It’s Not Just About How Much You’re Paid
It's Not Just About How Much You're Paid
David M. Levine
Bruce E. Landon
0 Department of Health Care Policy, Harvard Medical School , Boston, MA , USA
1 Harvard Medical School , Boston, MA , USA
2 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital , Boston, MA , USA
3 Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center , Boston, MA , USA
P cians is a national priority, particularly in primary care
romoting wellness and preventing burnout among
physiwhere a burgeoning work force shortage is looming.1
Prominent national physician organizations including the American
College of Physicians, The American Medical Association,
and the American Academy of Family Physicians are
dedicating significant resources to programs to improve physician
work life and well-being. Prior research on physician career
satisfaction has shown that satisfaction is related to many
aspects of physician work place conditions including time
pressures, a lack of control over day-to-day decisions affecting
patient care, and collegiality.2 Work place satisfaction is
strongly associated with burnout and stress, as well as intent
to leave and actually leaving practice,3 and some data suggest
that physician satisfaction might be associated with patient
satisfaction and quality of care.4
Yet, for the hundreds of articles written about physician
satisfaction and dozens of national trainings available to
improve physician work place conditions, the relationship
between compensation and physician work place satisfaction is
relatively poorly understood. Clearly, compensation, at least to
some extent, drives career choices. For instance, medical
students increasingly gravitate to specialties that are more
highly compensated and have a better potential for work life
balance.5 Primary care and other cognitive specialties wherein
most compensation is derived from evaluation and
management services rather than performing procedures has been
particularly impacted, and this is thought to be one of the
primary reasons that fewer medical students choose to enter
these fields. However, those choosing to enter primary care
know this information at the time they are making their
choices and one might expect that those who think primary
care compensation Bunfair^ would choose to enter another
The determinants of fairness in physician compensation
thus likely are multifactorial and might relate to the frame of
reference. At one extreme, physicians might compare
themselves to those in other professions they might have
selected such as law or finance, which might leave even those
in high-paying medical specialties feeling like their pay is not
fair. At the other extreme, physicians might compare relative
pay within their field (or even their practice). Lastly, rather
than focusing on exact compensation, fairness might be
judged by understanding and agreeing with the methods used
to determine pay in their particular setting.6 High-performing
organizations nurture work place cultures built upon a
foundation of trust and mutual understanding, and the methods
used to determine compensation and reward performance can
be an important contributor to workplace culture.
In this issue of JGIM, Kao and colleagues examine the
association between physicians’ perception of how fairly they
are paid with work satisfaction, intent to leave practice, and
personal health.7 They surveyed a random sample of 4000
physicians from the Physician Masterfile by mail, ultimately
collecting 2263 responses for an adjusted 63% response rate.
The sample included physicians from all specialties.
Importantly, primary care physicians were not over-sampled and the
response rate by specialty is not shown. As in most studies of
physician career satisfaction, most physicians were satisfied at
work, were unlikely to leave their practice, and were in very
good or excellent self-reported health. Those with higher
compensation were more satisfied and less likely to leave
practice, but intriguingly, after adjusting for perceived pay
fairness, there was no significant relationship between higher
compensation and satisfaction, intent to leave, or health. Yet, it
is not clear how physicians interpreted some of the single item
non-validated questions used and to what extent missing data
could have altered the study’s conclusions.
Although this study provides potentially important insights
for practicing physicians and those managing physician
practices, it also raises several questions. First, although the survey
instrument was cognitively tested, no information is presented
on how physicians actually interpreted the question on
compensation fairness. As noted above, it may be the case that
physicians judge the fairness of their pay relative to the pay of
others in the same specialty in the same geographic region of
the country. Thus, it would be interesting to see results stratified
by region and specialty within region. Second, it also might be
important to understand how compensation had changed over
time. For instance, radiology, which is considered relatively
well compensated, has seen pay decreases over some recent
years, which also might influence their perceptions of fairness.8
Third, little is known about other aspects of the workplace for
respondents including work hours and conditions, the
functionality of the electronic health record, expectations of
productivity, work flow, and availability and types of support staff.
It is likely that perceptions of pay fairness also are associated
with other aspects of the workplace making it difficult to know
if there are other confounders. For instance, physicians who
perceive their pay to be fair might be more likely to work in
supportive settings with a positive workplace environment.
More importantly, because of the cross-sectional nature of this
study, it is difficult to tell if the observed associations are
causal. For instance, physicians who are dissatisfied with their
current workplace are the most likely to leave and might point
to inadequate compensation as one of the reasons. Finally, there
was substantial missing data (over 20%) for the compensation
question, and these data likely were not missing at random,
which might introduce bias into some of the analyses.
So how should our profession proceed? First, as the authors
point out, the human resources literature already has clearly
described the phenomenon of perceived pay fairness. One
tried and true method used in human resources is the use of
360-degree feedback and other strategies that improve
transparency and perceived fairness. Anecdotally, this rarely
happens in clinical medicine but could be adapted to improve
perceived pay fairness. Second, as reimbursement shifts from
fee-for-service to value, we need to be cognizant that that we
do not increase perceived unfairness, as many do not agree
with the measures used to determine quality bonuses, the
timeliness of data and feedback, or the algorithms that are
used to attribute patients to clinicians or organizations for
purposes of accountability. Third, given that employees who
understand the process for determining compensation and
understand all the factors affecting their pay perceive pay to
be fair, it would likely benefit organizations to practice highly
transparent hiring and salary practices. Fourth, in the
healthcare context, we likely should not perceive this to be a
problem only of physicians. Interestingly, a very similar study
completed among nurses reached similar conclusions, and
there is no reason to think that medical assistants and other
key staff in practices would not have similar views.8 Perhaps,
lessons can be learned from other healthcare professional
leadership, or a concerted approach can be taken together.
The bottom line: it is time to pay attention to how
physicians perceive their paycheck. Doing so might be one easily
implemented strategy for promoting workplace wellness and
preventing burnout, something that most studies and trainings
have failed to do. It may even help direct more physicians
toward primary care and lower-paying specialties. It is
important that this study reminds us that it is not just about the level
of compensation, but also the extent to which physicians
perceive their compensation as fair. Future work to improve
perceptions around compensation may be among the most
impactful burnout prevention tools seen to date.
Corresponding Author: Bruce E. Landon, MD MBA MSc;
Department of Health Care Policy Harvard Medical School, Boston, MA
02115, USA (e-mail: ).
Compliance with Ethical Standards:
Conflict of Interest: The authors declare that they do not have a
conflict of interest.
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8. Bernstein N. Job Prospects Are Dimming for Radiology Trainees . The New York Times. http://www.nytimes.com/ 2013 /03/28/health/trainees -inradiology-and-other-specialties-see-dream-jobs-disappearing . html. Published March 27 , 2013 .