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Original Research

Women, family medicine, and career choice

An opportunity cost analysis

Essary, Alison C. DHSc, MHPE, PA-C; Coplan, Bettie H. MPAS, PA-C; Cawley, James F. MPH, PA-C; Schneller, Eugene S. PhD; Ohsfeldt, Robert L. PhD

Author Information
Journal of the American Academy of PAs: September 2016 - Volume 29 - Issue 9 - p 44-48
doi: 10.1097/01.JAA.0000490949.02814.bc
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Abstract

Over time, women have successfully integrated into health professions that were once male-dominated. Women now account for nearly half of all medical school graduates and about 67% of practicing physician assistants (PAs).1,2 Despite this progress, female physicians and PAs earn less in almost every medical specialty, and women practicing in primary care are among the lowest paid in both fields.3-7 Compared with PAs, as well as most other healthcare professionals, physicians have longer training, higher educational costs, higher debt burdens, and start practice later in their careers.8,9 In 2012, Chen and Chevalier concluded that men made a sound investment in physician education.10 The economic investment made by women, however, was not as robust, and the authors determined that the PA profession would be a better investment.10 Consequently, the question of an economically optimal career choice for women merits further analysis.

Women in the PA physician professions are more likely to choose primary care specialties than their male counterparts, and although women account for just 30.2% of the physician workforce, they account for nearly half of all primary care physicians.4,11,12 In fact, by 2005, a 40% increase in female primary care physicians helped compensate for a 16% decrease in male primary care physicians.13 Additionally, although female physicians tend to work fewer hours and see fewer patients than male physicians, research suggests that they see more female patients, engage in more patient-centered communication, and are more likely to provide preventive services for women.10,14-16 These are but a few of the important ways that female primary care physicians affect the healthcare system.

PAs also make substantial contributions to healthcare and can perform 85% to 90% of the tasks of primary care physicians.17 PAs, however, spend considerably less time in training and can readily switch specialties. The careers of physicians and PAs have been compared due to similarities in the educational preparation required to enter these professions and because PA training is an option for those who choose to go to medical school.

In this study, we used the economic analysis performed by Chen and Chevalier as a catalyst for comparing the financial value of PA and medical training for women pursuing a career in family medicine. Chen and Chevalier relied on 2005 data, considered cost at a single private university, did not analyze student loan debt or career interruptions for maternity leave, and used hourly wage as their primary metric. Due to the variety of assumptions that must be made to calculate hourly wages and because a woman may be unable to predict how many hours she will work in the future, this study focused on annual compensation. In addition, calculations included the mean annual tuition and fees for US physician and PA training programs and assessed the effect of debt load, maternity leave, and plausible alternative scenarios, such as a PA transition to specialty practice.

MATERIAL AND METHODS

Study design

The costs of training to become a family medicine physician, including the opportunity costs of forgone earnings during the longer training period required for physicians versus PAs, were compared with the higher salaries earned by female family medicine physicians.18 Specifically, the economic investment was considered for a hypothetical 24-year-old female with a bachelor's degree and a portfolio of academic and other accomplishments sufficient to gain admission to at least one physician training program and one PA training program in the United States. Negative earnings (tuition and other training costs) and positive earnings (practice earnings) were estimated during each year, from the beginning of training at age 25 years to permanent retirement at age 67 years for both career paths.19

The training phase for the female PA career includes the first 2 years, with practice earnings beginning in year 3 and continuing to retirement. For the female family medicine physician, the training phase includes the first 7 years (4 years of medical education and 3 years of residency). Negative earnings are associated with tuition expenses for the first 4 years (medical school) and opportunity costs of forgone PA earnings for years 3 and 4 (because PA practice income begins in year 3) and for years 5 through 7 (because mean residency salary is less than forgone PA income). Once the female family medicine physician generates practice income in year 8, family medicine physician income exceeds primary care PA income in every year through retirement (Table 1).

TABLE 1
TABLE 1:
Data for opportunity cost analysis for women physicians and PAs in family medicine8,9,19,22,27

To aggregate these earnings over time, we calculated the net present value (NPV) for multiple scenarios to draw comparisons between the potential earnings of a female family medicine physician and a female PA. By calculating the NPV of potential earnings, we are able to directly compare earnings that occur at different times. That is, the NPV adjusts earnings to account for the time-value of money (that is, a dollar today is worth more than a dollar tomorrow). This concept is particularly important for this study because earnings for physicians and PAs occur at different times—PAs enter clinical practice after 26 months of education, while physicians enter family medicine after 4 years of education and 3 years of residency. We converted the potential earnings to 2012-equivalent dollars. Analyses were based on robust data points from standardized, publically available sources (Table 1). The institutional review board of Arizona State University deemed the study protocol exempt from review.

Net present value

Compensation estimates for female family medicine physicians and PAs, stratified by specialty and years of practice, were obtained from the Medical Group Management Association physician compensation and production survey, a 2013 report based on 2012 data, and were used to calculate NPVs for the base case scenario (Table 2).18 The projected real growth in PA and family medicine physician salary over time was based on average annual growth in nominal salaries from 2003 to 2012 of 3.6% for PAs and 2.6% for family medicine physicians, as reported by the Bureau of Labor Statistics (BLS), minus the overall annual rate of inflation over the same period (2.2%) as defined by the Consumer Price Index.20,21 Thus, in the base case scenario, real female family medicine physician income was assumed to increase 0.4% per year and real PA income was assumed to increase by 1.4% per year. Finally, in the NPV calculations, we assumed real practice income declines by 2.5% per year from age 61 years to retirement at age 67 years for both PAs and physicians.19 Based on the Association of American Medical Colleges (AAMC) data, real growth in family medicine residency stipends was assumed to be the nominal annual growth rate from 2008 to 2013 (2.4%) minus the inflation rate over the same period (2.1%), or 0.3% per year.22 The real rate of growth in tuition costs used in the NPV calculations was based on the 5-year trend in annual tuition increases minus the rate of inflation over the same period: 3% per year for medical school (2008 to 2013) and 5% for PA programs (2006 to 2010).9,23 The nominal interest rate on educational debt was assumed to be 5.5% minus 2% annual inflation, yielding a real interest rate of 3.5%. The base case NPV was calculated using a 5% discount rate; in sensitivity analysis, NPVs using discount rates of 3% and 10% also were calculated (Table 3). The discount rate is the rate of financial return used in a discounted earning analysis to determine the present value of future earnings (Table 3).

TABLE 2
TABLE 2:
Estimated 2013 practice income for female family practice physicians and PAs18,24
TABLE 3
TABLE 3:
Estimated NPVs for investment in physician and PA training

Finally, alternative NPV estimates were calculated for several plausible scenarios: higher rate of growth for female family medicine physician income compared with female family medicine PA income, the effect of PA movement from family medicine to a higher-paying specialty, and career interruptions for maternity leave. MGMA data were used for the base case scenario because collection methods are the same for physicians and PAs.18 MGMA total compensation data include salary, bonus, incentive payments, and honoraria. The 2013 AAPA base salary data do not; however, we also calculated NPV using AAPA data in order to illustrate differences that can result from different methods of collecting information.24 These alternative NPV calculations serve to provide a more complete assessment of the investment value of physician versus PA training for women than the base case scenario alone.

RESULTS

For the base case scenario, the NPV of the investment for a woman to become a family medicine physician was $2,015,000 compared with an NPV of $1,751,000 for family medicine PA training (Table 3). The present value of tuition and other direct training costs were greater for physician training ($184,000) compared with PA training ($67,000). However, the present value of the opportunity costs of forgone PA earnings during the longer physician training period ($236,000) exceeded direct training costs. The costs were offset by the present value of projected future practice earnings: $2,435,000 for a female family medicine physician and $1,818,000 for a family medicine PA.

ALTERNATIVE SCENARIOS

The base case scenario was based on a 5% discount rate, but a higher discount rate (10%) places relatively more weight on the higher upfront costs for physician versus PA training and relatively less weight on higher future earnings for physicians. As a result, at a 10% discount rate, the NPV for PA training exceeded the NPV for physician training and the opposite occurred when a lower discount rate (3%) was used; the favorable gap between the NPV for physician training and PA training widened compared with the base case.

In a scenario where future real physician earnings growth was 2% compared with no real growth for PAs, the NPV for physician training was substantially greater than that for PA training ($2,979,000 versus $1,359,000). In contrast, if the historic gap in real annual earnings growth between female physicians and PAs widens in future years, the NPV for PA training ($1,962,000) would exceed the NPV for physician training ($1,820,000) (Table 3). For a family medicine PA who transitioned to a surgical specialty practice setting after 5 years in family medicine, the NPV for PA training approached the base case NPV for physician training. Finally, when future PA earnings based on median total compensation estimates from the AAPA survey were used to calculate NPV for PA training rather than the MGMA, the NPV for PA training equaled or exceeded the NPV for physician training, depending on the assumed fringe benefit rate (Table 3).

DISCUSSION

Women selecting either physician or PA careers will have ample future earnings to offset initial training costs. Contrary to Chen and Chevalier's findings, considering the base case scenario, the results of this study suggest that women who become family medicine physicians realize a greater NPV than women who become PAs who practice in family medicine. However, female family medicine physicians do not fare quite as well financially when one considers a higher discount rate of 10%. Finally, the effect of maternity-related career interruptions, even assuming unpaid maternity leave, is minimal—about a 6% reduction in NPV compared with the base case for both female physicians and PAs (Table 3).

Factors other than financial gain play a prominent role in career selection.25 With regard to specialty choice for example, physicians likely to practice in primary care as opposed to other specialties report more altruistic beliefs about healthcare, attribute greater importance to social responsibility, and place less value on prestige.26,27 Interestingly, compared with male physicians, female primary care physicians report higher levels of morale and lower levels of pessimism.27 The rewards of physician practice clearly extend beyond financial compensation. Nonetheless, current efforts to attract physicians to primary care include competitive compensation.28

Results of this study support PA practice as an excellent career choice for women from a purely economic perspective. Therefore, it may be that lower educational costs and strong earnings are already attracting women who would otherwise consider a career as a physician to the PA profession, which is now close to 70% female.1

LIMITATIONS

Although this study accounts for a variety of scenarios, limitations include a narrow focus on women in family medicine and an inability to definitively predict future financial considerations, including the interest rate on debt, inflation, tuition growth rates, and future returns on financial investments. In an effort to minimize the effect of pay differences among primary care specialties, we intentionally chose to examine family medicine; however, doing so may limit the application of study findings to all primary care disciplines.

CONCLUSIONS

This study shows that there likely is a small financial difference between a woman choosing a career in family medicine as a PA or physician. Instead, she should focus on the values associated with each profession. Both are grounded in providing comprehensive patient-centered care, but clearly differ in career mobility, professional identity, training, and practice autonomy. Prospective candidates would be well-served to reflect on the importance of these factors in the context of their professional and personal goals, with the knowledge that both career paths are worthy financial investments.

The PA team-based approach to healthcare relies heavily on physician collaboration. Therefore, considering the career options available to women and the effect that female physicians have on the medical workforce, salaries for female primary care physicians, as well as other female healthcare providers, need to be competitive. These analyses provide insight into the cost of education and training and the changing healthcare workforce. Thus, continuing and substantive research that includes female and male physicians and PAs is warranted.

REFERENCES

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Keywords:

physician assistant; family medicine; women; career choice; training; opportunity cost

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