Understanding Physician Salaries: Why Some Specialties Earn Less

Financial Reality Check: Why Some Specialties Earn Less

In medical education, discussions about specialty choice often focus on passion, prestige, competitiveness, and lifestyle. Less openly discussed—but critically important—are the financial realities of different medical specialties. Many premeds and early medical students assume that “all doctors are well-paid,” but healthcare economics is far more nuanced.

For residency applicants and trainees facing six-figure student loan balances, understanding which specialties tend to be the lowest paid, and why, is a key part of making informed career choices. This doesn’t mean you should choose a specialty solely based on income—but ignoring physician salaries and financial structure can have long-term consequences for your quality of life, flexibility, and financial stability.

This article breaks down the major forces that shape earnings across specialties, explains why some vital fields like primary care, pediatrics, and geriatrics consistently sit at the lower end of the compensation spectrum, and offers practical guidance on how to navigate these differences while still building a meaningful career in medicine.

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Core Economic Drivers of Physician Salaries

1. Supply and Demand in Medical Specialties

Like any labor market, physician salaries are heavily influenced by supply and demand: how many doctors are trained in a specialty versus how many are needed.

Oversupplied vs. Undersupplied Fields

• Oversupplied fields (or those perceived as easier to enter) often face:

  • More competition for jobs
  • Lower bargaining power for compensation
  • Employers who can set lower salaries because they have more applicants than open positions

• Undersupplied or highly specialized fields often see:

  • Strong negotiating leverage
  • Signing bonuses and incentive-based contracts
  • Higher base salaries to attract and retain scarce talent

Example:
Family medicine and general internal medicine have relatively large residency class sizes and are present in most communities. Despite being essential to population health, this larger workforce dilutes earning power, especially in saturated urban or suburban areas.

Contrast this with neurosurgery or pediatric cardiothoracic surgery. Not only do these fields have limited residency positions and long training pathways, but the number of practicing physicians is small. Hospitals must offer competitive compensation to ensure adequate coverage and avoid losing specialists to other systems or regions.

Geographic Variation in Demand

Demand is also geographically uneven:

• Urban areas may have:

  • Many primary care physicians and general specialists
  • More competition for outpatient positions
  • Lower starting salaries, especially in desirable cities

• Rural or underserved areas may:

  • Struggle to recruit any physicians, especially primary care
  • Offer higher salaries, loan repayment, or retention bonuses
  • Provide broader scope of practice but sometimes fewer academic opportunities

This explains why a family medicine physician in a rural Midwest community hospital may earn more than a family physician employed by a large academic center in a major coastal city, despite the specialty’s overall lower national median income.

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2. Reimbursement Structures and Healthcare Economics

Beyond supply and demand, how physicians get paid—i.e., the reimbursement model—is a central driver of income variation between medical specialties.

Fee-for-Service vs. Capitation vs. Salary Models

• Fee-for-Service (FFS):

  • Physicians are paid per service performed (procedures, tests, visits).
  • Financial incentives align with higher volume and more billable procedures.
  • Many procedural and surgical specialties benefit from this model.

• Capitation / Value-Based Models:

  • Practices receive a fixed payment per patient per month or per year.
  • The focus is on population health, prevention, and cost control.
  • Common in primary care, with emphasis on cognitive work rather than procedures.

• Straight Salary or RVU-Based Compensation:

  • Many employed physicians (especially in hospital systems) are paid via:
    • Base salary plus productivity bonus (RVUs)
    • Quality metrics or panel size incentives
  • Even within the same hospital, procedural specialists often generate more RVUs per hour than cognitive specialists.

Why Primary Care and Cognitive Fields Earn Less

Primary care, geriatrics, general pediatrics, and psychiatry are primarily cognitive specialties—their value lies in clinical reasoning, counseling, complex care coordination, and long-term relationships with patients. Unfortunately, traditional reimbursement systems in the U.S. have historically undervalued cognitive work versus procedures.

Example:

• A dermatologist may perform several high-reimbursing procedures (biopsies, excisions, cosmetic procedures) in a half-day clinic session.
• A general internist in the same time might spend 30–60 minutes with each complex patient managing multiple chronic conditions. The billing codes for such visits generally reimburse far less per unit time.

Recent efforts like E/M code revisions and value-based care initiatives attempt to better recognize cognitive complexity, but the gap remains significant in many settings.

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The Procedural Advantage: How the Nature of Work Shapes Income

3. Procedural vs. Non-Procedural Specialties

One of the strongest predictors of physician salary is whether the specialty is primarily procedural or non-procedural.

Procedural Specialties

These include:

• Orthopedic surgery
• Neurosurgery
• Interventional cardiology and radiology
• Dermatologic surgery
• Gastroenterology (endoscopy-heavy practices)
• Ophthalmology (especially cataract and refractive surgery)

Revenue in these specialties is often driven by:

• High-value CPT codes for procedures and surgeries
• Facility fees (collected by hospitals or ASC owners)
• Ancillary services (e.g., imaging, injections, implants)
• High demand for certain elective or semi-elective interventions

Because these procedures are well-reimbursed and often require years of specialized training and high malpractice coverage, compensation packages are correspondingly higher.

Non-Procedural (Cognitive) Specialties

Lower-paid specialties often include:

• Family medicine
• General internal medicine
• Pediatrics
• Geriatrics
• Psychiatry
• Public health and preventive medicine
• Palliative care

Their work focuses on:

• Diagnosis and medical decision-making
• Longitudinal management of chronic conditions
• Preventive care
• Counseling and coordination of multidisciplinary care

Despite the immense impact on population health and healthcare spending, current payment systems and relative value units (RVUs) still favor procedures over complex cognitive tasks. This structural bias is a major reason why many of the lowest paid specialties are the ones that form the backbone of primary and mental healthcare.

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4. Hours Worked, Workload, and On-Call Requirements

Compensation must also be interpreted in the context of workload and lifestyle.

Income per Hour vs. Total Salary

Some specialties with relatively modest total annual income may still have favorable income per hour due to:

• Predictable clinic schedules
• Minimal or no call
• Part-time or flexible work options

For example, outpatient psychiatry or some outpatient pediatrics positions may offer:

• 4-day clinic weeks
• Limited evening or weekend responsibilities
• Lower burnout risk compared to high-acuity inpatient roles

In contrast, some specialties with high headline salaries may demand:

• 60–80+ hour weeks
• Frequent overnight call or 24/7 coverage
• Physically and emotionally exhausting work environments

When you adjust for hours and intensity, the pay gap between certain specialties looks smaller than the raw salary numbers suggest.

Under-Compensated High-Burden Fields

There are also fields that experience both high workload and relatively modest pay. Geriatrics and general internal medicine in busy safety-net hospitals, for example, can involve:

• Heavy patient volumes
• Complex multimorbidity
• Limited resources and support staff
• Significant non-billable work (care coordination, paperwork, social issues)

Yet compensation may not adequately reflect this intensity, especially when compared to procedural peers.

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Additional Forces Shaping Lower-Paid Specialties

5. Research Funding, Industry Support, and Advocacy

Some specialties benefit from strong pharmaceutical, device, or research funding, which indirectly enhances physician income and opportunities.

• High-industry-support specialties (e.g., oncology, cardiology, some surgical subspecialties) may see:

  • Sponsored clinical trials
  • Funded research positions
  • Speaking, consulting, and advisory roles
  • More grant funding and institutional support

• Lower-visibility specialties like geriatrics, addiction medicine, or general preventive medicine may:

  • Receive less targeted industry support
  • Have fewer funded research opportunities
  • Operate in under-resourced clinical environments

Organized advocacy also matters. Specialties with powerful professional societies and lobbying efforts can influence:

• Reimbursement schedules
• Relative value unit (RVU) assignments
• Federal and private payer policies

Historically, this has favored procedure-heavy disciplines, reinforcing existing salary hierarchies.

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6. Patient Population, Payer Mix, and Practice Setting

What type of patients you see—and who pays for their care—plays a major role in physician income.

Payer Mix and Reimbursement

• Commercially insured patients typically generate higher reimbursement per visit or procedure.
• Medicare and Medicaid pay lower rates, especially for cognitive services.
• Uninsured or underinsured patients may result in uncompensated or undercompensated care.

Specialties and practice settings that predominantly serve:

• Underserved communities
• Public health clinics
• Community mental health centers
• Safety-net hospitals

often deal with a high proportion of Medicaid or uninsured patients, which translates into lower revenue despite high clinical need.

Examples of Impacted Specialties

• Pediatrics: Children are often covered by Medicaid or CHIP, which reimburse at lower rates than many commercial plans. Pediatricians thus tend to earn less than adult medicine counterparts, even with similar training lengths.
• Geriatrics: Older adults are primarily covered by Medicare. Geriatricians manage complex multimorbidity, polypharmacy, and social issues, often for lower reimbursement per visit compared to procedure-based specialties.
• Public health and preventive medicine: Physicians in these fields frequently work in government, academic, or non-profit settings with salary structures that are not driven by fee-for-service revenue at all.

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Implications for Career Choice and Healthcare Quality

7. Impact on Patient Care and the Healthcare System

The fact that many of the lowest paid specialties are foundational to population health has far-reaching consequences.

Burnout, Turnover, and Access

• Lower compensation coupled with high workload can increase burnout rates among primary care, geriatrics, and safety-net clinicians.
• Burnout leads to:
  • Reduced clinical hours
  • Early retirement or career switching
  • Lower continuity of care for patients

This directly affects access—patients in many communities struggle to find primary care physicians, psychiatrists, geriatricians, and child psychiatrists, even as procedural specialists cluster in better-paying urban markets.

Maldistribution of the Workforce

Financial incentives pull trainees toward higher-paying, procedure-heavy specialties and away from lower-paid but high-need fields. The result is:

• Oversupply in some subspecialties in competitive markets
• Critical shortages in:
  • Rural primary care
  • Geriatrics
  • Child and adolescent psychiatry
  • Public health and addiction medicine

Over time, this misalignment exacerbates health disparities and increases overall healthcare costs by emphasizing downstream, high-cost interventions instead of upstream preventive care.

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8. Emerging Trends and Policy Efforts to Support Lower-Paid Specialties

There is growing recognition among policymakers, health systems, and medical educators that the current compensation imbalance is unsustainable.

Loan Forgiveness and Financial Incentive Programs

To attract residents to high-need, lower-paid specialties and locations, various programs offer:

• Federal and state loan repayment programs for:
  • Primary care
  • Psychiatry
  • Rural and underserved practice
• Public Service Loan Forgiveness (PSLF) for physicians working in qualifying non-profit or government institutions
• Institutional bonuses or stipends for:
  • Geriatrics
  • Academic primary care
  • Public health roles

These programs can substantially offset lower physician salaries, especially over a 10–20 year career span.

Payment and Policy Reforms

Examples of evolving reforms include:

• Enhanced primary care payments in some value-based care models
• Revisions to E/M codes that boost reimbursement for complex cognitive visits
• Alternative payment models (APMs) that reward:
  • Population health outcomes
  • Preventive care
  • Reduced hospitalizations and emergency visits

Professional organizations continue to advocate for adjustments to the Medicare Physician Fee Schedule and RVU assignments to better value cognitive work and time-intensive care coordination.

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Navigating Specialty Choice: Practical Guidance for Students and Residents

9. Balancing Passion, Lifestyle, and Financial Reality

Choosing a specialty is a deeply personal decision that must integrate:

• Clinical interests and personality fit
• Lifestyle preferences and tolerance for call
• Long-term career goals (clinical, academic, public health, research)
• Financial realities, including:
  • Debt burden
  • Desired geographic location
  • Family considerations

A few practical steps:

1. Know the Data
   Review recent surveys (e.g., Medscape compensation reports, MGMA data, specialty society surveys) to understand:

   • Median salaries
   • Variability by region and practice type
   • Trends over time in your chosen field

2. Calculate Debt-to-Income Scenarios
   Use loan repayment calculators to model:

   • Different incomes by specialty
   • Various repayment strategies (IDR, PSLF, refinancing)
   • How many years it might take to reach financial stability

3. Talk to Physicians Across Settings
   Ask attendings and mentors in your field:

   • How compensation differs in academic vs. private practice vs. employed models
   • What they would do differently, financially, if starting over
   • How their specialty impacts family life and long-term satisfaction

4. Consider Non-Salary Benefits
   Some lower-paid specialties may offer:

   • More predictable schedules
   • Fewer overnight shifts
   • Stronger sense of mission and meaning
   • Academic or public health opportunities

Those intangible benefits can be just as important as raw income numbers.

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10. Strategies to Improve Financial Outcomes in Lower-Paid Specialties

If you are called to one of the lower-paid medical specialties, there are still many ways to build a secure financial future:

• Choose practice setting strategically:

  • Consider high-need areas that offer premium salaries or loan repayment.
  • Evaluate academic vs. community vs. private practice options.

• Develop niche expertise:

  • For example, a family physician with additional training in sports medicine, addiction medicine, or hospital medicine may command higher compensation and more flexibility.
  • Geriatricians or pediatricians with specialized skill sets (e.g., complex care, palliative care, developmental pediatrics) may find unique roles.

• Understand and negotiate contracts:

  • Learn basics of RVUs, productivity formulas, and bonus structures.
  • Negotiate for CME funds, moving expenses, sign-on bonuses, and call pay.

• Plan personal finances early:

  • Start budgeting and investing as soon as possible, even with small amounts.
  • Consider working with a financial advisor experienced with physician compensation and student loans.
  • Protect yourself with disability and life insurance appropriate to your circumstances.

Aligning your career choice with both your values and a clear-eyed understanding of healthcare economics will help you build a sustainable, fulfilling professional life.

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FAQs: Physician Salaries and Lower-Paid Specialties

Q1: Which medical specialties are typically the lowest paid?
Commonly lower-paid specialties (on a median salary basis) include family medicine, general internal medicine, pediatrics, geriatrics, psychiatry, public health and preventive medicine, and palliative care. Compensation within each can still vary widely by region, practice type, and experience.

Q2: Can physicians in lower-paid specialties still achieve financial security?
Yes. Many primary care physicians and pediatricians reach strong financial stability by:

• Choosing favorable practice settings or geographic areas
• Utilizing loan forgiveness or repayment programs
• Living below their means early in their careers
• Investing consistently and planning strategically.
  The timeline may differ compared to higher-paid procedural fields, but long-term security is absolutely achievable.

Q3: How much should salary influence my choice of specialty?
Salary should be one important factor, but not the only one. A poorly matched specialty with a high income can still lead to burnout and dissatisfaction. Ideally, integrate:

• Your genuine interests and strengths
• Desired lifestyle and call schedule
• Financial goals, including debt and family plans
  Awareness of healthcare economics lets you choose deliberately rather than by assumption.

Q4: Are all primary care physicians paid the same?
No. Primary care compensation varies significantly based on:

• Practice setting (academic vs. community vs. private practice)
• Region (rural vs. urban, high vs. low cost of living)
• Payer mix and patient volume
• Additional skills (e.g., procedures, hospitalist work, leadership roles)
  A rural family physician in a high-need area may out-earn an urban counterpart in an academic center.

Q5: What policy changes could help raise earnings in lower-paid specialties?
Key changes include:

• Increasing reimbursement for cognitive and primary care services
• Expanding value-based care models that reward prevention and chronic disease management
• Enhancing loan forgiveness and financial incentives for high-need specialties and regions
• Supporting advocacy efforts to rebalance the relative value of cognitive vs. procedural work

Ultimately, aligning compensation with the true value of preventive, mental, and longitudinal care is essential for a more equitable and effective healthcare system.

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Understanding why some specialties earn less—and how that fits into broader healthcare economics—empowers you to make better-informed, intentional career decisions. Whether you choose a high-paying procedural field or one of the traditionally lowest paid specialties, pairing your medical education with financial literacy will help you thrive both professionally and personally.