlanc said, with opportunities to catch up with old colleagues and meet new ones, learn how far oncology has come and where it’s headed, and hear clinical pearls to take back the clinic.

This year’s theme, selected by ASCO President Lynn M. Schuchter, MD, is “The Art and Science of Cancer Care: From Comfort to Cure.” 

Dr. LeBlanc, a blood cancer specialist at Duke University, Durham, North Carolina, said the theme has been woven throughout the abstract and educational sessions. Most sessions will have at least one presentation related to how we support people — not only “when we cure them but also when we can’t cure them,” he said.

Topics will include patient well-being, comfort measures, and survivorship. And for the first time the plenary session will include a palliative care abstract that addresses whether or not palliative care can be delivered effectively through telemedicine. The session is on Sunday, June 2. 

Other potentially practice changing plenary abstracts tackle immunotherapy combinations for resectable melanoma, perioperative chemotherapy vs neoadjuvant chemoradiation for esophageal cancer, and osimertinib after definitive chemoradiotherapy for unresectable non–small cell lung cancer.

ASCO is piloting a slightly different format for research presentations this year. Instead of starting with context and background, speakers have been asked to present study results upfront as well as repeat them at the end of the talk. The reason behind the tweak is that engagement and retention tend to be better when results are presented upfront, instead of just at the end of a talk.

A popular session — ASCO Voices — has also been given a more central position in the conference: Friday, May 31. In this session, speakers will give short presentations about their personal experiences as providers, researchers, or patients.

ASCO Voices is a relatively recent addition to the meeting that has grown and gotten better. The talks are usually “very powerful narratives” that remind clinicians about “the importance of what they’re doing each day,” Dr. LeBlanc said.

Snippets of the talks will be played while people wait for sessions to begin at the meeting, so attendees who miss the Friday talks can still hear them.

In terms of educational sessions, Dr. LeBlanc highlighted two that might be of general interest to practicing oncologists: A joint ASCO/American Association for Cancer Research session entitled “Drugging the ‘Undruggable’ Target: Successes, Challenges, and the Road Ahead,” on Sunday morning and “Common Sense Oncology: Equity, Value, and Outcomes That Matter” on Monday morning.

As a blood cancer specialist, he said he is particularly interested in the topline results from the ASC4FIRST trial of asciminib, a newer kinase inhibitor, in newly diagnosed chronic myeloid leukemia, presented on Friday.

As in past years, this news organization will be on hand providing coverage with a dedicated team of reporters, editors, and videographers. Stop by our exhibit hall booth — number 26030 — to learn about the tools we offer to support your practice.
 

A version of this article appeared on Medscape.com .

About 45,000 people will descend on Chicago for the American Society of Clinical Oncology (ASCO) annual meeting, starting May 31.

From its origins in 1964, ASCO’s annual event has grown to become the world’s largest clinical oncology meeting, drawing attendees from across the globe.

More than 7000 abstracts were submitted for this year’s meeting a new record — and over 5000 were selected for presentation.

This year’s chair of the Annual Meeting Education Committee, Thomas William LeBlanc, MD, told us he has been attending the meeting since his training days more than a decade ago.

The event is “just incredibly empowering and energizing,” Dr. LeBlanc said, with opportunities to catch up with old colleagues and meet new ones, learn how far oncology has come and where it’s headed, and hear clinical pearls to take back the clinic.

This year’s theme, selected by ASCO President Lynn M. Schuchter, MD, is “The Art and Science of Cancer Care: From Comfort to Cure.” 

Dr. LeBlanc, a blood cancer specialist at Duke University, Durham, North Carolina, said the theme has been woven throughout the abstract and educational sessions. Most sessions will have at least one presentation related to how we support people — not only “when we cure them but also when we can’t cure them,” he said.

Topics will include patient well-being, comfort measures, and survivorship. And for the first time the plenary session will include a palliative care abstract that addresses whether or not palliative care can be delivered effectively through telemedicine. The session is on Sunday, June 2. 

Other potentially practice changing plenary abstracts tackle immunotherapy combinations for resectable melanoma, perioperative chemotherapy vs neoadjuvant chemoradiation for esophageal cancer, and osimertinib after definitive chemoradiotherapy for unresectable non–small cell lung cancer.

ASCO is piloting a slightly different format for research presentations this year. Instead of starting with context and background, speakers have been asked to present study results upfront as well as repeat them at the end of the talk. The reason behind the tweak is that engagement and retention tend to be better when results are presented upfront, instead of just at the end of a talk.

A popular session — ASCO Voices — has also been given a more central position in the conference: Friday, May 31. In this session, speakers will give short presentations about their personal experiences as providers, researchers, or patients.

ASCO Voices is a relatively recent addition to the meeting that has grown and gotten better. The talks are usually “very powerful narratives” that remind clinicians about “the importance of what they’re doing each day,” Dr. LeBlanc said.

Snippets of the talks will be played while people wait for sessions to begin at the meeting, so attendees who miss the Friday talks can still hear them.

In terms of educational sessions, Dr. LeBlanc highlighted two that might be of general interest to practicing oncologists: A joint ASCO/American Association for Cancer Research session entitled “Drugging the ‘Undruggable’ Target: Successes, Challenges, and the Road Ahead,” on Sunday morning and “Common Sense Oncology: Equity, Value, and Outcomes That Matter” on Monday morning.

As a blood cancer specialist, he said he is particularly interested in the topline results from the ASC4FIRST trial of asciminib, a newer kinase inhibitor, in newly diagnosed chronic myeloid leukemia, presented on Friday.

As in past years, this news organization will be on hand providing coverage with a dedicated team of reporters, editors, and videographers. Stop by our exhibit hall booth — number 26030 — to learn about the tools we offer to support your practice.
 

A version of this article appeared on Medscape.com .

For those outside the medical profession, it took a global pandemic to finally understand how pervasive distress and suicide are among medical professionals, particularly surgeons.

For James Harrop, MD, it was made real years earlier by a colleague he’d trained alongside and worked with for decades — “one of the best surgeons I’ve ever seen” who, one day, just wasn’t there.

Lost in his own work, it wasn’t until Dr. Harrop, a professor of neurological and orthopedic surgery at Thomas Jefferson University, Philadelphia, read an article in The New England Journal of Medicine and realized his friend Michael Weinstein, MD, MPH, had been profoundly depressed for years and was hospitalized for his own safety.

Dr. Weinstein recovered and later gave grand rounds at Thomas Jefferson University, where he is an associate professor of surgery in the Acute Care Surgery Division. But the story stuck with Dr. Harrop.

“I said to Mike afterward, I’ve known you for 20 years and, retrospectively, going back, I never saw a single sign that you were depressed, sad, or had any issues, and he said to me ‘that’s because I did everything I could to make sure no one knew I had a problem,’ ” Dr. Harrop said during a talk on physician suicide on May 4 at the American Association of Neurological Surgeons (AANS) 2024 Annual Meeting.

“And that scared me because we need to help these people, we need to identify who they are.”

Surgeons at Greater Risk

Studies have reported that suicide and suicidal ideation are nearly twice as common among physicians, compared with among the general population. Among 9175 physicians surveyed in the 2023 Medscape Physician Suicide Report, 9% had considered suicide, and 1% had attempted it. The average for US adults is 4.9% and 0.5%, respectively.

Surgeons are at particularly high risk. A 2011 survey of 7905 US surgeons found that 1 in 16 (6.3%) had considered suicide in the previous year. A post-pandemic survey of more than 600 surgeons and surgical trainees reported that one in seven had suicidal ideation.

It’s often estimated that between 300 and 400 physicians die by suicide each year in the United States, but exact numbers are not known. Recent updated estimates from the National Violent Death Reporting System put the number at 119 physician suicides annually.

Notably, that’s no better than data reported more than 50 years ago in the landmark policy paper The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence. It sounded the alarm on poor mental health in physicians and reported that 100 doctors died by suicide annually — the equivalent of the average medical school graduating class at the time.

“If I take my med school class and double it, that’s how many physicians die each year,” Dr. Harrop said. “And here’s the bad news, it starts in medical school.”

Research shows higher rates of depression and suicidal ideation in medical students and residents than in other graduates, with rates varying by stage of training, he noted.

In a multischool study, 12% of medical students and residents had probable major depression, 9.2% mild/moderate depression, and suicidal ideation jumped from 6.6% in the first year of medical school to 9.4% in year 4.

A recent AANS survey of 346 neurosurgery residents revealed 67% had burnout, and 41% seriously considered quitting. Burnout rose to a high of 76% in the second year and decreased to 49% and 54% in years 3 and 4, respectively.

Inadequate operating room exposure, hostile faculty, and stressors outside work were tied to burnout, whereas mentorship was linked to a threefold lower likelihood of burnout.

Notably, a 2019 study conservatively estimated that the annual cost of burnout-related physician turnover and reduced clinical hours was $4.6 billion nationally and $7600 per employed physician for an organization.

“We need to be kinder to each other, to look out for each other, and to talk to each other,” Dr. Harrop told conference attendees.

‘Death by a 1000 Cuts’

A host of factors are associated with physician suicide including long work hours, delayed gratification, difficulty balancing work and home life, changing healthcare systems, lawsuits, and the unique ability to prescribe medications, said Dr. Harrop.

“In my life, I think of it as death by 1000 cuts. Every day I come in, you’ve got another person attacking you,” he said, referencing Death by 1000 Cuts: Medscape National Physician Burnout & Suicide Report 2021.

Dr. Harrop told this news organization that talking with numerous experts in this field has made him appreciate that anyone is at a risk for suicide.

“The problem is an overload of external resources crushing your existence to the point that you become paralyzed and make the irrational thought that the best solution is to end your life,” he said.

Ann Stroink, MD, immediate past president of the AANS, said in an interview that one potential trigger for burnout is the current shortage of neurosurgeons in the United States, which has led to increased workloads and potential sleep deprivation among existing neurosurgeons.

“To address this critical issue, we’ve been advocating through legislative channels for additional Medicare[-funded] slots” to train more neurosurgeons, she said. “It’s imperative that we take proactive steps to ensure that our healthcare system can sustainably meet the needs of patients, while also supporting the well-being of our neurosurgical professionals.”

The AANS is also advocating for decreased regulatory burdens associated with Medicare and insurance coverage, such as prior authorization, to help alleviate the administrative burdens that often contribute to burnout among its members, Dr. Stroink said.

A Model for Suicide Prevention

Dr. Harrop emphasized that suicide is preventable and that there is “some good news.” Turning to another high-risk profession, he noted that the US Air Force was able to reduce its suicide rate by 42.7% between 1994 and 1998 by doing three basic things.

The agency established a central surveillance database, restructured prevention services, and, more importantly, began conducting annual suicide prevention and awareness training, using gatekeepers to channel at-risk personnel to appropriate agencies and performing mental health questionnaires at enrollment and annually.

Similarly, education, screening, and access to mental health treatment are core recommendations for a national response to depression and suicide in physician trainees, said Dr. Harrop, who noted that his own hospital has started using the Patient Health Questionnaire 9-item for its staff.

Asked by this news organization how much progress has been made since The Sick Physician report, Dr. Harrop said, “we are probably doing worse” in terms of the number of physician suicides, but “on a positive note, we are better with resources and acknowledgment that a problem exists.”

He noted that the AANS, which has published a physician burnout series on its Neurosurgery Blog, has shown great interest in this topic and is working to spread the word to help neurosurgeons. “My simple talk has led to me being approached by numerous people and healthcare organizations on how to further focus resources and prevention of this problem.”

Asked the one thing he would tell his friend, Michael Weinstein, a fellow surgeon, or trainee who’s struggling, Dr. Harrop said, “I am here for you, and we will get over these temporary problems, which are not significant in the big picture of what you mean to the world.”

Dr. Harrop reported serving as an adviser for Ethicon and Spiderwort.

A version of this article appeared on Medscape.com.

For those outside the medical profession, it took a global pandemic to finally understand how pervasive distress and suicide are among medical professionals, particularly surgeons.

For James Harrop, MD, it was made real years earlier by a colleague he’d trained alongside and worked with for decades — “one of the best surgeons I’ve ever seen” who, one day, just wasn’t there.

Lost in his own work, it wasn’t until Dr. Harrop, a professor of neurological and orthopedic surgery at Thomas Jefferson University, Philadelphia, read an article in The New England Journal of Medicine and realized his friend Michael Weinstein, MD, MPH, had been profoundly depressed for years and was hospitalized for his own safety.

Dr. Weinstein recovered and later gave grand rounds at Thomas Jefferson University, where he is an associate professor of surgery in the Acute Care Surgery Division. But the story stuck with Dr. Harrop.

“I said to Mike afterward, I’ve known you for 20 years and, retrospectively, going back, I never saw a single sign that you were depressed, sad, or had any issues, and he said to me ‘that’s because I did everything I could to make sure no one knew I had a problem,’ ” Dr. Harrop said during a talk on physician suicide on May 4 at the American Association of Neurological Surgeons (AANS) 2024 Annual Meeting.

“And that scared me because we need to help these people, we need to identify who they are.”

Surgeons at Greater Risk

Studies have reported that suicide and suicidal ideation are nearly twice as common among physicians, compared with among the general population. Among 9175 physicians surveyed in the 2023 Medscape Physician Suicide Report, 9% had considered suicide, and 1% had attempted it. The average for US adults is 4.9% and 0.5%, respectively.

Surgeons are at particularly high risk. A 2011 survey of 7905 US surgeons found that 1 in 16 (6.3%) had considered suicide in the previous year. A post-pandemic survey of more than 600 surgeons and surgical trainees reported that one in seven had suicidal ideation.

It’s often estimated that between 300 and 400 physicians die by suicide each year in the United States, but exact numbers are not known. Recent updated estimates from the National Violent Death Reporting System put the number at 119 physician suicides annually.

Notably, that’s no better than data reported more than 50 years ago in the landmark policy paper The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence. It sounded the alarm on poor mental health in physicians and reported that 100 doctors died by suicide annually — the equivalent of the average medical school graduating class at the time.

“If I take my med school class and double it, that’s how many physicians die each year,” Dr. Harrop said. “And here’s the bad news, it starts in medical school.”

Research shows higher rates of depression and suicidal ideation in medical students and residents than in other graduates, with rates varying by stage of training, he noted.

In a multischool study, 12% of medical students and residents had probable major depression, 9.2% mild/moderate depression, and suicidal ideation jumped from 6.6% in the first year of medical school to 9.4% in year 4.

A recent AANS survey of 346 neurosurgery residents revealed 67% had burnout, and 41% seriously considered quitting. Burnout rose to a high of 76% in the second year and decreased to 49% and 54% in years 3 and 4, respectively.

Inadequate operating room exposure, hostile faculty, and stressors outside work were tied to burnout, whereas mentorship was linked to a threefold lower likelihood of burnout.

Notably, a 2019 study conservatively estimated that the annual cost of burnout-related physician turnover and reduced clinical hours was $4.6 billion nationally and $7600 per employed physician for an organization.

“We need to be kinder to each other, to look out for each other, and to talk to each other,” Dr. Harrop told conference attendees.

‘Death by a 1000 Cuts’

A host of factors are associated with physician suicide including long work hours, delayed gratification, difficulty balancing work and home life, changing healthcare systems, lawsuits, and the unique ability to prescribe medications, said Dr. Harrop.

“In my life, I think of it as death by 1000 cuts. Every day I come in, you’ve got another person attacking you,” he said, referencing Death by 1000 Cuts: Medscape National Physician Burnout & Suicide Report 2021.

Dr. Harrop told this news organization that talking with numerous experts in this field has made him appreciate that anyone is at a risk for suicide.

“The problem is an overload of external resources crushing your existence to the point that you become paralyzed and make the irrational thought that the best solution is to end your life,” he said.

Ann Stroink, MD, immediate past president of the AANS, said in an interview that one potential trigger for burnout is the current shortage of neurosurgeons in the United States, which has led to increased workloads and potential sleep deprivation among existing neurosurgeons.

“To address this critical issue, we’ve been advocating through legislative channels for additional Medicare[-funded] slots” to train more neurosurgeons, she said. “It’s imperative that we take proactive steps to ensure that our healthcare system can sustainably meet the needs of patients, while also supporting the well-being of our neurosurgical professionals.”

The AANS is also advocating for decreased regulatory burdens associated with Medicare and insurance coverage, such as prior authorization, to help alleviate the administrative burdens that often contribute to burnout among its members, Dr. Stroink said.

A Model for Suicide Prevention

Dr. Harrop emphasized that suicide is preventable and that there is “some good news.” Turning to another high-risk profession, he noted that the US Air Force was able to reduce its suicide rate by 42.7% between 1994 and 1998 by doing three basic things.

The agency established a central surveillance database, restructured prevention services, and, more importantly, began conducting annual suicide prevention and awareness training, using gatekeepers to channel at-risk personnel to appropriate agencies and performing mental health questionnaires at enrollment and annually.

Similarly, education, screening, and access to mental health treatment are core recommendations for a national response to depression and suicide in physician trainees, said Dr. Harrop, who noted that his own hospital has started using the Patient Health Questionnaire 9-item for its staff.

Asked by this news organization how much progress has been made since The Sick Physician report, Dr. Harrop said, “we are probably doing worse” in terms of the number of physician suicides, but “on a positive note, we are better with resources and acknowledgment that a problem exists.”

He noted that the AANS, which has published a physician burnout series on its Neurosurgery Blog, has shown great interest in this topic and is working to spread the word to help neurosurgeons. “My simple talk has led to me being approached by numerous people and healthcare organizations on how to further focus resources and prevention of this problem.”

Asked the one thing he would tell his friend, Michael Weinstein, a fellow surgeon, or trainee who’s struggling, Dr. Harrop said, “I am here for you, and we will get over these temporary problems, which are not significant in the big picture of what you mean to the world.”

Dr. Harrop reported serving as an adviser for Ethicon and Spiderwort.

A version of this article appeared on Medscape.com.

For those outside the medical profession, it took a global pandemic to finally understand how pervasive distress and suicide are among medical professionals, particularly surgeons.

For James Harrop, MD, it was made real years earlier by a colleague he’d trained alongside and worked with for decades — “one of the best surgeons I’ve ever seen” who, one day, just wasn’t there.

Lost in his own work, it wasn’t until Dr. Harrop, a professor of neurological and orthopedic surgery at Thomas Jefferson University, Philadelphia, read an article in The New England Journal of Medicine and realized his friend Michael Weinstein, MD, MPH, had been profoundly depressed for years and was hospitalized for his own safety.

Dr. Weinstein recovered and later gave grand rounds at Thomas Jefferson University, where he is an associate professor of surgery in the Acute Care Surgery Division. But the story stuck with Dr. Harrop.

“I said to Mike afterward, I’ve known you for 20 years and, retrospectively, going back, I never saw a single sign that you were depressed, sad, or had any issues, and he said to me ‘that’s because I did everything I could to make sure no one knew I had a problem,’ ” Dr. Harrop said during a talk on physician suicide on May 4 at the American Association of Neurological Surgeons (AANS) 2024 Annual Meeting.

“And that scared me because we need to help these people, we need to identify who they are.”

Surgeons at Greater Risk

Studies have reported that suicide and suicidal ideation are nearly twice as common among physicians, compared with among the general population. Among 9175 physicians surveyed in the 2023 Medscape Physician Suicide Report, 9% had considered suicide, and 1% had attempted it. The average for US adults is 4.9% and 0.5%, respectively.

Surgeons are at particularly high risk. A 2011 survey of 7905 US surgeons found that 1 in 16 (6.3%) had considered suicide in the previous year. A post-pandemic survey of more than 600 surgeons and surgical trainees reported that one in seven had suicidal ideation.

It’s often estimated that between 300 and 400 physicians die by suicide each year in the United States, but exact numbers are not known. Recent updated estimates from the National Violent Death Reporting System put the number at 119 physician suicides annually.

Notably, that’s no better than data reported more than 50 years ago in the landmark policy paper The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence. It sounded the alarm on poor mental health in physicians and reported that 100 doctors died by suicide annually — the equivalent of the average medical school graduating class at the time.

“If I take my med school class and double it, that’s how many physicians die each year,” Dr. Harrop said. “And here’s the bad news, it starts in medical school.”

Research shows higher rates of depression and suicidal ideation in medical students and residents than in other graduates, with rates varying by stage of training, he noted.

In a multischool study, 12% of medical students and residents had probable major depression, 9.2% mild/moderate depression, and suicidal ideation jumped from 6.6% in the first year of medical school to 9.4% in year 4.

A recent AANS survey of 346 neurosurgery residents revealed 67% had burnout, and 41% seriously considered quitting. Burnout rose to a high of 76% in the second year and decreased to 49% and 54% in years 3 and 4, respectively.

Inadequate operating room exposure, hostile faculty, and stressors outside work were tied to burnout, whereas mentorship was linked to a threefold lower likelihood of burnout.

Notably, a 2019 study conservatively estimated that the annual cost of burnout-related physician turnover and reduced clinical hours was $4.6 billion nationally and $7600 per employed physician for an organization.

“We need to be kinder to each other, to look out for each other, and to talk to each other,” Dr. Harrop told conference attendees.

‘Death by a 1000 Cuts’

A host of factors are associated with physician suicide including long work hours, delayed gratification, difficulty balancing work and home life, changing healthcare systems, lawsuits, and the unique ability to prescribe medications, said Dr. Harrop.

“In my life, I think of it as death by 1000 cuts. Every day I come in, you’ve got another person attacking you,” he said, referencing Death by 1000 Cuts: Medscape National Physician Burnout & Suicide Report 2021.

Dr. Harrop told this news organization that talking with numerous experts in this field has made him appreciate that anyone is at a risk for suicide.

“The problem is an overload of external resources crushing your existence to the point that you become paralyzed and make the irrational thought that the best solution is to end your life,” he said.

Ann Stroink, MD, immediate past president of the AANS, said in an interview that one potential trigger for burnout is the current shortage of neurosurgeons in the United States, which has led to increased workloads and potential sleep deprivation among existing neurosurgeons.

“To address this critical issue, we’ve been advocating through legislative channels for additional Medicare[-funded] slots” to train more neurosurgeons, she said. “It’s imperative that we take proactive steps to ensure that our healthcare system can sustainably meet the needs of patients, while also supporting the well-being of our neurosurgical professionals.”

The AANS is also advocating for decreased regulatory burdens associated with Medicare and insurance coverage, such as prior authorization, to help alleviate the administrative burdens that often contribute to burnout among its members, Dr. Stroink said.

A Model for Suicide Prevention

Dr. Harrop emphasized that suicide is preventable and that there is “some good news.” Turning to another high-risk profession, he noted that the US Air Force was able to reduce its suicide rate by 42.7% between 1994 and 1998 by doing three basic things.

The agency established a central surveillance database, restructured prevention services, and, more importantly, began conducting annual suicide prevention and awareness training, using gatekeepers to channel at-risk personnel to appropriate agencies and performing mental health questionnaires at enrollment and annually.

Similarly, education, screening, and access to mental health treatment are core recommendations for a national response to depression and suicide in physician trainees, said Dr. Harrop, who noted that his own hospital has started using the Patient Health Questionnaire 9-item for its staff.

Asked by this news organization how much progress has been made since The Sick Physician report, Dr. Harrop said, “we are probably doing worse” in terms of the number of physician suicides, but “on a positive note, we are better with resources and acknowledgment that a problem exists.”

He noted that the AANS, which has published a physician burnout series on its Neurosurgery Blog, has shown great interest in this topic and is working to spread the word to help neurosurgeons. “My simple talk has led to me being approached by numerous people and healthcare organizations on how to further focus resources and prevention of this problem.”

Asked the one thing he would tell his friend, Michael Weinstein, a fellow surgeon, or trainee who’s struggling, Dr. Harrop said, “I am here for you, and we will get over these temporary problems, which are not significant in the big picture of what you mean to the world.”

Dr. Harrop reported serving as an adviser for Ethicon and Spiderwort.

A version of this article appeared on Medscape.com.