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Academia and the Profession |

Subspecialty Training: Is It Financially Worthwhile?

Mark J. Prashker, MD; and Robert F. Meenan, MD, MPH, MBA
[+] Article and Author Information

Grant Support: In part by grant AR20613 from the Multipurpose Arthritis and Musculoskeletal Diseases Center Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health.

Requests for Reprints: Mark Prashker, MD, Boston University Arthritis Center, 80 East Concord Street, Boston, MA 02118.

Current Author Addresses: Drs. Prashker and Meenan: Boston University Arthritis Center, 80 East Concord Street, Boston, MA 02118.


©1991 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1991;115(9):715-719. doi:10.7326/0003-4819-115-9-715
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Objective: To determine the financial return of additional training in a cognitive-oriented medical subspecialty (rheumatology) and in a procedure-oriented medical subspecialty (gastroenterology) relative to general internal medicine.

Design: Analysis of existing data to compare lifetime discounted earnings of physicians in different medical specialties.

Participants: General internists, gastroenterologists, and rheumatologists were surveyed.

Main Outcome Measures: Using data from surveys conducted by Medical Economics and the American College of Rheumatology, we constructed lifetime earnings streams that allowed the calculation of the net present values of discounted lifetime earnings in general internal medicine, gastroenterology, and rheumatology. Net present values of lifetime earnings were calculated for each group at two discount rates. Sensitivity analyses were done to estimate how changes in relative income would affect calculations of the net present values.

Main Results: The average net incomes before taxes for general internists, gastroenterologists, and rheumatologists in 1988 were $115 825, $201 875, and $118 056, respectively. At 5% and 10% discount rates, the net present values of the estimated career earnings stream for additional training in gastroenterology relative to general internal medicine were + $1 101 863 and + $512 952, respectively; for additional training in rheumatology relative to general internal medicine, the respective values were - $84, 748 and - $92, 467. If the incomes of general internists were decreased by 3% and the incomes of gastroenterologists were decreased by 25% to reflect the effect of potential changes due to the resource-based relative value scale (RBRVS), or if gastroenterology training were increased to 3 years and rheumatology fellowship stipends were increased by 30%, large differences would still exist between the groups.

Conclusion: Gastroenterologists have an extremely large return on their additional investment in training, but rheumatologists have a negative return. When considered exclusively as a financial decision, fellowship training in a cognitive-oriented medical subspecialty such as rheumatology is a poor investment. Even major changes in reimbursement policies will not affect the relative pecuniary attractiveness of procedure-oriented medical subspecialties.

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