International Urogynecology Journal

, Volume 19, Issue 1, pp 151–156

Income differentials required to make fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral


    • University of Missouri at Kansas City
    • Truman Medical Center
  • William B. Weeks
    • VA Outcomes Group REAP
    • Dartmouth’s Center for the Evaluative Clinical Sciences
    • Department of Psychiatry, Department of Community and Family MedicineDartmouth Medical School
    • Department of Community and Family MedicineDartmouth Medical School
Original Article

DOI: 10.1007/s00192-007-0407-8

Cite this article as:
Muffly, T.M. & Weeks, W.B. Int Urogynecol J (2008) 19: 151. doi:10.1007/s00192-007-0407-8


We used standard financial techniques and a return-on-educational-investment model to calculate the required annual income necessary to render additional fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral. To explore a range of potential outcomes, we conducted a sensitivity analysis that used various discount rates and retirement ages. Compared to obstetrics/gynecology residents who go directly into private practice, residents who pursue fellowship training in female pelvic medicine and reconstructive pelvic surgery experience a financial loss of more than $400,000 to $600,000, assuming there is no income differential after fellowship. To render the additional training financially neutral requires an annual income that is 16–31% higher than that of general obstetrician/gynecologists. Required additional annual income was on the lower end of this spectrum when modeling later retirement age estimates and using lower discount rates. Fourth year obstetrician/gynecology residents considering female pelvic medicine/reconstructive surgery require higher incomes over the working lifetime to render fellowship training financially neutral.


Human capitalFemale pelvic medicine and reconstructive pelvic surgeryEducational investmentGraduate medical educationInternship and residencySalaries and fringe benefitsHealth economicsUrogynecology


In the United States, medical education is expensive, competitive, and lengthy. Medical students graduate with substantial debt and earn relatively low salaries while completing residency training [1]. Previous studies have shown that the return on educational investment for physicians is not excessive when compared to other professional groups [2, 3]. Within internal medicine, techniques have been used to determine whether the financial returns on fellowship training warrant the additional time and opportunity cost associated with that training. Findings have depended on the specialty examined: returns appear to be adequate for medical specialty training [4] but not for training in geriatrics [5].

`Some specialties are relatively new or may have little income information available on them. We were curious about whether return-on-educational-investment models could be used as an adjunct to decision making for physicians considering additional fellowship training. Using these models, residents considering a fellowship could calculate the additional annual income required to render the fellowship training financially neutral.

Fourth year obstetrics/gynecology residents are largely motivated by non-economic factors when deciding to enter fellowship. The non-economic factors influencing medical specialty choice include prestige, residency environment, and personal characteristics. Future earnings does not consistently drive specialty choice: some studies have found a correlation between future expected income and specialty choice while others show no such relationship [6, 7]. However, one can hypothesize that a specific motivator for residents to enter female pelvic medicine and reconstructive pelvic surgery (FPM&RS) is the variety of medical and surgical procedures involving complex anatomy that can improve a woman’s quality of life. Another factor may be an increased sense of control due to the absence of an obstetrical practice. Although residents rarely formally evaluate the financial impact of fellowship training, to make an informed decision, it is important that individuals understand the costs, as well as the benefits, of that training. While there is no evidence that residents incorrectly calculate the costs of additional training, there are no resources to help a resident make these complex financial calculations. We sought to address this need.

Since 1998, accredited fellowships in female pelvic medicine and reconstructive surgery have been available for graduates of U.S. obstetrics/gynecology residencies. We chose to study female pelvic medicine and reconstructive pelvic surgery because it is the least researched of the four subspecialties and is rapidly expanding. Because it is a relatively new fellowship, data on the incomes of graduates of FPM&RS fellowships are not available. However, a recent paper [8] provided age-specific estimates of the incomes of obstetrician/gynecologists; importantly, that paper identified an association between gender, race, and obstetrician/gynecologists’ annual incomes, thereby allowing us to conduct analyses that were not confounded by these variables. Therefore, we applied financial techniques to determine the increase in annual incomes that would render the additional fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral from the perspective of a white female and male fourth year obstetrics/gynecology resident.

Materials and methods

We took the perspective of a fourth year obstetrician/gynecology resident who was considering entering a fellowship in female pelvic medicine and reconstructive pelvic surgery. We used information on mean student debt, residency stipends, and age-specific incomes of obstetrician/gynecologists to create a model of expected income for obstetrician/gynecologists over the working lifetime [1]. We then included fellowship stipends to create an income model for FPM&RS fellows. Finally, we used discounted cash-flow analysis to calculate the additional annual income that would be necessary to render the additional training financially neutral across a variety of retirement ages and discount rates. This study was approved by Dartmouth Medical School’s Committee for the Protection of Human Subjects, Hanover, NH (CPHS # 17707).


We assumed a fixed working lifetime, defined as residency graduation at age 31 to retirement at one of two ages: 50 or 60. We assumed that residencies and fellowships are completed without interruption. Upon completion of specialty training, we also assumed that physicians immediately become employed in their chosen field. We also assume that each career path was associated with the mean educational indebtedness of graduating medical students, for each year examined, as published by the AAMC [9]. We assumed that interest on debt was capitalized during residency or fellowship training. We assumed that, upon completion of residency or fellowship, educational debt was repaid over 15 years, at a fixed annual interest rate of 5%. Finally, we assumed that there were no differences in work hours between obstetrician/gynecologists and urogynecologists.

To obtain specialty and age-specific information on incomes, we used two data sources. To estimate income during residency and fellowship training, we used year-specific house staff stipends as published by the American Association of Medical Colleges. To estimate income after completion of fellowship programs, we used aggregated respondent data from the American Medical Association’s (AMA) socioeconomic monitoring system from 1992 to 2002 (approximately 261 obstetrician/gynecologist respondents per year, approximately 63% response rate), as reported elsewhere [8]. We split our analysis to the perspectives of white female and male obstetrician/gynecologist in her/his fourth year of residency training for three reasons. First, there are income differences among obstetrician/gynecologists that are associated with race and gender of the provider [8]. Because the incomes of white females are the lowest, their use provides a lower bound of results in our analysis. Second, because white females make up more than 80% of residents nationwide, this is the next generation of fellows. Thirty-eight percent of fellows from the American College of Obstetricians and Gynecologists are female as well [10]. All analyses used inflation-adjusted income data (2004 dollars).

The model that we used focused exclusively on the financial return on educational investment for additional training in female pelvic medicine and reconstructive pelvic surgery. The opportunity cost is the income that a person could have generated had he not pursued additional fellowship FPM&RS training; in this analysis, the opportunity cost is represented by the age-specific income earned by a practicing obstetrician/gynecologist who had just completed residency training. Because the minimum training for American Board of Obstetrics and Gynecology approved fellowship is 3 years of postgraduate work, we assumed that the resident-physician completed 3 years of fellowship and then entered practice.

While we chose to focus on FPM&RS fellows, the data are applicable to residents considering fellowship in Reproductive Endocrinology/Infertility, Gynecologic Oncology, and Maternal-Fetal Medicine. We modeled income loss during 3 years of fellowship training and determined the subsequent net increase in income to make subspecialty training financially neutral. In essence, we solved for the percentage of a general obstetrician/gynecologist’s annual income needed to offset the income loss for 3 years of training compared to residents going directly into general obstetrics/gynecology. Therefore, this manuscript creates a model for any OB/GYN subspecialty training.

To calculate the required income necessary to make the financial return on educational investment neutral, we entered estimates of age-specific incomes that were calculated using a common multiplier that was applied to age-specific incomes of obstetrician gynecologists. We performed a sensitivity analysis along the following parameters:

Age of anticipated retirement. We varied the age of retirement, at which income from the practice of medicine would cease, from age 50 to age 60.

The discount rate. A dollar earned today is worth more than a dollar earned in the future because today's dollar can be invested at an interest rate to produce an immediate return. We discounted future earnings by 5%, and 10% to recognize this reality.

Finally, we calculated the net present value of each educational pursuit: obstetrician/gynecology and female pelvic medicine and reconstructive surgery. For this analysis, we defined the annual cash flow of investment returns (CF) as the after expense annual income (Y), minus educational costs (E), minus opportunity costs (O). By recognizing that a dollar today is worth more than a dollar in the future because today's dollar can be invested at an interest rate (r) to produce an immediate return, and by identifying the timing of future anticipated returns on educational investments, one can calculate today's net present value (NPV) of an expected financial return on educational investment over time (j to n), as shown in the following equation:
$$ {\text{NPV}} = {\sum\limits_{j = 0}^n {\frac{{{\text{CF}}_{j} }} {{{\left( {1 + r} \right)}^{j} }}.} } $$


The annual incomes of white female and male obstetrician/gynecologists across the working lifetime demonstrates a typical inverted-U pattern (Fig. 1). For females completing residency, annual incomes are approximately $175,000 per year; they increase to approximately $230,000 per year after about 15 years of practice, and then fall with age. Males follow a similar income progression with a starting salary of approximately $240,000 per year and a maximum income of about $300,000 per year.
Fig. 1

Trendline of mean annual incomes for white female and male obstetrician gynecologists, across the working lifetime

Female pelvic medicine and reconstructive pelvic surgery fellows experience a relative loss of income during the three required fellowship years. Assuming fellowship training is not associated with an increased income level in post-fellowship years, when compared to a general obstetrician/gynecologists’ income level, fellowship training in FPM&RS is associated with a negative return of more than $400,000 to $600,000 over the working lifetime (Fig. 2). The majority of the costs are experienced during the fellowship years, because of the lower incomes. Because fellows have accumulated capitalized debt during the fellowship years, their relative income continues to decline until loans are repaid, at which point the cumulative adjusted net present value of additional training plateaus.
Fig. 2

The cumulative net present value of fellowship training in female pelvic medicine and reconstructive pelvic surgery discounted at 5%, across the working lifetime for male and female residents

The additional annual income required to render the investment in FPM&RS fellowship training financially neutral ranged from 16 to 31%, depending on the discount rate used, gender, and the anticipated retirement age of the urogynecologist (Fig. 3). Use of lower discount rates and higher retirement ages resulted in relatively lower required income multiples. Therefore, fellows anticipating working longer would require a less substantial annual increase in income to make their fellowship training financially neutral than those anticipating a shorter work life. Similarly, those making more conservative estimates of dollar devaluation would require less substantial annual increases in income than those anticipating greater dollar devaluation.
Fig. 3

Additional annual income required to render the investment in female pelvic medicine and reconstructive pelvic surgery fellowship training financially neutral, expressed as a multiple of the mean annual age-specific incomes of general obstetrician gynecologists, at two different discount rates and two different retirement ages by gender


We found that completing a 3-year fellowship in female pelvic medicine and reconstructive pelvic surgery would require substantially higher than mean incomes over the working lifetime to render the fellowship financially neutral. Residents who are considering a career in FPM&RS and do not believe that the market will provide that income differential may be hesitant to enter a female pelvic medicine and reconstructive pelvic surgery fellowship because they are unsure about the impact of that fellowship training on their ability to repay educational debt. We demonstrated a method whereby those considering fellowship training in subspecialties for which annual incomes are not readily available could generate estimates of incomes necessary to render the costs of fellowship training financially neutral.

Although there are many more factors important to specialty choice other than anticipated income, we believe that this approach can provide some useful information to residents who are in the decision-making process regarding sub-specialization. At a minimum, the analysis can provide a general sense of the financial costs of the choice to pursue fellowship training. In addition, this type of analysis can help residents going through the decision-making process determine whether the calculated income differential is realistic and achievable. Finally, such analyses may be useful to those who have completed fellowship training by providing valuable information for negotiation of salaries or work conditions.

The results are very similar when modeling male and female residents. The major difference is that males make, on average, $71,000 more per year than their age-matched female counterparts. This accounts for the larger negative net present value for males when they defer financial returns by going to fellowship. Sensitivity analyses showed minimal differences in the multiple of annual income required to create financial neutrality between male and females.

There are several limitations to our approach. First, our results are dependent on the data available, and are reliant in particular on the accuracy of self-reported income. The challenge in interpreting results from such data is that the physicians who entered obstetrics/gynecology were not randomly assigned to that specialty group: individual physician characteristics associated with choice of specialty may be associated with specialty-specific incomes. Therefore, our findings should not be interpreted as the return of specialty training for any given individual. Second, the returns are calculated using historical data generated from practicing physicians; past returns and salary levels may not be indicative of future returns and salary levels. Finally, our analysis was restricted by the assumptions inherent to the model.

Therefore, analyses examining different genders, races, or timing of career paths may have different results. In particular, our model assumed that urogynecologists and general obstetrician/gynecologists work the same number of hours. Nevertheless, because leisure time has value, the analysis could be applied to work hours as well: in lieu of additional income between 16 to 31%, a reduction in work hours by a like amount should result in a similar hours-adjusted return on educational investment. Therefore, the model can be used to outline the parameters of either annual incomes or work conditions that can accomplish financial neutrality.

We demonstrated that additional annual incomes are required to render fellowship training in female pelvic medicine and reconstructive pelvic surgery financially neutral. During post-fellowship years, higher incomes could be achieved through provision of a greater number of higher reimbursed procedures, actions that may not promote overall population health [11]. Alternatives to increased annual incomes over the working lifetime include professional development awards or supplemental incomes during fellowship, actions that could be promoted by the American Urogynecological Society and other gynecology societies. Subspecialty organizations are beginning to recognize the need to make fellowship training financially neutral [12], particularly when demographic changes in the US population suggest an unfilled future need for rare specialties. While factors other than income are critical to decisions regarding career choice and fellowship training, policy makers and specialty societies would be remiss if they ignored the powerful influence of the up-front costs of professional training and residents’ concern about their ability to repay the debt they incur, and the potential impact of those financial pressures on the overall population served.


This work was supported in part by Veterans Affairs Health Services Research and Development Grant ERA 03-098. Thank you to Dr. Richard Hill for his assistance.

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© International Urogynecology Journal 2007