Cost of living and its effect on anesthesiology resident stipends across the United States

Abstract

Background

Cost of living is one of the key factors in residency selection among U.S. medical graduates, given rising student loan debt. No studies have investigated anesthesiology stipends relative to regional cost of living. This study aimed to compare anesthesiology resident stipends nationwide using the Cost-of-Living Index (COLI) to assess purchasing power.

Methods

The AAMC directory was queried to obtain accredited anesthesiology residency programs for the 2024–2025 academic year. CA1 (post graduate year 2) stipends were collected via internet search and residency programs were assigned to metro areas using region specific COLI metrics. City, state, geographic region, and reputation ranking were recorded and absolute and relative discrepancies were calculated.

Results

Of 174 anesthesiology residency programs, 118 (67.8%) were analyzed. The national average CA-1 stipend was $70,757 ± $9,718, with medians of $66,137 in low COLI areas and $74,046 in high COLI areas (median difference $7,909, [95% CI $5,969-$12,728, p < 0.001]. California showed the largest adjusted deficit (-$26,969, -30.98%), whereas Oklahoma had a $13,096 surplus (+ 21.00%). In the 10 major cities, average stipends decreased from $76,052 ± $10,860 to $59,499 ± $11,252 after COLI adjustment (-21.8%, p < 0.001). The absolute discrepancy between small and medium programs was not significant (-$3,498, p = 0.19), while large programs faced a 12.82% shortfall ($9,742) despite higher unadjusted salaries. Among the top 12 programs based on reputation ranking, stipends were higher in high COLI regions with half showing > 30% loss after COLI adjustment.

Conclusions

Anesthesiology residency stipends showed substantial variation after adjusting for regional cost of living, with many high COLI areas experiencing marked reductions in real purchasing power. Given rising educational debt, applicants should consider COLI adjusted stipends when evaluating programs to better assess regional affordability and financial impact.

Trial registration

N/A.

Background

Every year, U.S. medical student graduates collect and analyze extensive amounts of information from residency interviews as they finalize their rank lists of prospective training programs for the National Resident Matching Program (NRMP) [1]. A 2021 NRMP survey found cost of living ranked alongside salary, geographic location, and program reputation as key factors influencing ranking decisions [2]. In 2023, approximately half of medical residents reported carrying student loan debt exceeding $200,000, highlighting a significant financial burden many residents encounter early in their medical careers [3]. A high cost of living, especially combined with significant educational debt, can substantially elevate stress levels and negatively impact academic performance among resident trainees.

A recent survey of anesthesiology residency applicants found that 82% view the resident stipend as an important factor when evaluating potential programs particularly when considering the impact of local cost of living [4]. Previous studies in internal medicine, radiology, and general surgery have investigated resident stipends in relation to regional cost of living using various indices [5–7]. However, no prior investigation has examined the association between cost of living and resident stipend in anesthesiology. Moreover, the size and geographic distribution of anesthesiology residency programs differ substantially from those of other specialties. As a result, findings from those specialties may not accurately represent the financial landscape experienced by anesthesiology residents. Understanding the relationship between cost of living and resident stipends would enable anesthesiology residency program leadership in high cost of living regions to adjust stipends appropriately and remain competitive with programs located in more favorable cost of living locations. The primary aim of this study was to compare anesthesiology resident stipend compensation across the United States using the Cost-of-living Index (COLI) metric to determine the stipend’s purchasing power value. We hypothesize that resident stipends in densely populated metropolitan areas, particularly those of the Northeast and West Coast, will not adequately offset the substantially higher cost of living. Although stipends in these regions may appear higher in absolute terms, we anticipate that they will not account for the elevated COLI, resulting in reduced purchasing power for residents.

Methods

This is a retrospective study of anesthesiology resident stipend compensation across the United States. The study was reviewed by the Brown Health Institutional Review Board (IRB # 2229289) and was determined not to involve human subjects therefore, no written informed consent was required. The study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [8].

Inclusion and exclusion criteria

The complete list of anesthesiology residency programs participating in the National Resident Matching Program (NRMP) Match for 2024–2025 academic year was obtained from the Association of American Medical Colleges (AAMC) Electronic Residency Application Service (ERAS) directory [9]. Each anesthesia program website was then visited using an internet search engine. Resident stipend information for first year Clinical Anesthesia (CA) 1 residents, corresponding to Postgraduate Year (PGY) 2, were extracted from each of the department’s website. If a program did not publicly publish stipend data on its website, efforts were made to locate resident stipend information on other departments’ webpages within the same institution, as graduate medical stipends are standardized across specialties within an institution. Resident stipends for fiscal years prior to FY 2024 and for the intern year (PGY-1), PGY-3, and PGY-4 were excluded from analysis. Stipends are presented in US Dollars.

The city, state, and zip code of each anesthesia residency program were also extracted from their department websites. In addition, the number of residents (PGY-2-PGY-4) in each anesthesia program was collected. Programs were categorized as small (< 20 approved positions), medium (> 20–49 approved positions), or large (> 50 approved positions) [10]. Each anesthesia program was allocated to one of nine ERAS designated geographic regions: Pacific, Mountain, West North Central, West South Central, East North Central, East South Central, New England, Middle Atlantic, South Atlantic [11]. A city was defined as having at least three anesthesiology programs.

Cost-of-living Index

The Cost-of-Living Index (COLI) measures living expenses across different regions in the United States at a specific point in time allowing for direct comparisons between areas. The index is published every three months by the Council for Community and Economic Research (C2ER), which compiles voluntarily submitted price data from participating economic agencies, university research centers, and chambers of commerce [12]. Access to the C2ER index is available for a fee. The COLI includes the costs of groceries, utilities, housing, transportation, healthcare, and various other expenses while excluding state and income taxes. For this study, we used COLI data from the second quarter of 2024, which included 251 urban areas across all 50 states, Washington, D.C., and Puerto Rico, to compare CA-1 residency stipends with COLI adjusted stipends for the same period. The quarterly report was published by the C2ER in August 2024. A composite index value greater than 100 indicates above average cost of living while a value below 100 implies to below average cost of living.

For each anesthesiology residency program, the associated zip code was identified and manually assigned to its corresponding urban area. This method ensured that anesthesia programs were correctly assigned to the appropriate COLI region. The CA-1 salaries were divided by the COLI value of their respective urban areas and multiplied by a factor of 100 to obtain an adjusted resident stipend for each training year. This adjusted resident stipend reflects the effective purchasing power of each resident’s salary within their specific geographic location of their program.

Statistical analysis

To illustrate the regional distribution of anesthesiology residency programs and associated Cost-of-living Index box plots were created. The distributions of the Cost-of-living Index across regions were compared using Kruskal-Wallis one way analysis of variance on ranks. The post hoc Dunn’s test was used for pairwise comparisons with adjustments for multiple comparisons. To evaluate differences in CA-1 resident stipends across cost of living regions, anesthesiology residency programs were categorized into high (> 102.8 COLI) and low (≤ 102.8 COLI) cost groups based on the median COLI. Group comparisons were performed using Wilcoxon rank sum test. At the state level, both resident stipends and corresponding COLI values for anesthesiology programs within the same state were averaged. The stipend received during the PGY-2 year was compared to the COLI adjusted stipend for that same period. The absolute discrepancy, expressed in US dollars, was defined as the difference between the COLI adjusted stipend and the stipend received, calculated by dividing the total discrepancy across all programs by the number of programs. The relative discrepancy (%) was defined as the difference between the stipend received and the COLI adjusted stipend divided by the stipend received, calculated as the total discrepancy across all programs divided by the total stipends, reflecting effective purchasing power after accounting for cost of living. Reputation rankings for the 12 top ranked anesthesiology residency programs along with CA-1 resident stipends and corresponding COLI values, were extracted to determine effective purchasing power. Median difference and 95% CI of the difference were calculated using 400 bootstrap samples. A p < 0.05 was considered statistically significant. The statistical analysis was performed using SigmaPlot 14.5 (SystatSoftware, Inc) and R (version 4.1.2; R Core Team, 2021).

Results

A total of 174 anesthesiology programs were identified in the AAMC ERAS directory. Resident stipend data were not published by nine programs, resulting in 165 programs reporting resident stipends. The national average stipend for CA-1 residents across these programs was $70,647±$9,012. Of the 165 programs with published stipends, 47 programs were not represented by the COLI value and were excluded leaving 118 (67.8%) programs that were included in the analysis.

The regional distribution of anesthesiology residency programs and associated cost-of-living index is shown in Fig. 1. Of the nine ERAS regions, the anesthesia programs located in the Pacific (median COLI value 146.3, (Interquartile range IQR 129.6 to 148.6), New England (median COLI value 144.1, IQR 110.2 to 144.1) and Middle Atlantic (median COLI value 125.2, IQR 102.9 to 176.6) regions have significantly less purchasing power than anesthesia programs in the West North Central (median COLI value 91.9, IQR 88.4 to 92.0), East North Central (median COLI value 96.3, IQR 91.8 to 115.0) and East South Central regions (median COLI value 91.6, IQR 89.8 to 94.4, p < 0.001).

Fig. 1.

Regional distribution of anesthesiology residency programs and associated cost-of-living index. Box plots showing regional distribution of anesthesiology programs and associated cost-of-living index. The median, interquartile range, and minimum and maximum are shown for each of the individual regions. The number in the parentheses describes the number of programs in that region. The solid line represents the Cost-of-living Index of 100 representing the average cost of living in the United States

The CA-1 resident stipends in high and low cost of living areas are shown in Fig. 2. The median CA-1 anesthesiology resident stipend was $66,137 (IQR $62,088 to $69,452) in low COLI areas and $74,046 (IQR $71,308 to $82,500) in high COLI areas. The median difference between groups was $7,909 (95% CI $5,969 to $12,728, p < 0.001).

Fig. 2.

Comparison of anesthesiology CA-1 resident stipends in high vs. low cost of living regions. Boxplots of CA-1 resident stipends are dichotomized by the median cost-of-living index (COLI). The median, interquartile range, and minimum and maximum are shown for each of the individual regions. Programs in regions with a COLI value above the median were classified as high COLI and those at or below the median value were classified as low COLI. Resident stipends differed significantly between groups (p < 0.001)

The top twelve states with the highest stipends and cost of living adjusted stipends for CA-1 anesthesia residents are presented in Table 1. The average salary of a CA-1 resident in programs with the highest salaries was $77,123±$4,950. The largest absolute discrepancy in CA-1 salary was observed in California where the adjusted stipend reflected a $26,969 deficit corresponding to a 30.98% reduction in purchasing power. In contrast, the absolute discrepancy for CA-1 residents in Connecticut was smaller in magnitude, amounting to $5,246 or a 6.37% decrease in purchasing power. After adjusting for cost of living, the highest CA-1 salaries were observed in Connecticut and Minnesota, with absolute discrepancies of -$5,246 and $4,830 respectively. Minnesota demonstrated a net gain in purchasing power (6.84%), whereas Connecticut experienced a modest reduction. Oklahoma and Indiana showed the largest relative gains after salary adjustment, with increases of 21.00% and 13.25% respectively. Although unadjusted CA-1 stipends in California, Massachusetts, New York, Washington, Oregon, Utah, New Jersey, Rhode Island, Vermont, and Arizona ranked among the highest nationally, all fell out of the top paying tier after adjusting for cost of living, revealing the impact of regional expenses on the real value of resident compensation.

Table 1.

The top twelve States with the highest unadjusted stipends and cost of living adjusted stipends for CA-1 anesthesia residents

Rank	Region	Location	Anesthesia Programs (n)	Average CA-1 Stipend ($)	COLI Index	COLI-adjusted Stipend ($)	Absolute Discrepancy ($)	Relative Discrepancy (%)
Top 12 highest unadjusted CA-1 stipends
1	1	California	7	87,058	145.4	60,088	-26,969	-30.98
2	7	Connecticut	1	82,388	106.8	77,142	-5,246	-6.37
3	7	Massachusetts	5	81,765	144.1	56,742	-25,023	-30.60
4	8	New York	15	81,738	161.1	54,287	-27,451	-33.58
5	2	Colorado	1	77,596	108.2	71,715	-5,881	-7.58
6	1	Washington	2	76,353	146.3	52,189	-24,164	-31.65
7	1	Oregon	1	73,878	116.0	63,688	-10,190	-13.79
8	2	Utah	1	73,686	109.5	67,293	-6,393	-8.68
9	8	New Jersey	2	73,473	114.2	64,374	-9,099	-12.38
10	7	Rhode Island	1	72,676	109.4	66,431	-6,245	-8.59
11	7	Vermont	1	72,667	113.8	63,855	-8,812	-12.13
12	2	Arizona	1	72,205	107.3	67,293	-4,912	-6.80
Top 12 highest adjusted CA-1 stipends
1	7	Connecticut	1	82,388	106.8	77,142	-5,246	-6.37
2	3	Minnesota	1	70,640	93.6	75,470	4,830	6.84
3	4	Oklahoma	2	62,369	82.7	75,465	13,096	21.00
4	5	Indiana	2	65,619	88.3	74,313	8,695	13.25
5	3	Kansas	1	67,608	91.9	73,567	5,959	8.81
6	3	Nebraska	1	67,504	92.0	73,374	5,870	8.70
7	4	Texas	9	68,447	93.5	73,273	4,826	7.05
8	3	Missouri	4	64,662	89.7	72,148	7,486	11.58
9	2	Colorado	1	77,596	108.2	71,715	-5,881	-7.58
10	8	Pennsylvania	5	71,924	101.1	71,117	-807	-1.12
11	6	Tennessee	3	64,381	92.2	69,722	5,341	8.30
12	9	Maryland	3	69,231	97.6	71,083	1,852	2.68

Abbreviations: Average CA-1 stipend for states with multiple programs, COLI Cost-of-Living Index, CA-1 Clinical Anesthesia first year resident; Region: 1=Pacific; 2=Mountain; 3=West North Central; 4=West South Central; 5=East North Central; 6=East South Central; 7=New England; 8=Middle Atlantic; 9=South Atlantic. COLI = measures relative prices of goods and services across regions, with 100 representing the national average. Absolute discrepancy defined as the difference between the COLI adjusted stipend and the stipend received; Relative discrepancy defined as the difference between the stipend received and the COLI adjusted stipend divided by the stipend received

Table 2 presents the twelve states (with the inclusion of Puerto Rico and the District of Columbia) with the lowest unadjusted and cost of living adjusted CA-1 salaries for anesthesia residents. The average salary of a CA-1 resident in programs with the lowest salaries was $60,276±$5,504. Among states with the lowest unadjusted CA-1 stipends, the largest absolute discrepancy was observed in Oklahoma, where the adjusted stipend reflected a $13,096 surplus, corresponding to a 21.00% gain in purchasing power. In contrast, among states with lowest adjusted stipends, New York and Washington State reflected absolute discrepancies of -$27,451 and -$24,164 respectively, corresponding to reductions in purchasing power of 33.58% and 31.65%. Notably, several states with the highest unadjusted CA-1 stipends were among the lowest when adjusted for cost of living, including New York, Washington, Massachusetts, and California.

Table 2.

The twelve states/territories/districts that have the lowest unadjusted and cost of living adjusted CA-1 resident stipends for anesthesia residents

Rank	Region	Location	Anesthesia Programs (n)	Average CA-1 Stipend ($)	COLI Index	COLI-adjusted Stipend ($)	Absolute Discrepancy ($)	Relative Discrepancy (%)
States with the lowest unadjusted CA-1 stipends
1	9	Puerto Rico	1	43,412	101.4	42,813	-599	-1.38
2	6	Mississippi	1	58,502	90.5	64,643	6,141	10.50
3	4	Louisiana	4	59,599	108.3	55,312	-4,287	-7.19
4	2	New Mexico	1	61,384	94.6	64,888	3,504	5.71
5	5	Michigan	4	61,704	100.8	61,307	-397	-0.64
6	4	Arkansas	1	62,088	93.5	66,404	4,316	6.95
7	6	Alabama	1	62,326	91.6	68,041	5,715	9.17
8	9	Georgia	2	62,356	89.7	69,226	6,870	11.02
9	4	Oklahoma	2	62,369	82.7	75,465	13,096	21.00
10	2	Nevada	1	62,858	99.7	63,047	189	0.30
11	9	South Carolina	1	63,101	101.2	62,353	-748	-1.19
12	6	Kentucky	2	63,619	93.1	68,377	4,757	7.48
States with the lowest adjusted CA-1 stipends
1	9	Puerto Rico	1	43,412	101.4	42,813	-599	-1.38
2	9	District of Columbia	2	71,244	140.6	50,671	-20,573	-28.88
3	8	New York	15	81,738	161.1	54,287	-27,451	-33.58
4	1	Washington	2	76,353	146.3	52,189	-24,164	-31.65
5	4	Louisiana	4	59,599	108.3	55,312	-4,287	-7.19
6	7	Massachusetts	5	81,765	144.1	56,742	-25,023	-30.60
7	1	California	7	87,058	145.4	60,088	-26,969	-30.98
8	5	Michigan	4	61,704	100.8	61,307	-397	-0.64
9	9	Florida	7	64,970	105.3	63,103	-1,867	-2.87
10	9	South Carolina	1	63,101	101.2	62,353	-748	-1.19
11	2	Nevada	1	62,858	99.7	63,047	189	0.30
12	5	Illinois	7	71,475	112.5	63,646	-7,829	-10.95

Abbreviations: Average CA-1 stipend for states with multiple programs, COLI Cost-of-Living Index, CA-1 Clinical Anesthesia first year resident, Region: 1=Pacific; 2=Mountain; 3=West North Central; 4=West South Central; 5=East North Central; 6=East South Central; 7=New England; 8=Middle Atlantic; 9=South Atlantic. COLI= measures relative prices of goods and services across regions, with 100 representing the national average. Absolute discrepancy defined as the difference between the COLI adjusted stipend and the stipend received; Relative discrepancy defined as the difference between the stipend received and the COLI adjusted stipend divided by the stipend received

Major city unadjusted and cost of living adjusted CA-1 resident stipends and relative discrepancies are shown in Table 3. A total of 10 major cities were identified to have 3 or more anesthesiology programs for a total of 49 anesthesiology programs of which 12 (24.5%) had unknown COLI values. New York City was assocated with multiple COLI indices, therefore the boroughs of Manhattan and Brooklyn were analyzed separately. The average unadjusted CA-1 stipend for all anesthesiology residency programs in the 10 major cites was $76,052 ± $10,860. After adjusting for cost of living, the major city average stipend was $59,499 ± $11,252 or a difference of -21.8%, p < 0.001. Two of the ten cities had positive purchasing power, Houston with a difference of $5,285 or 7.53% and Cleveland with a difference of $6,187 or 9.05%.

Table 3.

Major City unadjusted and cost of living adjusted CA-1 resident stipends and relative discrepancies

Location	Anesthesia Programs (n)	Average CA-1 Stipend ($)	COLI Index	COLI-adjusted Stipend ($)	Absolute Discrepancy ($)	Relative Discrepancy (%)
Manhattan	5	89,913	226	39,785	-50,128	-55.75
Brooklyn	3	85,485	160.2	53,361	-32,124	-37.57
Boston	5	81,765	144.1	56,738	-25,023	-30.60
Los Angeles	3	86,208	148.6	58,014	-28,195	-32.70
Chicago	6	72,440	115	62,991	-9,449	-13.04
New Orleans	3	59,893	112.6	53,191	-6,702	-11.19
Detroit	3	62,645	103.7	60,410	-2,235	-3.57
Philadelphia	3	74,173	103.1	71,943	-2,230	-3.01
Houston	3	70,209	93	75,494	5,285	7.53
Cleveland	3	68,358	91.7	74,545	6,187	9.05

Abbreviations: A city was defined as at least 3 or more anesthesiology programs reside in the city. Average CA-1 stipend for city, COLI Cost-of-Living Index, CA-1 Clinical Anesthesia first year resident. COLI= measures relative prices of goods and services across regions, with 100 representing the national average. Absolute discrepancy defined as the difference between the COLI adjusted stipend and the stipend received; Relative discrepancy defined as the difference between the stipend received and the COLI adjusted stipend divided by the stipend received

The average CA‑1 anesthesia resident stipends by program size and cost of living adjusted values are shown in Table 4. Although unadjusted CA-1 stipends increased with program size, COLI-adjusted stipends revealed progressively larger reductions in purchasing power, with the largest programs experiencing the greatest absolute and relative decreases. The difference in absolute discrepancy between small and medium programs was not different (-$3,498, p = 0.19). However, large programs, despite offering the highest unadjusted CA-1 salaries, had the largest average shortfall of -$9,742, representing a 12.82% decline in purchasing power. Compared to small programs, large programs experienced a significant decline in purchasing power, with a difference in absolute discrepancy of -$8,961, p = 0.01. There was no difference in COLI-adjusted stipends across program size.

Table 4.

Mean CA‑1 anesthesia resident stipends by program size and cost-of-living adjusted values

Anesthesia Program size	Anesthesia Programs (n = 118)	Average CA-1 Stipend ($)	COLI Index	COLI-adjusted Stipend ($)	Absolute Discrepancy ($)	Relative Discrepancy (%)
Small	27	66,737	106	65,956	-782	-1.17
Medium	59	69,756	111	65,476	-4,280	-6.14
Large	32	75,994	124	66,251	-9,742	-12.82

Abbreviations: Average CA-1 stipend for program size, COLI Cost-of-Living Index, CA-1 linical Anesthesia first year resident. COLI= measures relative prices of goods and services across regions, with 100 representing the national average. Absolute discrepancy defined as the difference between the COLI adjusted stipend and the stipend received; Relative discrepancy defined as the difference between the stipend received and the COLI adjusted stipend divided by the stipend received

In the top 12 Doximity ranked anesthesiology residency programs, CA-1 resident stipends were higher in high COLI regions; however, after adjusting for cost of living, half of these programs demonstrated a loss of purchasing power greater than 30% (Table 5).

Table 5.

CA-1 resident stipends and cost of living adjusted values among the top 12 anesthesiology residency programs by reputation ranking

Location	Reputation rank†	CA-1 Stipend ($)	COLI Index	COLI-adjusted Stipend ($)	Absolute Discrepancy ($)	Relative Discrepancy (%)
Mass General Brigham/Massachusetts General Hospital	1	82,500	144.1	57,255	-25,245	-30.60
Stanford Health Care-Sponsored Stanford University	2	94,305	143*	65,946	-28,359	-30.07
University of California (San Francisco)	3	94,777	167.4	56,595	-38,182	-40.29
Mass General Brigham/Brigham and Women’s Hospital	4	82,500	144.1	57,255	-25,245	-30.60
Duke University Hospital	5	69,996	103.2	67,788	-2,208	-3.15
Johns Hopkins University	6	73,135	100.7	72,621	-514	-0.70
University of Michigan	7	77,609	90.9*	85,370	7,761	10.00
University of Pennsylvania Health System	8	74,712	103.1	72,495	-2,217	-2.97
Mayo Clinic College of Medicine and Science (Rochester)	9	71,286	98.9	72,077	791	1.11
New York Presbyterian Hospital (Columbia Campus)	10	98,700	226	43,670	-55,030	-55.75
UCLA David Geffen School of Medicine/UCLA Medical Center	11	91,754	148.6	61,732	-30,022	-32.72
Vanderbilt University Medical Center	12	72,450	99.9	72,523	73	0.10

Abbreviations: *Average COLI for the state was used as there was no COLI available for this area. Reputation rank for anesthesiology residency programs was obtained from Doximity network

†Reputation rank for anesthesiology residency programs was obtained from Doximity network

Discussion

The most important finding in our study is that anesthesiology resident stipends, particularly in densely populated regions of the Northeast and West Coast, are not adjusted for the higher cost of living in these areas. Consequently, CA-1 residents in these regions experience markedly reduced purchasing power compared to those in lower COLI regions. In the US, resident salaries are typically not adjusted to match the cost of living in the areas where they work. While salaries do increase each training year, these increments frequently do not keep pace with rising costs, reinforcing perceptions of compensation relative to workload.

It was also interesting to note that residents in high-cost regions such as the Pacific (e.g., San Francisco, Los Angeles) and Middle Atlantic (e.g., New York, Boston) experience a substantial reduction in their real income after adjusting for the cost of living, reflecting not only what others earn but also the additional burden of higher housing, utilities, and everyday expenses. In contrast, in the Midwest and South (including East and West South Central divisions), where cost-of-living indices traditionally fall well below the national average, those same stipends provide greater affordability and financial comfort. A recent study using the MIT Living Wage Calculator reported that general surgery residents in the Northeast had the greatest income surplus compared to other regions [7]. In contrast, our data shows that while unadjusted stipends in the Northeast states are among the highest nationally, Connecticut is the only state in the region that remains among the top 12 for COLI adjusted CA-1 stipends. These variations highlight the importance of considering regional economic factors when evaluating residency programs, as they can impact residents’ financial obligations and quality of life.

Several prior studies have examined whether resident salaries adequately reflect regional variations in the cost of living. A 2019 study using the U.S. Bureau of Economic Analysis Regional Price Parities (BEA RRP), which provides annual estimates of prices for goods and services across states and metropolitan areas relative to the national average, found that first year (PGY-1) internal medicine resident salaries correlated only moderately with BEA RPP data (R² = 0.4), suggesting that resident stipends did not consistently account for regional differences in cost of living [5]. Todd et al. investigated internal medicine resident base salaries in the ten most expensive US metropolitan areas and concluded that neither base salaries nor base salaries with additional benefits adequately compensated for higher living costs [13]. In radiology, Ertreo and colleagues reported that high-COLI cities are associated with substantial losses in real resident income (29.7% to 53.8%), while low-COLI cities provide greater purchasing power [6]. Our findings demonstrate a similar pattern in Anesthesiology: high-COLI cities such as Manhattan, Brooklyn, Boston, and Los Angeles show substantial reductions in real income after COLI adjustment (30% to 56%), whereas residents in low-COLI cities such as Cleveland and Houston gain purchasing power (7% to 9%). These results highlight that residents in high cost cities may experience significant financial strain despite supplemental stipends or benefits. Although our study is unique in focusing on anesthesiology CA-1 salaries, it reinforces a broad body of evidence that unadjusted resident stipends do not adequately reflect financial realities across geographic regions.

When evaluating potential residency programs, medical students often prioritize geographic location due to family or friend support systems in the area [14]. However, a recent survey of applicants to anesthesiology programs found that cost of living plays a vital role in their decision to select a training program [4]. In our study, states such as California, Massachusetts, and New York offered some of the highest CA‑1 anesthesiology stipends, but after COLI adjustment, these stipends were significantly diminished. For example, California’s average CA-1 resident stipend of $87,058 decreased to $60,088 after adjusting for cost of living representing a 30.98% drop in real income. Similar reductions were observed in Massachusetts, New York, and Washington, all of which ranked among the lowest after COLI adjustment despite high unadjusted stipends. Among locations with the lowest unadjusted CA-1 stipends, Oklahoma and Georgia showed substantial gains in purchasing power after cost-of-living adjustment, whereas Louisiana experienced the largest reduction. Puerto Rico had the lowest CA-1 stipend among all locations and its COLI value of 101.4 indicates that living costs are near the U.S. average. This finding suggests that the low stipend reflects genuinely lower salaries rather than being offset by a lower cost of living.

Another significant finding is that as anesthesia program size increases, unadjusted CA-1 stipends rise, but their real purchasing power declines markedly after adjusting for cost of living. Specifically, although unadjusted stipends increase from an average of $66,737 in small programs to $75,994 in large programs, the adjusted values narrow to a statistically insignificant range of $65,956 to $66,251 among small and large size programs. While larger anesthesia programs offer higher unadjusted CA‑1 stipends, residents in these programs, typically located in major urban areas with elevated living costs, experience a disproportionately greater loss of purchasing power. The significant difference in absolute discrepancy between COLI-adjusted and unadjusted stipends between large and small programs suggests that the majority of large anesthesiology programs exist in higher cost of living metro areas than small anesthesiology programs.

Consistent with our findings, a study of surgical residents found that programs situated in major cities showed a 26% loss in COLI adjusted stipend value relative to standard pay [15]. These findings highlight the importance of factoring program size and geographic cost differences into stipend evaluations.

The reputation of the residency program is an important factor that medical school applicants take into consideration when evaluating a residency program. Doximity’s Residency Navigator, a widely used physician networking tool, publishes reputation rankings available to the public [16]. Prior studies have shown that these reputation rankings can influence residency selection [17, 18]. In our study, CA-1 stipends were higher at high reputation programs in high cost-of-living regions; however, after COLI adjustment, there were notably marked reductions in purchasing power compared with lower-cost areas. This imbalance accentuates the inequity in anesthesiology CA-1 stipends as training in high reputation urban programs may impose greater financial strain. Addressing this issue through COLI salary adjustments or supplemental benefits may improve equity and broaden access to competitive programs.

Our study should only be interpreted in the context of its limitations. First, we used published graduate medical education stipends and did not include non-stipend benefits that may be included in the resident compensation, such as meal stipends, housing subsidies, health insurance coverage, moonlighting opportunities, and wellness or educational funds. Although these benefits can impact the resident’s financial wellbeing and stability, such information was not consistently available across all anesthesiology programs. Second, while the majority of all anesthesiology programs were included, some were excluded because either they did not have published salaries available online or they were located in regions not represented by the COLI index. Therefore, some rural programs are underrepresented in our analysis which may limit generalizability to rural training environments. Third, COLI index is a quarterly report that shows the comparison of goods and services at a single point of time and changes from one quarter to the next. Thus, the index reflects relative rather than longitudinal cost changes. Moreover, due to the complexity of tax jurisdictions, it’s not feasible to calculate the state or local tax burdens reliably.

Conclusion

Given the rising costs of medical education and the burden of student debt, anesthesiology residency programs applicants should carefully evaluate the expected cost of living and its effect on the value of resident’s stipends. Regional variations in living expenses can substantially influence real income and financial stress, particularly in regions with less purchasing power. Therefore, graduating medical school students applying to anesthesiology residency programs should assess cost adjusted stipends to accurately gauge regional affordability and its implications on their quality of life. Furthermore, programs located in greater cost-of-living areas should adjust their stipend not only to attract the best applicants but also to minimize the financial stress on anesthesiology trainees.

Abbreviations

AAMC

Association of American Medical Colleges

CA

Clinical Anesthesia

C2ER

Council for Community and Economic Research

CI

Confidence Interval

COLI

Cost-of-Living Index

ERAS

Electronic Residency Application Service

FY

Fiscal Year

IRB

Institutional Review Board

NRMP

National Resident Matching Program

PGY

Postgraduate Year

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

Authors’ contributions

Conceptualization, B.C. and M.K.; methodology, M.K, G.D.O.; validation, B.C., M.C., C.M., and M.K.; formal analysis, M.K.; investigation, B.C., C.M., M.C., G.D.O.; data curation, B.C., M.K., C.M., M.C.; writing original draft preparation, B.C., M.K., writing review and editing, C.M., M.C., G.D.O. All authors have read and agreed to the published version of the manuscript.

Funding

None.

Data availability

All the data in this study are shown in the manuscript.

Declarations

Ethics approval and consent to participate

The study was reviewed by the Brown Health Institutional Review Board (IRB# 2229289) and was determined not to constitute research involving human subjects. Accordingly, 45 CFR 46 did not apply, and ethics approval and informed consent were not required. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.