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Heartbeats and Bank Statements: A Survey of The Financial Pulse of Cardiologists
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00292. Epub October 24, 2024.
Abstract
Objectives. The financial well-being of cardiologists has received limited study. The authors conducted an international, online survey of attending cardiologists to assess their financial well-being.
Methods. The authors performed an online, anonymous, international survey of the financial well-being of cardiologists from June to August 2024.
Results. Three hundred thirty-eight attending cardiologists participated in this survey. Most were from the United States (78%), men (89%), and had a median age of 46 to 50 years. US participants had a median yearly income of $600 000 to $699 000, spent a median of 60 hours/week at work, had a median of 5 weeks/year of vacation, and 14.5% had college/medical school debt. Median incomes varied by practice type: university ($500 000-$599 000), private group ($700 000-$799 000), and community hospital ($700 000-$799 000). Less than half (44%) of the US participants received cardiology-related income such as royalties, 9% took locum/moonlighting shifts, and most (55%) had individual, own-occupation, specialty-specific disability insurance. Most (79%) were married and never divorced. Most (73%) led family financial planning, 59% had an investment advisor, 91% used tax-advantaged investment accounts, 70% knew where their money was invested, and 28% owned real estate with tenants. The median net worth of the US participants was $3 to $5 million, and 78% had a retirement net worth goal, with a median target of approximately $10 million. Half (50%) had trust and estate planning. One-third (32%) of the US participants said they would take a 25% pay cut to work 25% less. Multiple linear regression analysis showed that past divorce and longer work hours were associated with emotional exhaustion, while higher net worth was associated with higher life satisfaction and less emotional exhaustion.
Conclusions. The survey provides novel insights into the financial well-being of cardiologists.
Introduction
Clinician well-being is a priority for the American College of Cardiology, the American Heart Association, the European Society of Cardiology, and the World Heart Federation.1
Approximately 50% of physicians reported being affected by burnout.2 Interventional cardiology is a particularly demanding field with long work hours and stressful working environment. In a recent survey, 69% of interventional cardiologists reported being affected by burnout,3 with insufficient income being one of the leading contributors.3 We conducted an international, online survey of attending cardiologists to assess their financial well-being.
Methods
The survey questions were prepared by the co-authors: 77 questions in English were included in the survey (Supplemental Material). The survey was administered via the Research Electronic Data Capture (REDCap) and was distributed to cardiology attendings from June to August 2024 via social media and email lists. The questions used in this survey were shown to perform similarly to the Maslach Burnout Inventory,4-6 a valid and reliable survey to measure burnout in medical professionals.
On a scale of 0-10, 0 represented the lowest grade and 10 represented the highest grade. Categorical variables were presented as absolute numbers and percentages and compared using the chi-square or Fisher’s exact test, as appropriate. Multivariable linear regression was used to investigate the association between emotional exhaustion, life satisfaction, physical health, burnout; and net worth, age, sex, work hours, vacation, having children, and divorce.
Statistical analyses were performed using Stata v18.0 (StataCorp LLC). The study was approved by the Allina Health institutional review board.
Results
Demographics and practice types
The survey was completed by 338 attending cardiologists (no trainees), of which approximately 20% participated through email lists, and the rest were recruited through social media or by individually emailing cardiologists from their institutions’ website contact information. Most participants were from the United States (78.5%) (45 states and territories), followed by the European Union (8.5%), Asia (4.2%), the Middle East (3%), Latin America (2%), Canada (1.5%), Turkey (1.2%), and Egypt (1%). The majority of participants were men (89%). The median age was 46 to 50 years, and participants spent a median of 60 hours/week at the hospital and had a median of 5 weeks/year of vacation. The median time in practice as an attending cardiologist was 15 years. Most participants were interventional cardiologists (82%), followed by general cardiologists (8%), cardiac imagers (3%), heart failure and transplant cardiologists (3%), electrophysiologists (2%), critical care cardiologists (1%), and adult congenital heart cardiologists (1%). Less than half (44%) worked for a university system, followed by community hospitals (25%), and private cardiology groups (22%), and most (95%) worked as a full-time cardiologist.
Most participants (65%) graduated from a medical school in the United States and were green-card holders or US citizens (98%). Those who attended medical school in the United States were more likely to currently have medical school debt (14.5% vs 3.3%, P = .005). Most participants (52%) had an administrative role and spent a median of 20% of their time with administrative work. Approximately one-quarter (24%) of participants spent at least 10 hours per week on research.
Most participants were currently married and never divorced (79%), approximately 15% had a divorce, 8.6% had 2 or 3 divorces, and only 3% were single and never married. Partners of cardiologists often worked in health care (56%), and were physicians (39%), or non-physicians (17%). Partners of cardiologists often did not work full-time (56%). Most (73%) cardiologists led financial planning for their family. Most cardiologists had children (88%), and 12% had 4 or more children.
Annual income and payment systems
The median annual income for US participants was $600 000 $699 000 (Figure 1) compared with $200 000 to $299 000 for non-US participants (P < .001). The median net worth of US participants was $3 to $5 million. Median incomes varied by practice type: university ($500 000-$599 000), private group ($700 000-$799 000), and community hospital ($700 000-$799 000). The median annual income for US participants by age group is demonstrated in Figure 2A. US participants were more likely to think they made enough money compared with non-US participants (69% vs 36%, P < .001). The most common payment systems for US participants were a combination of fixed salary and relative value unit (RVUs) (39%), followed by fixed salary (31%), and only RVUs (20%). Non-US participants were more likely to have a fixed salary compared with US participants (44% vs 31%, P = .045).
US participants were more likely to seek legal counsel to review work contracts compared with non-US participants (39% vs 14%, P < .001), and, of those, 55% said they benefited from seeking legal counsel. One-fifth (20%) said their hospital accurately tracks their RVUs, 41% were not sure, and 39% did not think their RVUs were accurately tracked. Approximately one-third (34%) of participants said their payment system changed in the last 3 years, and, of those, only 38% said their cardiology group was consulted prior to the change, and, of those, 40% did not have a final say in how their payment structure changed.
Most participants (68%) moonlighted during residency or fellowship. Of those who did not moonlight, 34% wanted to but were not eligible to moonlight (visa issues or time constraints). Locums/moonlighting shifts were more often taken by non-US participants compared with US participants (25% vs 9%, P = .001). Non-US participants more often had non-clinical income (consulting, royalties) compared with US participants (59% vs 44%, P = .023).
Financial planning
Most (55%) US participants had an individual, own-occupation, specialty-specific disability insurance, approximately 40% did not have one, and 5% were not sure. US participants were more likely to have an accountant/tax professional (82% vs 70%, P = .024), and more likely to use the retirement (tax-advantaged) investment accounts compared with non-US participants (97% vs 44%, P < .001). US participants were also more likely to have a financial/investment advisor compared with non-US participants (59% vs 25%, P < .001). US participants often paid their financial/investment advisor a percentage-based fee (79%) or per-hour fee (6%), but 12% were not sure how their advisor was paid. US participants were more likely to know where their money was invested (if that information was available to them) (70% vs 42%, P < .001). In this cohort, the median weight of low-cost index or exchange-traded funds in financial portfolio was 50% and was lower in older participants. Approximately one-third (34%) of participants invested in target-date funds, and 29% of participants did not know how much commission/expense ratio they were paying. One-fifth (20%) of participants were buying and selling options in the stock market. While 16% of participants did not invest any money in individual company “stocks”, 24% of participants had half of their investments in individual companies. Approximately 28% owned real estate for investment purposes and had tenants. Almost three-quarters (74%) said they would be interested in learning more about physician-specific financial circumstances in medical conferences.
The association between the net worth of US participants and their age is demonstrated in Figure 2B. More than three-quarters (78%) of US participants had a target net worth in their mind for when they would retire (median: approximately $10 million). The frequency of tracking net worth was weekly (20%), monthly (18%), every quarter (15%), twice a year (14%), once a year (15%), and less than once a year (18%). Half (50%) had trust and estate planning in place, and 34% reported considering taking action to establish one.
Burnout metrics
More than one-third (37%) of participants reported being emotionally exhausted. Most (62%) reported being physically healthy, and three-quarters (76%) reported being happy overall. Most (82%) stated they were satisfied with their lives. Less than half (46%) reported feeling frustrated with their work, and more than half (55%) reported being too stressed. Less than half (41%) reported being burned out, and more than one-third (35%) reported feeling lonely during the last year. The burnout metrics were numerically, but not statistically, worse for women (Figure 3).
On a scale of 0 to 10, having had a divorce was associated with 1.95-point higher (95% CI, 0.49-3.41; P = .009), working longer hours was associated with a 0.53-point lower (95% CI, 0.17-0.89; P = .004) emotional exhaustion score, and higher net worth (~$1 million increase) was associated with a 0.38-point lower (95% CI, 0.10-0.67; P = .008) emotional exhaustion score after adjusting for age, sex, vacation time, and having children (Figure 4A). On a scale of 0 to 10, higher net worth (~$1 million increase) was associated with a 0.50-point higher (95% CI, 0.16-0.84; P = .004) life satisfaction score after adjusting for age, sex, hours worked, vacation time, having children, and having had a divorce (Figure 4B). Higher net worth was not associated with physical health after adjusting for age, sex, hours worked, vacation time, having children, and having had a divorce (Figure 4C). On a scale of 0 to 10, higher net worth (~$1 million increase) was associated with 0.63-point lower (95% CI, 0.15-1.11; P = .010) burnout score, and longer work hours (10-hour increase) with a 0.56-point higher (95% CI, 0.19-0.95; P = .004) burnout score after adjusting for age, sex, vacation time, having children, and having had a divorce (Figure 4D). Almost one-third (32%) of participants indicated they would be willing to take a 25% pay cut in exchange for working 25% less.
Discussion
Our study provides contemporary data on the financial and psychological well-being of cardiologists in 2024. The main findings of our study are the following: (a) the median annual income for US participants is $600 000 to $699 000; (b) the most common payment system for US participants is a combination of fixed salary and RVUs (39%); (c) 39% of US participants sought legal counsel for their contract, and of those 55% reported benefiting from it; (d) 39% believed their hospital was not accurately tracking their RVUs, with only 20% believing that RVUs were tracked accurately; (e) 40% did not have an individual, own-occupation, specialty specific disability insurance, and 79% paid their financial advisor on a percentage-basis, as opposed to an hourly fee; and (f) higher net worth was associated with less emotional exhaustion, greater life satisfaction, and less burnout, while longer work hours were associated with more emotional exhaustion and burnout, and a past divorce was associated with more emotional exhaustion.
According to the Medscape Cardiologist Compensation Report 2024, the average income for US cardiologists was $525 000.7 In our study, the median annual income was $600 000 to $699 000, which may be attributed to the higher representation of interventional cardiologists in our survey (82%). Similar to the Medscape Survey, where 48% said they were paid fairly, in our study, 57% thought they were paid fairly. In the Medscape survey, 10% of participants did moonlighting, which is similar to our study (9%).7
Our findings are consistent with those of Medscape’s 2024 Physicians and RVUs report, where 42% reported RVUs playing a role in their payment (vs 39% in our study).8 While we did not assess whether physicians are satisfied with the RVU system, in our study, 39% did not believe RVUs were accurately tracked, and only 20% believed RVUs were accurately tracked, which is consistent with the Medscape Report where approximately 60% were unhappy with how RVUs affected them financially.8,9 In addition, our study shows that when the payment system was changed, cardiologists were often not consulted (62%), and, if they were consulted, 40% did not have a say in how the payment system would change. This implied distrust of the system and the hospital administration, along with a lack of a seat at the table, may worsen burnout, whereas more transparency in the payment systems may improve the well-being of cardiologists.
Burnout was less prevalent in our study compared with prior studies conducted in 2023 (41% vs 69%)3,10,11 and may indicate a potential improvement in the well-being of physicians. This improvement was also observed in the Medscape Physician Burnout & Depression Report 2024.11 However, burnout remains more prevalent than pre-COVID-19.11 In addition, our study suggests that women cardiologists may be at a higher risk for burnout, emotional exhaustion, frustration, and stress (Figure 3).
Burnout and mental health are increasingly recognized as priorities for cardiologists and professional societies, and cardiologists express a desire to learn more about physician-specific financial education (74% in our study). Therefore, it may be beneficial to organize such sessions at cardiology meetings.
Since higher net worth was associated with greater life satisfaction and lower emotional exhaustion and burnout, while past divorce was associated with increased exhaustion, we identified several opportunities to enhance the financial well-being of cardiologists. First, one of the biggest financial risks cardiologists face is losing the ability to convert their knowledge and skills gained over at least a decade into financial wealth.12 Orthopedic injuries and radiation exposure are common among interventional cardiologists (~50%) and can impact their livelihood.13-16 Despite the high incidence of these occupational hazards, in our survey, 40% of US participants reported not having individual, specialty-specific, disability insurance. Therefore, obtaining disability insurance, especially in early career, may be beneficial.12
Second, most cardiologists pay their financial advisor a percentage-based fee (79% in our study). Switching to an hourly fee instead (especially when you have accumulated considerable wealth) or learning how to do it oneself may lead to significant savings over years.17,18
Third, 30% of participants did not know where their money was invested despite that information being available to them, and 29% were unaware of the commission or expense ratios they were paying, indicating that at least a quarter of cardiologists may have some room for improvement in their investment strategy to minimize expenses and retain more for themselves.19
Fourth, 20% of participants reported buying and selling options in the stock market, and 26% reported having half of their net worth in individual companies. Given that most participants in our study have busy practices (60-hour work weeks), they likely lack the time and expertise to pick individual stocks effectively. Both The White Coat Investor and Warren Buffett emphasize the benefits of consistently investing in a low-cost S&P 500 fund,20,21 including minimizing expense ratios and tax liabilities by reducing frequent trading.
Fifth, 14.5% of participants who graduated from US medical schools continued to have college or medical school debt. Utilizing the 529 college savings plans and choosing more affordable medical schools may help alleviate this burden for future generations.
Sixth, past divorce had the strongest association with increased emotional exhaustion. Cardiology is a demanding field and may take a toll on a marriage.22 Warren Buffett, one of the richest people in the world,23 who still goes to work happy at the age of 94 years, recommends that if one is going to get married, one should want a marriage that will last, and choose accordingly.24
Limitations
First, participating cardiologists may be more interested in finance, wellness, and research, which might result in selection bias. Second, distribution by email lists and social media (X, LinkedIn) may also skew toward younger participants and academic cardiologists, and most participants in our survey were interventionalists. Third, given that the survey was anonymous (recruitment was largely through social media and emails sent to cardiologists individually), the response rate is indeterminate. Fourth, questions on past mood/feelings are subject to recall bias. Fifth, while burnout is often dichotomized, there is no universally accepted definition, and there is likely a continuum in burnout severity.
Conclusions
Our survey provides an assessment of the current financial and mental well-being of cardiologists and identifies opportunities for improvement in financial well-being.
Affiliations and Disclosures
Bahadir Simsek, MD1; Bavana V. Rangan, BDS, MPH2; Yousif Ahmad, BMBS, PhD3; Lorenzo Azzalini, MD, PhD, MSc4; Rhian E. Davies, DO, MS5; Jennifer Frampton, DO, MPH6; Jaikirshan Khatri, MD7; Ajay J. Kirtane, MD8; Alexandra J. Lansky, MD6; William L. Lombardi, MD4; Yader Sandoval, MD2; Andrew J. Sauer, MD9; Jeffrey Wilson, MD10; Emmanouil S. Brilakis, MD, PhD2
From the 1Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; 2Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota; 3Division of Cardiology, University of California San Francisco, San Francisco, California; 4Division of Cardiology, University of Washington, Seattle, Washington; 5Department of Cardiology, WellSpan Health, York, Pennsylvania; 6Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; 7Section of Interventional Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio; 8Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York; 9Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri; 10Black Hills Heart and Vascular Institute, Rapid City, South Dakota.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Funding: The authors are grateful for the White Coat Investor’s support for the free book gift: “The White Coat Investor: A Doctor's Guide to Personal Finance and Investing”, and the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs. Mary Ann and Donald A Sens; Mrs. Diane and Dr. Cline Hickok; Mrs. Wilma and Mr. Dale Johnson; Mrs. Charlotte and Mr. Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation's Science Center for Coronary Artery Disease (CCAD) helped support this research project.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. Email: esbrilakis@gmail.com; X: @bahadirsimsekmd; @esbrilakis
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