Physician Salary by Specialty: A Neurosurgery Residency Guide

Understanding Neurosurgery as a Highest-Paid Specialty

Neurosurgery consistently ranks at or near the very top of lists of highest paid specialties. When people talk about “physician salary by specialty,” neurosurgeons are often used as a benchmark for the upper end of physician compensation. But the reality behind a brain surgery residency, and the income trajectory that follows, is far more nuanced than a single headline number.

If you are considering neurosurgery residency—or are already on that path—understanding compensation at each stage of training and practice is critical for:

• Setting realistic expectations
• Planning student loan repayment
• Negotiating contracts
• Choosing subspecialty training and practice settings

This guide walks through the salary landscape specifically from the neurosurgery perspective: from medical school through residency and fellowship and into attending practice, including academic vs private practice, subspecialty differences, and geographic variation.

Throughout, keep in mind that salary figures are ranges and averages; real offers vary with regional market forces, group needs, and your individual negotiation leverage.

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Why Neurosurgery Is Among the Highest Paid Specialties

When you look at doctor salary by specialty across the board, neurosurgery almost always appears in the top three, often number one. Several structural factors explain why neurosurgery is one of the highest paid specialties:

1. Length and Intensity of Training

• Typical training pathway:
  • 4 years undergraduate
  • 4 years medical school
  • 7 years neurosurgery residency (sometimes 6 with a structured research year)
  • 0–2 years fellowship (e.g., spine, vascular, functional, pediatrics, skull base)
• Total: 15–17 years after high school before independent practice

The time cost and opportunity cost are substantial. Compensation at the attending level partly reflects this long training arc and high barrier to entry.

2. Procedure-Heavy, High-Risk Work

Neurosurgeons perform complex procedures with high stakes:

• Craniotomies for tumor, trauma, vascular lesions
• Spine surgery (decompressions, fusions, deformity)
• Functional procedures (DBS, epilepsy surgery)
• Endovascular procedures (in centers where neurosurgeons do them)

These are high-RVU, high-reimbursement services. The combination of surgical volume and complexity drives compensation upward.

3. Limited Supply, High Demand

• Very small number of residency positions each year compared with other specialties
• Many metropolitan areas have a limited number of practicing neurosurgeons, especially in community and rural hospitals
• Call coverage is essential—hospitals cannot function without emergent neurosurgical coverage for trauma and hemorrhage

Limited supply paired with essential, time-sensitive services increases market value.

4. Intensity of Lifestyle and Call

High compensation also reflects:

• Frequent overnight and weekend call
• Emergency cases at unpredictable hours
• Heavy medico-legal risk and malpractice premiums
• Significant emotional and cognitive load

This is not “easy money”—it represents high risk, high workload, and high responsibility.

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Salary During Neurosurgery Residency and Fellowship

When applicants hear that neurosurgery is among the highest paid specialties, they sometimes overestimate income during training. Residency income is relatively standardized across specialties.

Neurosurgery Residency Salary

In the U.S., resident salary typically depends on postgraduate year (PGY), not specialty. That means neurosurgery residents earn similar base pay to internal medicine or pediatrics residents at the same PGY level, though:

• Neurosurgery residents often receive more call pay or moonlighting opportunities (depending on program policies).
• Some programs offer neurosurgery-specific stipends for books, courses, or conferences.

Typical annual base salary ranges (approximate, pre-tax, U.S.):

• PGY-1: $60,000–$70,000
• PGY-2: $63,000–$73,000
• PGY-3: $66,000–$76,000
• PGY-4: $69,000–$79,000
• PGY-5: $72,000–$82,000
• PGY-6: $75,000–$85,000
• PGY-7: $78,000–$90,000

These ranges vary by:

• Cost of living (major coastal cities vs Midwest/South)
• Unionization status (some resident unions negotiate higher pay)
• Hospital/health system policies

Resident benefits (health insurance, disability insurance, meals, parking, educational funds) significantly affect the effective value of compensation, especially in high cost-of-living areas.

Call Pay and Moonlighting

Neurosurgery residents often have intense call schedules, but whether that translates into extra pay depends on the program:

• In many academic programs, in-house call is part of your base salary with no additional hourly pay.
• Some programs offer small stipends for extra shifts (e.g., covering additional hospitals or moonlighting in ICU or ED).
• Moonlighting may be limited or prohibited in earlier years due to duty hour rules and workload.

If you are comparing brain surgery residency programs, ask explicitly:

• Is there additional compensation for home call or backup call?
• Are PGY-5+ residents allowed to moonlight?
• Are there incentive structures for productivity on certain services?

Fellowship Compensation

Post-residency neurosurgery fellowships—spine, endovascular, skull base, pediatrics, functional, etc.—usually offer salary similar to a senior resident or slightly higher:

• Typical range: $75,000–$100,000
• Many are designated as PGY-7/8 positions, with institutional salary scales

Endovascular and complex spine fellowships more often include attending-level opportunities (billing under supervision, bonus structures) that can push compensation higher, especially in high-volume centers.

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Attending Neurosurgeon Salaries: Core Drivers and Typical Ranges

Once you complete neurosurgery residency (and possibly fellowship), you enter the attending market—where neurosurgery becomes one of the highest paid specialties in medicine.

Typical Salary Ranges for Neurosurgeons

For full-time attending neurosurgeons in the U.S., approximate total compensation (base + bonus) often falls into these ranges:

• Starting salary (first 1–2 years):

  • $550,000–$800,000 in many markets
  • Can be lower in academic centers ($450,000–$650,000)
  • Can be higher in underserved rural areas or heavy-call positions ($800,000–$1,000,000+)

• Mid-career (5–10 years out):

  • $750,000–$1,200,000+ depending on:
    • Case volume
    • Payer mix
    • Subspecialty focus (e.g., spine vs tumor vs functional)
    • Practice type (academic vs private vs hybrid)

• High-volume private practice or large group partners:

  • Commonly $1,000,000–$2,000,000+ in total compensation for very productive surgeons in competitive markets

These numbers assume full-time clinical practice with call responsibilities. Part-time, primarily research, or administrative-heavy roles will differ.

Major Factors That Affect Neurosurgery Compensation

1. Practice Setting

   • Private practice / large multi-specialty groups
     • Often higher upside potential
     • Production-based compensation (RVUs, collections)
     • May require several years to build volume
   • Employed by hospital/health system
     • More predictable base salary
     • RVU or quality-based bonuses
     • Stronger benefits and retirement plans
   • Academic centers
     • Generally lower physician salary compared to private practice
     • Non-monetary benefits: research, teaching, prestige, subspecialty focus
     • Compensation increasingly includes RVU requirements

2. Subspecialty Focus

   • Spine-focused neurosurgeons
     • Often command higher compensation due to high procedural volume and reimbursement per case
   • Functional, tumor, vascular, skull base
     • High complexity; income depends heavily on volume and institutional payer mix
   • Pediatric neurosurgery
     • Often housed in academic children’s hospitals
     • Lower average income than adult spine-focused practice, though still well compensated

3. Geography and Cost of Living

   • Rural and underserved regions
     • Often offer higher starting salaries and sign-on bonuses
     • Larger call stipends to cover multiple hospitals
   • Desirable urban centers
     • Lower relative physician salary offers
     • Higher cost of living eats into net income

4. Call Burden

   • Heavy call schedules—especially trauma coverage—may be compensated with:
     • Additional stipends
     • Enhanced base salary
     • “Unassigned” call pay from hospitals separate from practice RVUs

5. Experience and Negotiation

   • Established surgeons with robust referral networks command stronger contracts.
   • Your ability to interpret and negotiate compensation models (RVUs, collections, partnership tracks) has major financial impact over time.

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Neurosurgery vs Other Specialties: Where It Fits in the Salary Spectrum

From a physician salary by specialty perspective, neurosurgery is consistently at the very top or in the top few. To understand the broader context as a neurosurgery applicant, compare ballpark U.S. averages:

• Neurosurgery:
  • Frequently $800,000–$1,000,000+ average total compensation
  • Often cited as #1 or #2 among the highest paid specialties
• Orthopedic surgery (including spine):
  • Roughly $600,000–$900,000+
• Cardiology (invasive):
  • $550,000–$800,000+
• Gastroenterology:
  • $500,000–$750,000+
• Radiology (diagnostic, interventional higher):
  • $450,000–$700,000+
• Emergency medicine:
  • $300,000–$450,000+
• Internal medicine, pediatrics, family medicine:
  • $220,000–$320,000 (varies widely)

Exact numbers shift year to year, but neurosurgery repeatedly occupies the top band when discussing doctor salary by specialty and highest paid specialties.

However, when interpreting this:

• High salary comes with significant trade-offs in lifestyle, length of training, call, and risk.
• Neurosurgery is extremely competitive; income potential should not be your sole motivator.
• Burnout and attrition are real concerns; aligning with the work itself is crucial.

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Key Contract Elements and Financial Planning for Future Neurosurgeons

For residents and fellows nearing graduation, understanding how neurosurgery compensation is structured is as important as knowing the approximate dollar amounts.

Common Components of Neurosurgery Employment Contracts

1. Base Salary

   • Guaranteed for 1–3 years in many employed positions
   • May be adjusted based on market benchmarks (e.g., MGMA percentile)
   • Higher for positions with heavy call or underserved locations

2. Productivity Incentives

   • RVU-based models:
     • You earn a base salary plus a certain number of dollars per RVU over a threshold.
   • Collections-based models:
     • You receive a portion of what the practice collects from your work.
   • Hybrid models are common (base + RVU bonus).

3. Quality and Value-Based Bonuses

   • Metrics may include:
     • Patient satisfaction
     • Complication rates
     • Readmission rates
     • Participation in quality improvement projects
   • Usually a smaller piece of total compensation but increasingly common.

4. Sign-On Bonuses and Relocation

   • Sign-on bonuses can range from $25,000–$200,000+ depending on:
     • Geographic desirability
     • Call requirements
     • Market competition
   • Relocation allowances often $10,000–$25,000.

5. Loan Repayment

   • Some hospital systems or rural programs offer:
     • Direct student loan repayment (e.g., $20,000–$50,000/year for several years)
     • Lump-sum amounts tied to service commitments

6. Call Pay

   • Separate from base salary in some systems:
     • Daily or nightly stipends for unassigned call
     • Additional pay for covering more than one hospital

7. Partnership Track (Private Practice)

   • Early years: lower base salary with a path to partnership.
   • At partnership: access to profit-sharing and ancillary revenue (e.g., imaging centers, surgery centers).
   • Key questions:
     • Timeline to partnership?
     • Buy-in amount?
     • Transparency in financials?

Financial Planning Considerations for Neurosurgery Trainees

Even though neurosurgery is a high-earning specialty, long training and late career start mean you must be strategic:

1. Student Loans

   • Large balances are common after 4 years of medical school and 7+ years of residency.
   • Strategies:
     • Income-driven repayment during residency/fellowship
     • Consider PSLF (Public Service Loan Forgiveness) if working at non-profit/academic hospital
     • Refinancing after securing a stable attending position with high physician salary

2. Delayed Retirement Savings

   • Many neurosurgeons delay serious retirement contributions until mid-30s or later.
   • Once in practice:
     • Maximize 401(k)/403(b) and 457 plans if available
     • Consider backdoor Roth IRA strategies
     • Explore defined benefit or cash-balance plans in private groups

3. Insurance

   • Disability insurance: essential given the manual and cognitive demands of neurosurgery.
   • Life insurance: especially important if you have dependents.
   • Malpractice coverage: understand whether it is occurrence vs claims-made and who pays for tail coverage.

4. Lifestyle Inflation

   • High income can lead to overspending early in your attending years.
   • Plan for:
     • Aggressive loan repayment or investing for the first 5–10 years
     • Reasonable housing choices vs overextending in high-cost markets
     • Balancing reward for your hard work with long-term financial security

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Practical Advice for Applicants Considering Neurosurgery

If you are still at the stage of choosing a specialty or applying to neurosurgery residency, here are practical considerations about salary and career fit:

1. Be Honest About Motivation

   • Neurosurgery is one of the highest paid specialties, but:
     • The day-to-day work is intense, emotionally heavy, and physically demanding.
     • Compensation alone will not sustain you through 7+ years of residency and decades of practice.
   • Align your choice with:
     • Interest in complex neuroanatomy and pathology
     • Enjoyment of surgery and acute care
     • Tolerance for uncertainty, pressure, and long hours

2. Compare Lifestyle Trade-Offs

   • Compared to many other fields, neurosurgeons:
     • Work more nights, weekends, and holidays
     • Have more emergencies and time-sensitive operations
     • Face higher medico-legal pressure
   • The higher doctor salary by specialty ranking reflects these realities.

3. Ask Programs Financially Relevant Questions

   • During interviews and second looks, ask:
     • Resident salary and benefits details
     • Policies on moonlighting
     • Case volume exposure that will prepare you for high-productivity practice
     • Alumni job placements (academic vs private, geographic spread, typical starting packages)

4. Think Long-Term About Subspecialty Direction

   • Spine-focused vs intracranial vs functional vs endovascular tracks carry different income potentials and lifestyle implications.
   • Consider where your interests, skills, and tolerance for certain call patterns align.

5. Develop Non-Clinical Skills

   • Business and negotiation skills are rarely taught formally but profoundly affect your lifetime earnings.
   • During residency/fellowship:
     • Seek mentors to explain contracts and compensation models.
     • Attend optional lectures on health economics, practice management, and physician finance.

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FAQs: Neurosurgery Residency and Physician Salary by Specialty

1. Is neurosurgery really the highest-paid medical specialty?

In many physician salary by specialty surveys, neurosurgery ranks at or near the top, often number one. Average total compensation commonly lands around $800,000–$1,000,000+ in the U.S., with high-volume private practice neurosurgeons exceeding that. However, these averages mask wide variability based on practice type, geography, subspecialty, and call burden. Cardiac surgery and orthopedic surgery sometimes approach or surpass neurosurgery in certain data sets, but neurosurgery reliably sits in the group of highest paid specialties.

2. How much do neurosurgery residents earn compared to other residents?

Neurosurgery residents earn similar base salaries to residents in other specialties at the same PGY level because most institutions pay by year of training rather than specialty. Typical ranges are around $60,000–$90,000 from PGY-1 to PGY-7. The difference is that neurosurgery residents often work more hours and have more intense call; this does not always translate into extra pay, though some programs offer call stipends or moonlighting opportunities.

3. Do academic neurosurgeons make significantly less than private practice neurosurgeons?

On average, academic neurosurgeons earn less than their private practice counterparts, but they still fall into a high-income bracket relative to most other specialties. A typical academic neurosurgeon might earn in the $450,000–$800,000 range, depending on rank, subspecialty, and RVU productivity, whereas private practice neurosurgeons commonly range from $700,000 to well over $1,000,000. In exchange, academic positions often offer prestige, subspecialized practice, research time, teaching opportunities, and a more structured institutional environment.

4. How quickly can a new neurosurgeon pay off medical school loans?

With starting salaries often in the $550,000–$800,000 range, a new neurosurgeon who lives below their means can pay off a typical U.S. medical school loan balance (e.g., $250,000–$400,000) in 3–7 years after residency, depending on interest rates and spending habits. However, many new attendings experience lifestyle inflation and stretch repayment over 10+ years. A deliberate financial plan—prioritizing high-interest debt and maximizing retirement accounts—can dramatically shorten the path to being debt-free while still allowing a comfortable lifestyle.

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By understanding how neurosurgery fits into the broader picture of physician salary by specialty—and by recognizing the trade-offs in training length, lifestyle, and responsibility—you can make better-informed decisions about whether a brain surgery residency aligns with your goals, values, and long-term vision for your life and career.