Primary care physician

Physician Salaries, Job Satisfaction Detailed in New Survey

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Although compensation is still a sore issue for many physicians, according to Medscape’s 2015 Physician Compensation Report, most saw modest to significant gains.

The top three earners in this year’s report are orthopedists ($421,000), cardiologists ($376,000), and gastroenterologists ($370,000). Likewise, in 2011 — the first year Medscape conducted this survey — orthopedists topped the list, followed by radiologists and anesthesiologists.

The average compensation for a primary care physician (PCP) in 2014 was $195,000 and for a specialist it was $284,000.
The three lowest earners for patient care were pediatricians ($189,000), family physicians ($195,000), and endocrinologists and internists (both at $196,000), according to the report. The bottom earners in 2011were also pediatricians, followed by primary care physicians, and endocrinologists.

More than 19,500 physicians in 26 specialties responded to this year’s survey between December 30, 2014, and March 11, 2015, reporting their compensation, number of hours worked, and career satisfaction.

Career, Compensation Satisfaction

About half of PCPs (47%) and half of specialists (50%) are happy with their compensation. PCPs feel about the same as they did in the 2011 Medscape Compensation Report, but specialists feel slightly less fairly compensated than in 2011, when 52% of them were satisfied.

Although only 48% of family physicians and 45% of internists feel they are fairly compensated, ophthalmologists (40%), allergists, and general surgeons (both 41%) are the least happy.
Dermatologists (61%) and emergency medicine physicians and pathologists (both 60%) are the most satisfied with their compensation. Compensation increased by 12% for emergency medicine physicians and pathologists in the past year.

According to the new report, the physicians with the highest career satisfaction are dermatologists (63%), followed by pathologists and psychiatrists (both 57%). The physicians with the least career satisfaction are internists (47%) and then nephrologists and general surgeons (48% and 49%, respectively).

In the 2011 Medscape Compensation Report, most physicians (69%) reported they would choose medicine as a career again, and 61% would choose their same specialty. In the newest report, 64% would still select medicine, but only 45% would stick with the same specialty.

Nonpatient Care Activities

Orthopedists also make the most compensation from nonpatient-care activities ($29,000), including expert witness duties, product sales, and speaking engagements. Next in line are urologists, plastic surgeons, and dermatologists (all three $26,000).

Radiologists ($6000), make the least in this category, followed by pediatricians ($7000), and anesthesiologists ($8000). Physicians, especially PCPs, who are at the lower end of patient-work compensation, also tend to get less in nonpatient-care compensation.

Rheumatologists, Urologists See Decrease, Others Increase
Compared with last year’s report, this year’s compensation for rheumatologists decreased the most, by 4%, followed by urologists, whose income decreased by 1%.

Compensation increased for all other physicians, with the greatest among infectious disease physicians (22%), followed by primarily hospital-based physicians: pulmonologists (15%) and emergency medicine physicians and pathologists (both at 12%).

Notably, compensation for family physicians increased by 10%.

Compensation Varies by Geographic Region

The wide variation in cost of living in certain geographic areas of the United States is problematic for the Centers for Medicare & Medicaid Services because of the need to balance the higher cost of living in some areas with the difficulty in attracting physicians to underserved areas with lower living costs.

Several government policies geared toward improving physician access in rural regions have resulted in higher incomes in several poorer regions, with the three top-earning states listed as North Dakota and Alaska ($330,000 each), and Wyoming ($312,000).

Overall, the highest salaries in this year’s survey were reported in the Northwest ($281,000) and South Central ($271,000) regions of the United States, and the lowest earnings were in the Northeast ($253,000) and the Mid-Atlantic ($254,000).

In 2011, the Medscape Compensation Report noted that the highest earners were in the West and North Central areas of the United States and the lowest earners were in the Southwest and Northeast.

This year’s report shows the lowest-paying regions were the District of Columbia ($186,000), Rhode Island ($217,000), and Maryland ($237,000) — all which are on the East Coast, where nonphysician incomes are generally higher than in other parts of the country. New Mexico and Utah were the only non-Eastern states in the bottom 10 for compensation.

Employment vs Self-Employment

In this year’s survey, most (63%) physicians are employed and make significantly less than the 32% of their colleagues who are in private practice. According to a major physician recruiter, 11% of physicians were employed by hospitals in 2004, and this rose to 64% in 2014.

PCPs who are employed make $189,000, and self-employed PCPs report annual earnings of $212,000. These figures are far less than average compensations for employed ($258,000) or self-employed ($329,000) specialists.

Women Earn Less, Work Fewer Hours

Women still earn less per year ($215,000) than their male counterparts ($284,000), according to the report, although the overall difference between women and men has decreased slightly since 2011, going from 28% in 2011 to 24% this year.

 Some of this discrepancy may be explained by the fact that women often work shorter hours and fewer weeks than men. Almost a quarter (24%) of female physicians who completed the survey work part-time compared with 13% of men.

The data show that even women who are employed full-time work fewer hours per week and see fewer patients than their male counterparts. Greater flexibility and shorter hours may help improve female physician satisfaction and fend off burnout.

Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care.

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Abstract

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression.

Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care.

Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative.

Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up.

Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008.

Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression.

Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression.

What is already known on this topic

  • Prospective studies have consistently shown a relation between depression and increased mortality in older adults
  • No randomized trials have reported that a depression management program can decrease risk
  • A 24% lower mortality risk was seen after a median of 98 months among patients with major depression in practices provided with resources for depression care management compared with usual care
  • The decline in mortality was across all causes of death, but with fewer deaths from cancer among people with major depression in intervention practices
  • A depression care manager working with primary care physicians to provide algorithm based care for depression can mitigate the detrimental effects of depression on mortality

What this study adds

 

Source: BMJ

 

 

nitial9 �ta � spacing:0px’ id=p-70>Our patients presented relatively late after the onset of illness, a median of five days overall (seven days for H5N1). Despite administration of oseltamivir, about 30% of those enrolled remained positive for viral RNA (the primary endpoint) after five days of treatment. Timing of oseltamivir treatment is important as several studies have shown that early treatment confers greater virological and clinical benefits.4 5 6 32 33 34 In particular, later viral clearance has been noted with delayed treatment with oseltamivir compared with treatment within two to three days after onset of symptoms in observational reports from patients with H1N1-pdm09, especially those with severe illness.35 36 37 38 39 40 In the current trial, 73 (22.4%) patients presented within three days of illness, but even in this subpopulation, double dose oseltamivir was not associated with more rapid viral RNA clearance. Over a quarter of patients received neuraminidase inhibitors before enrolment, which could have influenced the effect size and contributed to the low proportion of patients shedding virus at day five in both treatment groups.

 

Although viral RNA detection in samples from the upper respiratory tract might not accurately reflect viral replication in the lower respiratory tract, especially in those with severe illness,39 prolonged viral RNA detection in upper respiratory tract samples has been shown to correlate with inpatient morbidity and prolonged hospital stay. In our study viral detection on day five was observed at about twofold the frequency in those meeting the criteria for clinical failure, although lack of clinical failure was not a surrogate for cessation of viral detection. Thus in our study the delays in starting treatment with oseltamivir also probably contributed to the substantial rates of admission to intensive care (18%), use of supplemental oxygen (30%), mechanical ventilation (12%), and mortality in hospital of 6.4%. Although our study was not placebo controlled for ethical reasons, other studies indicate that early oseltamivir treatment in people with severe influenza is associated with both clinical benefits and more rapid viral clearance from upper respiratory tract samples.

Possible reasons for findings

It is unclear why double dose oseltamivir does not seem to offer benefit over standard dose in patients with severe influenza. Blood trough concentrations of oseltamivir carboxylate from 75 mg or 150 mg twice daily in influenza exceed the IC50 (inhibitory concentration) of influenza viruses.42 43 Inhibition of viral neuraminidase by oseltamivir might be a saturable process, and maximal inhibition might be achieved with a standard dose; exceeding these concentrations might not produce an additional clinical or virological effect. In this regard, a randomised oseltamivir controlled study of intravenous peramivir (BioCryst Pharmaceuticals, Durham, NC), which reaches over 20-fold higher peak blood concentrations of active metabolite than oseltamivir carboxylate, found similar viral reductions in patients with influenza A virus admitted to hospital.44 Further studies of peramivir and other intravenous neuraminidase inhibitors currently in progress should provide additional evidence regarding this hypothesis.

Infection with avian H5N1 virus, higher baseline viral load, and severity of disease were independently associated with longer viral RNA detection. The association between avian H5N1, severe illness, and prolonged shedding has been well described.14 The clearance kinetics of influenza viruses, both without antiviral treatment and with oseltamivir treatment,32 41 could explain longer viral RNA detection with higher baseline viral loads. It is unclear whether the independent association with disease severity might be related to impaired mechanisms of viral clearance or higher intrinsic rates of viral replication or both in these patients. Severe chronic comorbidities are seen commonly in industrialised countries and are related to prolonged viral shedding but most of our patients lacked these comorbidities.40 41

The heterogeneous population characteristics, geographical differences in recruitment (most patients were from Vietnam but there were no significant differences between Vietnam and other sites), and the variety of infecting viruses in our trial reflect the clinical circumstances in South East Asia during our study but might be viewed as a limitation. Most of these patients were children and had low or normal BMI, and for all patients only about a fifth reported a chronic underlying medical condition. Thus, our findings are applicable primarily to the region where the study was conducted and other settings with similar characteristics of influenza epidemiology. We did not have many adults in our study and results were inconclusive but indicate no difference in efficacy between the two oseltamivir regimens. We would caution the extension of our results to, for example, morbidly obese adults with severe influenza and those who could have underlying chronic illnesses. We conducted several statistical comparisons and inevitably subgroup analyses involved small numbers; thus power was limited and some significant results could have resulted by chance. Additionally, as all patients were randomised to an active treatment, our study was not designed to evaluate the efficacy of oseltamivir in severe influenza nor in H5N1 infections. This large randomised trial did, however, examine an important clinical and public health question and showed a lack of a clinical or virological benefit of double dose compared with standard dose oseltamivir in patients admitted to hospital with severe influenza. Our results and other observational reports from avian H5N110 and H1N1-pdm0911 36 infections do not support routine use of double dose oseltamivir to treat severe influenza. These findings have implications for both clinical management and pandemic preparedness including during the current H7N9 epidemic.16 17 18

What is already known on this topic

  • Clinical trials in patients with uncomplicated influenza have shown that treatment with oseltamivir has clinical and virological benefit when administered within 48 hours of onset of symptoms
  • Observational studies in severe influenza have shown that oseltamivir treatment, if given early, is associated with reduced mortality and shorter length of hospital stay. Reduced mortality has also been reported for patients with H5N1 influenza treated with oseltamivir
  • Several authorities have suggested the use of double dose oseltamivir for severe influenza, although there is no clinical evidence to support this
  • In the largest randomised trial on the treatment of severe influenza, no clinical or virological benefit of double dose oseltamivir over standard dose was found
  • These findings have implications for both clinical management of severe influenza and for pandemic preparedness of emerging influenza viruses including the current H7N9 epidemic

What this study adds

 

 

Source: BMJ

 

 

Chest Pain: What Happens After the Emergency Department?

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Patients who follow up with cardiologists do best.

 

Researchers examined patterns of follow-up care and outcomes in high-risk patients with chest pain who presented to Ontario emergency departments (EDs) from 2004 to 2010. High risk was defined as having a prior diagnosis of cardiovascular disease, diabetes, or both. The primary outcome was a composite of all-cause death and hospitalization for myocardial infarction within 1 year after the index visit.

Of nearly 57,000 patients, 17% followed up with a cardiologist (with or without a visit to primary care) within 30 days after ED discharge, 57% followed up with a primary care practitioner only, and 25% did not have a visit to a physician recorded. After adjustment for clinical, demographic, and hospital characteristics, the cardiologist group had a significantly lower hazard ratio for the composite outcome (HR, 0.79; P<0.001) than the no–follow-up group and the PCP-only group (HR, 0.85; P<0.001). PCP-only follow-up was significantly beneficial compared to no follow-up (HR, 0.93; P<0.023). Patients seen by cardiologists underwent more testing and received more evidence-based therapies within 100 days after discharge.

Comment: These robust results demonstrate that what happens after the emergency department visit is as important as what happens during the ED visit, and that postdischarge care for patients with high-risk chest pain should include timely assessment by a cardiologist.

 

Source: Journal Watch Emergency Medicine

Clinicians Should Listen to Their Guts When Treating Kids, Study Suggests

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When assessing children with acute illness, clinicians should not discount their “gut feeling” that something is seriously wrong, even if clinical examination suggests otherwise, according to a BMJ study.

Researchers recorded primary care physicians‘ overall clinical impression (based on history, observation, and exam) of children presenting with acute symptoms. They also recorded the physicians’ intuitive, or “gut,” feelings about illness severity.

Roughly 3400 children were clinically assessed as having a nonserious illness, six of whom were eventually admitted with a serious infection (most frequently, pneumonia or pyelonephritis). When clinicians had a gut feeling that something was wrong despite their assessment, the likelihood of serious illness increased 26-fold.

The authors conclude: “We suggest that having a gut feeling that something is wrong should make three things mandatory: the carrying out of a full and careful examination, seeking advice from more experienced clinicians (by referral if necessary), and providing the parent with carefully worded advice to act as a ‘safety net.'”

Source: BMJ