Academic hand surgeons may earn millions less over a career, financial model finds

Hand surgeons who choose academic careers may earn substantially less over a lifetime than peers in private practice, but the size of the gap depends heavily on which salary survey is used to model it, according to a new net present value analysis published in Archives of Orthopaedic and Trauma Surgery. The study, led by John W. Moore and colleagues including Jason Silvestre, projected lifetime salary compensation for theoretical 32-year careers in academic versus non-academic hand surgery, drawing on 2025 benchmark data from the Medical Group Management Association (MGMA) and the American Medical Group Association (AMGA). Under MGMA benchmarks, academic practice yielded 19.7 percent less lifetime compensation than non-academic practice, 12.6 million dollars versus 15.7 million dollars in 2024 US dollars. Under AMGA benchmarks, the relationship reversed slightly, with academic practice coming out 2.7 percent ahead at 15.0 million dollars versus 14.6 million dollars.

Net present value, or NPV, is a standard financial technique that converts a stream of future income into today’s purchasing power by applying a discount rate. Each year’s projected salary is divided by a factor of one plus the discount rate raised to the power of the number of years into the career that the salary arrives, and these discounted values are summed across the career. Money earned decades from now therefore counts for less than money earned this year, which mirrors how economists and investors compare long-term revenue streams. The authors applied this framework to hand surgery because, although prior work has shown that academic surgeons generally earn less than non-academic surgeons and that hand surgery fellowship training may be associated with lower lifetime earnings than general orthopaedic practice, no previous study had directly compared lifetime salary compensation between academic and non-academic hand surgeons.

The modeling assumed a 32-year career ending at a retirement age of 65 for orthopaedic surgeons, an assumption consistent with prior surveys conducted by the American Academy of Orthopaedic Surgeons. The base case used a 3 percent annual discount rate. Because salary benchmark surveys report only summary statistics rather than individual earnings, the researchers built five theoretical career trajectories from the 25th percentile, median, and 75th percentile compensation values: a fixed salary at each of those three percentiles, a standard career in which pay starts at the 25th percentile for years one through three, rises to the median for years four through ten, peaks at the 75th percentile for years eleven through twenty, and returns to the median for the final twelve years, and an accelerated career that reaches the 75th percentile by year eight and stays there. The standard trajectory reflected prior findings that physician earnings typically peak in mid-career and decline gradually afterward.

The results were strikingly consistent under MGMA data. Across all five simulated trajectories, academic practice produced lower lifetime compensation than non-academic practice, with differences clustered around 20 percent. At fixed 25th percentile salaries the gap was 21.3 percent, 10.0 million versus 12.7 million dollars. At fixed median salaries it was 19.7 percent, and at fixed 75th percentile salaries it was 19.6 percent, 16.4 million versus 20.4 million dollars. The standard and accelerated career trajectories showed gaps of 19.8 percent each. In other words, whether a hand surgeon was modeled as a modest earner, a typical earner, or a high earner, the academic penalty under MGMA benchmarks remained nearly constant in relative terms, translating into roughly three million dollars of discounted lifetime earnings.

The picture changed almost completely when the same calculations were run with AMGA benchmarks. Lifetime compensation was similar between the two practice settings across every career trajectory, with differences of less than 3 percent in all comparisons, ranging from 0.0 to 2.7 percent. The authors attribute this divergence to differences in survey methodology between the two data sources. Large healthcare organizations with a greater representation of hospital-employed physicians tend to concentrate in AMGA data relative to MGMA, which may explain why academic and non-academic hand surgeons appear similarly compensated in AMGA data. Conversely, the MGMA survey may sample a larger share of hand surgeons in non-academic practice who have access to ancillary practice revenue, a stream of income that academic salaries typically do not include.

To test how sensitive the conclusions were to the underlying financial assumptions, the team ran sensitivity analyses varying career length across 28, 30, 32, 34, and 36 years and discount rates from 1 to 5 percent. Holding salary at the median and the career at 32 years, the MGMA-based gap between academic and non-academic practice persisted across all discount rates, with academic values ranging from 9.7 million to 16.8 million dollars against non-academic values of 12.1 million to 20.9 million dollars, a relative difference of 19.4 to 19.8 percent. Under AMGA data the two settings again remained nearly equivalent, with academic values of 11.6 million to 20.0 million dollars versus 11.3 million to 19.5 million dollars for non-academic practice, a difference of 2.3 to 2.7 percent. Varying career length produced the same pattern: under MGMA the gap stayed between 19.4 and 20.2 percent across all five career lengths, while under AMGA it remained between 2.6 and 3.0 percent.

The researchers then added a Monte Carlo simulation to model uncertainty in the projections. For each practice setting they ran 10,000 iterations, and in every iteration the model randomly selected a fixed salary at the 25th percentile, median, or 75th percentile, a random discount rate between 1 and 5 percent, and a random integer career length between 28 and 36 years. Results were summarized as median net present values with interquartile ranges and compared using Mann Whitney U tests with a significance threshold of 0.05. With MGMA data, academic practice showed a median of 12.9 million dollars with an interquartile range of 10.5 to 15.4 million, versus 16.0 million dollars with an interquartile range of 13.3 to 19.2 million for non-academic practice, a 19.4 percent difference that was statistically significant at P less than 0.001. With AMGA data the medians were nearly identical, 15.1 million versus 15.0 million dollars, a 0.7 percent difference that was not statistically significant at P equal to 0.182.

The authors emphasize that compensation is only one dimension of career value. Citing prior survey work, they note that academic orthopaedic surgeons tend to report greater satisfaction with research opportunities, reputation, and continued education but dissatisfaction with ancillary income, while private-practice surgeons report the reverse pattern. A survey by the American Society for Surgery of the Hand found high job satisfaction across practice settings despite a high prevalence of burnout, and lower burnout rates were observed among hand surgeons who did not take call regardless of call compensation. Academic surgeons may also see lifetime earnings rise with promotion from assistant to associate professor, though promotion typically depends on research productivity, service line leadership, and national recognition. Hybrid compensation models that pair a base salary with incentives for case volume and academic output may offer flexibility but often add administrative burden, and academic hand surgeons frequently have greater access to industry consulting and research funding.

The findings may matter for workforce planning as well as individual decisions. High rates of faculty attrition can threaten the teaching and research missions of academic orthopaedic departments, and large compensation disparities may hinder recruitment of hand surgery faculty as financial pressures grow. The authors suggest that institutions seeking to attract top hand surgeons might consider enhanced incentive structures, protected research time, loan repayment programs, leadership development, or formal recognition of educational achievement within existing compensation frameworks. They also observe that vertical integration of private practices into large health systems, combined with declining fee-for-service reimbursement, could push future pay for academic and private-practice hand surgeons closer together.

Several limitations frame the conclusions. Both the MGMA and AMGA surveys are voluntary and nonrandom, so the benchmarks may not capture regional variability, practice-specific differences, or reimbursement changes over time. The projections rest on assumptions about salary growth, retirement age, and inflation, and although variations in these parameters could shift absolute estimates, the authors note that relative differences between practice settings may remain similar. The analysis included only direct salary compensation with ancillary revenue streams for hand surgeons with orthopaedic surgery training, since plastic surgery hand surgeon benchmarks were unavailable; it excluded equity ownership, consulting income beyond salary, debt repayment, cost-of-living adjustments, and non-salary benefits, and it did not assess career satisfaction, burnout, or work-life integration. Policy and reimbursement shifts over a three-decade career could also reshape the financial balance between the two paths. The study followed the Consolidated Health Economic Evaluation Reporting Standards 2022 and was published as open access research on 21 October 2026.

Subject of Research: Lifetime salary compensation of academic versus non-academic hand surgeons modeled using net present value analysis

Article Title: Net present value analysis of total salary compensation in hand surgery: academic versus non-academic careers

Article References: Moore, J. W., Minerva, A. J., Daley, D. N., Daly, C. A., & Silvestre, J. (2026). Net present value analysis of total salary compensation in hand surgery: academic versus non-academic careers. Archives of Orthopaedic and Trauma Surgery, 146(1), Article 378. https://doi.org/10.1007/s00402-026-06547-2

Image Credits: AI Generated

DOI: 10.1007/s00402-026-06547-2

Keywords: hand surgery, net present value, salary compensation, academic careers, MGMA, AMGA, Monte Carlo simulation, orthopaedic surgery, career planning, discount rate, physician income, workforce retention