From Data to Dollars: Real Talk on Family Physician Compensation

Transcript

Emily Holwick: Welcome to Inside Family Medicine, where you hear from leaders and peers in your specialty while learning about new tools and resources. I'm your host, Emily Holwick, a member of Team AAFP. Today, Dr. Yalda Jabbarpour and Dr. Stacey Bartell are joining us to talk about the critical topic of physician compensation, what it means to know your worth, why data is necessary to unlock family physicians' career potential, the essential resource of the AAFP Career Benchmark Dashboard, and the role of compensation in attracting new physicians to the specialty.

Dr. Yalda Jabbarpour is the director of the Robert Graham Center, associate professor at Georgetown, and a practicing family physician. Her research focuses on how payment models and investment in primary care impact care delivery across the us.

Dr. Stacey Bartell is a board-certified family physician with a passion for prevention, chronic disease care and women's health. She's the AAFP's medical director for career and practice and is in independent practice now in Livonia, Michigan.

Thank you both for joining us.

Dr. Yalda Jabbarpour: Thanks for having us.

Dr. Stacey Bartell: Thank you.

I’d like to start out by asking each of you why you chose family medicine as your specialty. Dr. Jabbarpour, I'll start with you.

Dr. Yalda Jabbarpour: It was an easy choice.

I mean, in medical school when I rotated through my family medicine rotation, that's where I felt most at home, both in terms of the practice of family medicine, but also in terms of the colleagues who were there teaching us family medicine. It felt like my people. And so, you know, going through medical school after that clerkship experience, I just knew there was no other choice but that.

Emily Holwick: And Dr. Bartell, what was it about family medicine that pulled you in?

Dr. Stacey Bartell: So very similarly, I knew very early. In fact, I think I probably knew before I went to medical school that family medicine was always what I was interested in. I think it's the full spectrum of taking care of a family. I think it's building relationships with patients, and I think it's doing a little bit of something different every day that was also challenging and appealing to me.

Emily Holwick: So we're going to talk about compensation today.

It's something that is, of course, on everyone's mind as they begin their careers and even all the way through when once they're seasoned physicians. It's always important.

So Dr. Jabbarpour, help us set the stage on this topic. What do we know about family physician compensation from research and what trends can we expect in compensation going forward?

Dr. Yalda Jabbarpour: Yeah, it's a great question. So at the Graham Center, us and colleagues over at the American Board of Family Medicine have looked at the American Board of Family Medicine data on compensation and family physicians. And what we have found is a few things.

Gender wage gap in family medicine

First, big picture, the gender wage gap exists even in family medicine. Early career family physicians, the females report earning $44,000 per year less than male family physicians. And again, these are all early career, so it's not based on seniority. That's about 17% lower that female family physicians are making than their male colleagues. If you look at that over a lifetime in terms of lost wages, we estimate that female family physicians are making about $2 million to $4.4 million less over their lifetime for equal work.

We did another study where we actually corrected for things like hours worked, the setting that you work in (because family physicians work in multiple settings), the principal activities that you provide (some family physicians do a lot of procedures, others don't). We corrected for all of that and we still saw that in a year, early career family physicians, females make $33,000 less than their male colleagues.

And so I guess the question is why. We've corrected for all of that, all of the things that you know you can correct for, and we're still finding that female physicians make less. Others have done research into why that's happening, and some of it is the payment environment that we're in.

On average, and this is not speaking for every single individual, but on average female physicians practice a little bit differently than males. Studies have shown that we spend more time with our patients and in any given visit we are actually handling more issues. Unfortunately, we are not compensated for that in a fee-for-service system.

Studies done by colleagues at Harvard in internal medicine actually show that female physicians tend to fare worse in a fee-for-service system. And so where is the trend going? If we're moving away from fee-for-service and towards a value-based system, then we can say that maybe this will start to get better for female family physicians, knowing that that value-based environment tends to equalize the gender wage gap. But that remains to be seen.

Emily Holwick: That is just a huge disparity in pay between genders, and I think that's probably shocking for people to hear those numbers and realize what disparity actually exists. And I know that it's one of the AAFP's priorities to work towards closing that gap in many different ways.

Dr. Bartell, how does transparency around pay impact physician morale and retention and equity in the workplace?

Dr. Stacey Bartell: So we're learning, as we're looking at the dashboard and we're hearing feedback from our physicians, that there are several groups that when you work for a large health care system, sometimes it's not very transparent what other groups in the system are making.

So whether it's across specialty or even across primary care, we're hearing that different groups, and even in the same health system, are making different amounts of money. So when I worked for a large health care system, we were not able to share what we made with other groups in the health care system. It was written into the contract. So that made that very challenging.

The power of pay transparency

As we open up this transparency, it helps us just make everything more equal across the board. So we we'll make the same as other specialties, such as internal medicine and other primary care specialties. And we're transparent across the board with what the specialists are making, and it overall just helps with equity.

As we're talking about male versus female and what we make in terms of compensation, I think it's important if you're not transparent in how your practice is getting paid and how all the physicians in your network are getting paid, then you really don't know that it is equal.

And I think that's important for morale, especially for women in the workplace who are trying to figure it out and make it work as parents and other competing agendas that we have.

I know through the years I always was able to work part-time and I feel being able to offer that is also important. And so I think just overall transparency and sharing what we all do is important.

Emily Holwick: In an effort to increase transparency, I want to talk about a wonderful resource the AAFP has: the Career Benchmark Dashboard that we mentioned, which is available to all AAFP members.

Dr. Bartell, you advise residents and new physicians as well, but why do all family physicians need an information source like this?

Dr. Stacey Bartell: So I think it's particularly important for new residents or recent, those about to graduate, to understand what all the opportunities are available in family medicine. And we want make sure that you understand by region and by state what you can make. We also just want to make you realize all the different diverse things going out there in the world and employment, and also just in independent practice.

There's a lot of new models popping up, so it's super important for new physicians—who, you know, the standard is most will not stay in their job more than two years if they're not happy. So our goal is to make sure that we're as transparent as we can be with all the great things you can do out there and all the opportunities available, and overall to understand how you expect to get paid when you go into those models.

We think you'll stay longer in employment, we think you'll be happier in your career paths if you have this information going in. So I think the dashboard is a great opportunity to provide that.

For physicians like myself who have been in practice a long time, some of us are changing careers. And if you're starting to make a career change, we think it's important for you to understand also what's going on out there.

I was an employed physician for a very long time, so I really didn't understand what the components were in independent practice before I joined independent practice.

So as the new models are popping up, I think it's good to use the dashboard as a good resource to understand.

Also, contracting these days is so diverse and what we see in our contracts is so very different across the board. One of the things the dashboard is able to provide is components by different practice setting, and all the different things that go into making up a physician contract, and what you can expect when you look at that and can compare it across the board.

So we felt it's important physicians to be able to use this data for that reason.

Emily Holwick: Absolutely. I wonder if each of you can share a moment in your own career when you felt that understanding your value really changed how you approached your work or career decisions. Dr. Jabbarpour.

Dr. Yalda Jabbarpour: I think there's a couple.

I mean, one was very early on in my career. I think Stacey mentioned the part-time work and I didn't really realize that that was even an option. You know, I was starting my family in residency, and then I came out of residency and I had that very first full-time job, trying to grow my family, have three kids under three at home. And honestly, it was too much for me and probably too much for any human being.

And I didn't know what to do. I didn't want stop practicing all together. And I was lucky to have amazing supervisors at my first job, and I remember just going into one of their offices and crying and saying, “I don't think I can do this. I'm going to step back from family medicine. I have so many responsibilities at home. I need to be there for the kids and I'm just burning out.”

And she was like, “No, we can't lose you. You are an amazing doctor. We love our family physicians. You can do a job share, you can work part-time.” And just having someone say that to me like, “No, no, no, no, we're not going to let you do that. We value you too much,” helped me understand my own value.

Negotiate your physician employment contract

And hey, you can negotiate for things that you may not think you can negotiate for when you're coming out as a brand new resident who's just used to that environment where people tell you what to do, you do what they tell you what to do. You're making so much more money than you did as a resident, so you feel like you can't ask for anything, and just knowing that you can ask for something was valuable.

And then fast-forward many, many years later, when we started doing the research on the gender wage gap in family medicine at the Graham Center, I honestly didn't think a specialty like family medicine would have a gender wage gap. I understood that that existed in surgery, you know, maybe more male-dominated specialties, but did not think that it was also a problem in family medicine.

When we started doing that research, all of a sudden that kind lit a fire in me to say, “Hey, not only am I valued as a family physician, but I should be valued as a female family physician and I should negotiate for more.”

Emily Holwick: I think that's so empowering for other physicians to hear, especially those in their early career, who, like you said, might not understand all the opportunities available, certain flexibilities, things they can ask for to make it work for them. Because their talents, their passions, still should be shared. They shouldn't have to step back or feel like, “I can't do this.” They should work with their employer to make it happen.

And it's wonderful that you had a supportive situation where they were willing to work with you, so I love that.

Dr. Bartell, how about for you? Was there a time in your career when you felt understanding your value really changed how you approached your career?

Dr. Stacey Bartell: So actually similar to Yalda, I also had some changes very early in my career. And I've been in practice for 25 years, so I've been changing for a lot of that time.

When I graduated, I first started in a couple of part-time roles because I was pretty sure I didn't want to work full-time. Those two part-time roles weren't great, and so I was able to go back to the health system I graduated from in a full-time role. But similar to what Yalda said, I worked that full-time position for about two to three years and then just realized I had two small kids at home, I was trying to juggle everything, and couldn't do it.

So I was fortunate enough to be able to negotiate a different position in our health system at a different site, and I was able to go down to three days a week. And for me, the majority of the time when my kids were young, I was able to work that three days a week.

And then as my kids got older, I was able to negotiate a different opportunity at work. And then I was able eventually to get into some leadership roles, but it did take some time. Again, when we talk about it's challenging for women in these careers, is we're negotiating and having these conversations. It's hard, right, to get into those leadership roles early because again, you're working part-time, you're juggling young kids at home. You're not understanding how you can do it all.

I fortunately also had very strong female mentors as I went through this process, who very much supported all of us in our roles and our faculty roles, in particular in the part-time world, which I think was great. And we were able to negotiate that as we went forward.

I think the challenges lie in understanding, is that opportunity always available to everyone? Is that opportunity available across different settings, work settings, and what does that look like, and are we losing pay as a result of that? I have no regrets in the decisions I made in my career, but I do know that we probably are held back a little bit based on what options we choose.

‘Your first job is not your permanent job’

Dr. Yalda Jabbarpour: And just to add on to what Stacy is saying, I would say to—and I always mentor our early career family physicians who come through the Graham Center—that your first job is not your permanent job. So if it's not working for you, if you're not feeling valued, first of all, first step, ask for what you want. Even if it's after the negotiation process.

My story was after the negotiation process. I had been working there already for a year with a contract signed, and I didn't know that I could ask for something different. All they can say is, no. Ask for what you want, even if it's after negotiation.

If they say no, you are in high demand as a family physician. Go somewhere else. Go somewhere else where you can get the job that you want.

The most important part that I always tell the residents that are graduating is the thing that you want to look for in your contract is to make sure that you are not locked in, in any contractual way, to that job, or that there is not some ridiculous non-compete, which means that you can't get a job within 50 miles or something like that.

And if you're making sure that that is true in your contract, that you have options after this job, it's never, you're never locked in. You should know your value and ask for what you want.

AAFP Career Benchmark Dashboard helps you advocate for yourself

Dr. Stacey Bartell: And I think to your point, I think one of the hardest things we learned how to do is how to advocate for ourselves.

And that's one of the reasons we think the dashboard is going to help everyone: Is look through the dashboard, take a look at the different filters, understand what's going out there, and learn how to advocate for yourself.

It doesn't hurt to hear the word no, and I was always impressed by friends and other family members I knew who would ask for things. And I was always surprised at what they would receive when you just ask. And so that was a hard thing that I had to learn, but that was my personal issues that I had to learn as I grew through my career, but I think that's so important. Don't hesitate to ask for what you need and what you want.

Emily Holwick: I so appreciate both of you sharing your own personal stories and also great advice for other people who are listening, especially in early career. That is so valuable.

Dr. Jabbarpour, I know you focus a lot on primary care workforce research and what's needed to get more people to choose careers in primary care.

What would you say is the role that compensation plays in attracting medical students to the specialty?

Dr. Yalda Jabbarpour: I think a couple things. I mean, the most obvious thing is that we all have student loans, and so if we are not being compensated fairly compared to other specialties, that is obviously detracting medical students from going into family medicine. Even if they love the practice of family medicine, if they find out that it's easier to pay off their loans doing other specialties, that might be a detractor.

I think, though, bigger picture, it's compensation for the practice. And what do I mean by that? If we are not getting enough payment going into our own practices, we don't have the resources that we need to actually practice family medicine.

We don't have the appropriate number of MAs, RNs, LPNs, front desk staff, scribes, all those resources that you need so that you can do your job as a doctor, and everyone else can help you do your job as a doctor by taking care of some of those administrative tasks that you should not be taking care of.

And so what happens is we have poorly compensated primary care practices. And then you have overworked, overburdened, under-resourced doctors working in those practices. And you have medical students rotating through and they compare the practices, right? They compare what it's like to work in a family medicine practice compared to what it's like to work in a cardiology practice, and hey, how come this doctor gets to spend all their time being a doctor, and this doctor is just overburdened with all this extra stuff.

So I think that is more why compensation matters. It's not necessarily your personal take-home compensation, although that does matter a lot, but it's the money being poured into the clinic based on our fee-for-service system, which unfortunately just does not value the practice of family medicine.

Emily Holwick: Really good points. Dr. Bartell?

Remember all the things you can do in family medicine

Dr. Stacey Bartell: I was going to add to that and say, you know, one of the things I'm super excited about when I talk to the young graduates today and those in medical school, are all the diverse things they want to do. And I think that they are finding ways to piece things together, to be independent.

I think they're finding ways to build the role they want to build. Sometimes they're doing part-time work to compensate and build up a practice, whether it's a telehealth practice or whether it's an independent practice or a DPC practice. But I'm super excited to see the way that the next generation is trying to put together the career that they want and making it work.

And so I think that that's what's important also to attract people to the specialty, is understanding all the different roles that family medicine gets to do and all the exciting career paths you get to do. There's a lot of opportunity out there. We just need to get information from each other, learn from each other, and share that information as much as we can.

Emily Holwick: There are truly so many opportunities in family medicine. I'm always amazed still as I learn of new types of jobs that our members have and what they're doing across the country and even traveling internationally to practice. I mean, there really are so many different things that you can do in family medicine.

Know your worth

When it comes to compensation and that transparency and knowing your worth, one of the things I love about the AFP's Career Benchmark Dashboard is that it's powered by real-world family physician data, and it's updated every two years. So the survey is periodically going to be open and available for responses so that our members can help their fellow members to know their worth and know what they should be advocating for.

So what would you say to someone who is maybe on the fence about taking the time to complete the survey? Dr. Bartell?

Dr. Stacey Bartell: So we were very, very excited at our survey responses and the amount of participation we had in the survey. I'd say going forward, the survey does not take very long to fill out. The survey is so important to help advocate for yourself, to advocate for the next generation in medicine, to learn from each other.

I feel that it is worth the effort and time it takes to put in. We also make it a little bit competitive across different states. So we want to hear from everyone from all walks of life. We don't care if you work part-time. We don't care if you work in a prison setting versus a community setting, versus you work in… You know, you may think that you don't have anything to add to the benchmark, and we would tell you that we want to hear from everyone. We want to hear from all different settings.

So we can learn from this, we can share from this, we can start to trend data from this. And overall, as we start to be more transparent, we will ultimately start to earn more. And that is the whole goal, is how can we support each other in making sure we're compensated well for what we're doing.

Emily Holwick: And Dr. Jabbarpour, why would you encourage people to take the survey?

Dr. Yalda Jabbarpour: I think Stacey was spot on. I mean, we need more information to help the discipline of family medicine.

So whether you are stable in your job or looking for a job, even if it's not an individual need to use the dashboard, and so then you're like, “I don't want do the survey, I am not even going to use this,” it will help your colleagues, it will help the practice of family medicine writ large. And so if only for that.

And as Stacey said, it doesn't take that much time. So it’s your own little contribution to the practice of family medicine and our discipline, is just filling out that survey.

Emily Holwick: Well, thank you so much to both of you for joining us and taking the time to share your insights and your experiences and talk a little bit more about the Career Benchmark Dashboard and compensation.

These are such important topics for our members. And to our listeners, if you'd like to learn more about the AAFP's compensation resources and the Career Benchmark Dashboard, we have links for you in the show notes.

If you enjoyed today's episode, let us know by dropping a line to aafpnews@aafp.org, and be sure to share the episode with your followers on social media and tag the AAFP.