The research, published in Global Surgical Education, the journal of the Association for Surgical Education, was led by Nicholas J. Iglesias and colleagues at the University of Miami Miller School of Medicine. The team set out to answer a deceptively simple question: what does a surgical intern’s starting salary actually buy in the place where it is earned? To find out, they queried the Residency Explorer database for all university-based and community-based, university-affiliated general surgery programs in the United States, extracting each program’s intern starting salary, university affiliation, and geographic region. They then applied federal and state income tax rates to calculate post-tax earnings and drew on county-level cost-of-living data from the Economic Policy Institute’s Family Budget Calculator, which estimates what a modest but adequate standard of living costs in a given locality.

The centerpiece of the analysis is a metric the authors call the Salary-to-Cost-of-Living Ratio, or StCOLR. It is calculated by dividing a program’s post-tax intern salary by the estimated local cost of living. A ratio of 1.0 means an intern’s take-home pay exactly matches what it costs to live in that county; anything below 1.0 means the intern is, in practical terms, running a deficit before the year even begins. The ratio offers a more honest picture of financial well-being than the nominal salary figures printed in program recruitment materials, because it folds in the two great eroders of resident purchasing power: taxation and geography.

The headline numbers reveal a system with wide and consequential variation. Among the 270 programs analyzed, the median pre-tax intern salary was $67,763, with an interquartile range stretching from $63,724 to $72,700 — a spread of nearly $9,000 before a single adjustment is made. Once federal and state taxes were applied, the median post-tax wage fell to $57,802, ranging from $54,652 to $61,653. Meanwhile, the median estimated local cost of living across program counties was $49,178, but the interquartile range ran from $44,558 to $58,753, meaning that two interns earning identical nominal salaries could face living costs differing by well over $14,000 a year. Dividing one by the other produced a median StCOLR of 1.15, with an interquartile range of 1.02 to 1.26 — a narrow-looking margin that conceals how many programs fall on the wrong side of the break-even line.

That wrong side is not a small corner of the map. The study found that 23 percent of programs across the United States offer categorical surgical interns a StCOLR below 1. In other words, nearly one in four surgical training programs pays its newest residents a post-tax salary that does not cover the estimated cost of living in the surrounding county. For interns at those programs, the shortfall must be bridged somehow: by loans, spousal income, deferred maintenance on their own health and housing, or debt accumulated on top of the already substantial borrowing many carry from medical school. The finding lands with particular force in an era when medical school debt continues to climb and prior research has linked student debt to worse mental health, altered specialty choices, and heavy trainee reliance on programs such as Public Service Loan Forgiveness.

Geography emerged as the dominant driver of these disparities. Programs located in the 20 most populous US cities had a significantly lower median StCOLR than programs in less populous areas — 1.12 versus 1.16, a difference the authors report as statistically significant with a p-value of 0.037. The pattern is counterintuitive only at first glance. Big-city programs often advertise higher nominal salaries, reflecting local wage norms and union activity in some markets, but those premiums are dwarfed by the housing, childcare, and transportation costs embedded in metropolitan budgets. The result is that the intern in a high-cost coastal metropolis who earns more on paper may end the year with less real purchasing power than a peer in a mid-sized Midwestern city earning several thousand dollars less.

Regional comparisons sharpened the picture further. Programs in the West North Central and East North Central census regions — the agricultural and industrial heartland stretching from the Dakotas and Kansas through the Great Lakes states — demonstrated significantly more favorable StCOLR values than programs in the South Atlantic, Pacific, New England, and Middle Atlantic regions, with all comparisons reaching statistical significance at p ≤ 0.004. The finding effectively redraws the financial map of surgical training. The corridors of prestige along the Atlantic seaboard and the Pacific coast, which attract disproportionate numbers of applicants, are precisely the regions where an intern’s stipend stretches thinnest. Meanwhile, programs in the nation’s interior, often perceived as less desirable destinations, offer their trainees the strongest real-world compensation in the country.

The technical design of the study deserves attention, because its conclusions rest on a chain of methodological choices. By restricting the sample to university-based and community-based, university-affiliated general surgery programs, the authors captured the institutional settings where most categorical surgical training occurs. Using the Residency Explorer database ensured a consistent, publicly available source for salary figures across programs. Applying state-specific income tax calculations matters because state tax burdens range from zero in some jurisdictions to substantial in others, meaning two programs offering the same gross salary can deliver meaningfully different take-home pay. And by anchoring cost-of-living estimates to the county level rather than the state level, the analysis avoids the smoothing error that would blur the difference between, say, an urban core and its rural periphery. The Economic Policy Institute’s Family Budget Calculator, with data in 2025 dollars, models family-type-specific budgets covering housing, food, childcare, transportation, health care, taxes, and other necessities, providing a defensible denominator for the ratio.

The study’s limitations are those inherent to any database-driven national analysis. Salary figures reflect what programs report and may lag behind mid-cycle raises or supplemental benefits such as housing stipends, meal allowances, or free parking, which can materially alter an intern’s real income in expensive cities. The cost-of-living estimates assume a particular family budget configuration, while many interns are single and some support dependents, so individual experiences will vary around the modeled values. The analysis also captures a single snapshot of intern compensation rather than the full trajectory across five or more years of surgical training, during which salaries rise but so do regional cost pressures. Still, the authors argue, none of these caveats blunts the central finding: even after taxes and local prices are held constant, surgical intern compensation remains highly variable across the United States.

The implications reach well beyond individual paycheck math. For applicants ranking programs in the Match, the study offers a quantitative tool for comparing offers that are nominally similar but financially worlds apart. For program directors competing for top candidates, it suggests that recruitment materials quoting gross salaries may be less persuasive — and less honest — than transparent accounting of what a stipend buys locally. For the sponsoring institutions and professional bodies that fund graduate medical education, the findings make the case that aligning compensation and supplemental benefits with local living costs is not a luxury but a matter of equity, financial well-being, and the long-term sustainability of the surgical workforce. As the authors conclude, a system in which nearly a quarter of programs leave their interns financially underwater each year is one that quietly taxes exactly the people it most needs to thrive.

Subject of Research: Geographic and program-level variation in the real value of surgical intern compensation across United States residency programs

Article Title: All surgical intern salaries are not created equal: geographic and program-level variation in surgical intern compensation

Article References: All surgical intern salaries are not created equal: geographic and program-level variation in surgical intern compensation. (n.d.). https://doi.org/10.1007/s44186-026-00594-4

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00594-4

Keywords: surgical residency, intern salary, cost of living, graduate medical education, compensation equity, StCOLR, geographic variation, medical student debt, Residency Explorer, tax-adjusted income, workforce sustainability, general surgery