Exploring Underpaid Medical Specialties: Insights for Future Physicians

Unmasking the Pay: A Closer Look at Underpaid Specialties in Medicine

The world of medicine is vast, diverse, and constantly evolving. As a medical student or resident, you’re asked to make career-defining decisions about specialty choice while balancing passion, lifestyle, and financial reality.

Some medical specialties—like orthopedic surgery, dermatology, and interventional cardiology—are well known for high earning potential. Others, including family medicine, pediatrics, psychiatry, and general internal medicine, are vital to the healthcare system yet consistently land near the bottom of physician compensation surveys.

This article takes a deeper look at underpaid specialties in medicine: how they’re defined, why the pay is relatively low, what that means for workforce challenges, and how you can think strategically if you’re considering one of these fields.

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Understanding the Landscape of Medical Specialties and Compensation

Physician compensation is shaped by a complex web of market, policy, and practice factors. For residency applicants, understanding these forces early can help you make informed specialty and career decisions.

Key Drivers of Physician Compensation

Several broad factors tend to influence which specialties are highly paid and which land on the “underpaid” end of the spectrum:

• Supply and demand dynamics

  • Specialties with a limited workforce relative to demand (e.g., orthopedic surgery, radiology, anesthesia) often command higher compensation.
  • Paradoxically, some shortages in primary care do not translate into high pay because of how reimbursement is structured.

• Procedural vs. cognitive work

  • Procedure-heavy specialties (surgery, cardiology, GI, interventional radiology) typically receive higher reimbursement per unit time.
  • Cognitive specialties—where the main “procedure” is thinking, diagnosing, and counseling—such as family medicine and general internal medicine, are reimbursed far less per visit, even when the complexity is high.

• Work hours and intensity

  • More call-heavy or high-acuity specialties often receive higher pay, though this is not a universal rule.
  • Primary care physicians may still work long hours, but a significant portion is non-billable (charting, messaging, care coordination).

• Practice setting

  • Employed vs. private practice
  • Academic vs. community
  • Urban vs. rural
  • Each of these can significantly alter compensation, even within the same specialty.

What Does “Underpaid” Really Mean in Medicine?

It’s important to acknowledge that almost all physicians in the U.S. earn an income that is high relative to the general population. “Underpaid” in this context doesn’t mean low income compared to other jobs, but rather:

Compensation that is disproportionately low relative to:

• Length and cost of training
• Level of responsibility and risk
• Complexity of decision-making
• Intensity of workload and burnout risk
• Critical importance to the healthcare system

By these measures, some specialties that are essential to population health and healthcare access are consistently undervalued in the current payment structure.

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A Closer Look at Commonly Underpaid Specialties

While compensation varies by region, practice type, and individual negotiation, certain fields reliably cluster near the bottom of national income surveys. These include family medicine, pediatrics, psychiatry, and general internal medicine.

1. Family Medicine: The Front Line of Healthcare

Overview

Family medicine physicians provide comprehensive, continuous care across the lifespan—newborns to older adults. They manage acute complaints, chronic diseases, preventive care, behavioral health concerns, and coordination with specialists.

• Core areas: preventive care, chronic disease management (diabetes, hypertension, COPD), women’s health, behavioral health, minor procedures.
• Practice settings: outpatient clinics, community health centers, rural hospitals, urgent care, telemedicine, academic roles.

Typical Compensation Range

While numbers fluctuate yearly and by survey, many recent national reports place family medicine salaries roughly in the $230,000–$270,000 range in the U.S., often at or near the bottom among all specialties.

Why Family Medicine Is Considered Underpaid

• Low reimbursement for cognitive visits:
  A 20–30 minute complex visit addressing multiple chronic conditions, medications, preventive counseling, and care coordination may be reimbursed less than a 15-minute minor procedure in another specialty.

• Heavy non-billable workload:
  High volumes of:

  • Electronic health record documentation
  • Prescription refills
  • Lab/result follow-up
  • Secure messaging and phone calls
  • Prior authorizations
    Much of this is unpaid yet essential, increasing burnout without boosting income.

• High responsibility, broad scope:
  Family doctors manage undifferentiated complaints and often serve as the first point of contact, requiring broad medical knowledge and rapid decision-making.

Career Perspective for Residents

For students and residents considering family medicine:

• Pros:
  • Broad scope, continuity of care
  • Flexible practice models (outpatient only, OB-focused, rural full-scope, urgent care, telehealth)
  • Opportunities in leadership, quality improvement, and population health
• Challenges:
  • Lower relative pay vs. training debt
  • High administrative burden
  • Increasing panel sizes in many systems

Strategically, some family physicians improve compensation and autonomy by choosing rural practice, urgent care, direct primary care (DPC), or focusing on niche areas (sports medicine, addiction medicine, geriatrics).

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2. Pediatrics: High Responsibility, Lower Reimbursement

Overview

Pediatricians focus on the health of infants, children, and adolescents. They provide well-child care, vaccinations, developmental and behavioral assessment, and manage common and chronic pediatric illnesses.

• Subfields: general pediatrics, hospitalist pediatrics, subspecialties (endocrinology, cardiology, NICU, heme/onc).
• Settings: outpatient clinics, children’s hospitals, academic centers, community hospitals.

Typical Compensation Range

General pediatrics often falls in the $220,000–$260,000 range, sometimes lower in academic positions. Many pediatric subspecialties earn comparable or only modestly higher salaries despite additional fellowship training.

Why Pediatrics Is Often Underpaid

• Payer mix and reimbursement:
  Pediatric practices often have a high proportion of patients covered by Medicaid, which reimburses significantly less than commercial insurance. This translates directly into tighter margins and lower physician compensation.

• High visit volume, time intensity:
  Managing developmental issues, parenting concerns, and complex chronic pediatric conditions can be time-consuming, with limited reimbursement per visit.

• Subspecialists not always better off:
  Many pediatric subspecialties (e.g., pediatric endocrinology, infectious disease, nephrology) actually earn less than some general pediatricians, despite extra years of training.

Career Perspective for Residents

For those drawn to pediatrics:

• Pros:
  • Profound impact on long-term health trajectories
  • Strong relationships with families over years
  • Opportunities in advocacy, public health, and global health
• Challenges:
  • Lower physician compensation compared with adult subspecialties
  • Emotional burden of caring for very ill children
  • Often academic-heavy environment with additional non-clinical expectations

Residents can improve their financial outlook by considering geographic flexibility, hospitalist roles, select high-demand subspecialties, or leadership positions in children’s hospitals and health systems.

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3. Psychiatry: High Demand, Mixed Financial Reality

Overview

Psychiatrists diagnose and treat mental health disorders, using both psychotherapy and pharmacologic management. They practice in outpatient clinics, hospitals, community mental health centers, correctional facilities, and increasingly via telepsychiatry.

Typical Compensation Range

Many psychiatrists earn in the $270,000–$330,000 range, though there is wide variability. Some positions, especially rural or underserved, may offer significantly higher salaries and signing bonuses due to acute workforce shortages.

Why Psychiatry Is Sometimes Viewed as Underpaid

Compared to surgical and interventional specialties, psychiatry can still be considered underpaid, especially given:

• Growing mental health crisis and high demand
• Long wait lists and limited access in many regions
• Significant emotional labor and risk of burnout

Key factors:

• Insurance and parity issues:
  Despite mental health parity laws, behavioral health is often reimbursed at lower rates and subject to more prior authorization hurdles.

• Complex, time-based care:
  45–60 minute sessions for psychotherapy or complex medication management may be reimbursed less favorably than a short procedure.

Career Perspective for Residents

Psychiatry remains attractive for many due to:

• Better control over schedule and call in many practice models
• Flexibility (telehealth, part-time, consulting, integrated behavioral health)
• Expanding need across all demographics

Psychiatrists can optimize compensation through locums work, private practice, niche expertise (addiction, forensics, C/L psychiatry), or leadership in integrated care models.

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4. General Internal Medicine: The Backbone of Adult Care

Overview

General internists (especially in outpatient primary care roles) manage acute and chronic diseases in adults, often serving as the primary contact for complex, multi-morbid patients.

Roles include:

• Outpatient primary care
• Hospitalist medicine
• Academic internal medicine
• Transitional care and post-acute care

Typical Compensation Range

• Outpatient general internal medicine: often $240,000–$290,000
• Hospitalists: frequently earn more ($280,000–$350,000+) due to shift-based, high-intensity work and nighttime coverage.

Why General Internal Medicine Is Underpaid in Outpatient Settings

• Cognitive, high-complexity care:
  Internists manage medication regimens for multiple diseases, interpret extensive lab/imaging data, and coordinate with numerous specialists—yet reimbursement is still anchored to short visits.

• Burnout and panel size pressure:
  Pressure to see more patients per day to maintain clinic financial viability increases workload without proportional compensation.

Career Perspective for Residents

Many internal medicine residents choose hospitalist roles for:

• Higher pay
• Defined shifts and blocks of time off
• Less chronic administrative burden per patient

Those passionate about longitudinal outpatient care can improve their situation by:

• Negotiating panel size and protected time
• Exploring concierge or membership-based models
• Combining clinical work with academic, quality improvement, or administrative roles.

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Why Certain Medical Specialties Remain Underpaid

Understanding the structural forces behind underpaid medicine is crucial both for individual career planning and for broader advocacy.

1. Work-Life Balance vs. Compensation

Some underpaid specialties are perceived as more “lifestyle-friendly,” which can indirectly suppress wages. For example:

• Outpatient primary care may have more predictable hours than surgical call schedules, but:
  • Charting after-hours is common.
  • Inbox and messaging burdens can significantly extend the workday.

Residents often assume that lower-compensation fields must at least offer better lifestyle. In reality, many underpaid specialties carry significant hidden workloads that erode that perceived advantage.

2. Structural Bias Toward Procedures

The current reimbursement system in many countries, especially the U.S., financially rewards procedures more than cognitive work:

• Procedural codes often pay more per minute than evaluation and management (E/M) codes.
• Hospitals and health systems may favor proceduralists because:
  • Procedures generate facility fees and high-margin revenue.
  • Primary care saves systems money (by reducing admissions and complications) but doesn’t directly generate as much billable income.

This structural bias perpetuates a system where specialties that are central to prevention, early diagnosis, and population health are among the lowest in physician compensation.

3. Educational Debt and Career Choices

Medical graduates frequently carry six-figure debt. Under current conditions:

• High debt pushes many toward better-paid specialties to secure financial stability sooner.
• Underpaid specialties then struggle to recruit, especially in high-cost-of-living areas.
• This worsens workforce shortages, particularly in primary care and rural and underserved communities.

For residency applicants, this tension between debt burden and professional calling is very real and legitimate. It’s critical to enter training with a realistic understanding of both numbers and non-financial rewards.

4. Workforce Challenges and Geographic Disparities

Underpaid fields such as family medicine and pediatrics experience:

• Chronic shortages, especially in rural areas and inner cities.
• Maldistribution: relatively more specialists in affluent, urban regions and fewer primary care clinicians where the need is greatest.

Ironically, in some under-resourced settings, these specialties may command higher salaries or loan repayment packages to attract physicians—but the workload can be intense and support structures limited.

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Real-World Implications of Underpaid Specialties

The relative underpayment of primary care and other cognitive fields has ripple effects far beyond individual physicians.

1. Workforce Shortages and Access to Care

• Fewer trainees selecting primary care and general pediatrics contributes to extended wait times and fewer available clinicians.
• Patients may:
  • Delay care
  • Rely on urgent care or emergency departments
  • Lose continuity, which worsens chronic disease outcomes

From a system standpoint, this undermines efforts toward value-based care and population health management.

2. Burnout, Turnover, and Early Exit

Physicians in underpaid specialties often experience a combination of:

• High volume expectations
• Administrative overload
• Emotional burden of complex care
• Limited recognition or financial reward

This can accelerate:

• Burnout
• Early retirement
• Shifts to non-clinical roles or reduced FTE

These workforce challenges can further strain remaining clinicians and destabilize practices and health systems.

3. Downstream Effects on Quality and Cost

When primary care is under-resourced:

• Preventive care is less robust.
• Chronic diseases are less tightly controlled.
• Fragmentation of care increases, contributing to:
  • Higher hospitalization rates
  • More emergency department use
  • Greater overall healthcare spending

Ironically, if underpaid specialties were better compensated and more robustly supported, health systems could likely achieve better outcomes at lower long-term cost.

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Practical Guidance for Students and Residents Considering Underpaid Specialties

If you’re drawn to an underpaid field, you’re not alone—and you’re not doomed financially. There are practical strategies to align passion with sustainability.

1. Do the Financial Math Early

• Use specialty-specific salary data (e.g., MGMA, Medscape, specialty societies).
• Model:
  • Loan repayment timelines under different specialty incomes
  • Cost-of-living differences between potential practice locations
  • Impact of academic vs. private vs. employed practice

Consider tools like:

• Public Service Loan Forgiveness (PSLF)
• State loan repayment programs for underserved areas
• National Health Service Corps or similar programs

2. Be Strategic About Practice Setting

Within any underpaid specialty, there is substantial variation in income and lifestyle:

• Urban academic center vs. rural community hospital
• FQHC/CHC vs. private practice vs. large health system employment
• Outpatient only vs. mixed inpatient/outpatient vs. hospitalist

If compensation is a concern, be open to:

• Negotiating RVU thresholds, panel size, and protected time
• Exploring higher-need geographic areas with better financial packages
• Considering leadership or administrative roles that come with stipends

3. Explore Niche Skills Within Your Specialty

Developing additional skills can help differentiate your practice and, in some cases, improve compensation or flexibility:

• Family medicine: sports medicine, addiction medicine, HIV care, women’s health, office procedures, point-of-care ultrasound.
• Pediatrics: hospitalist pediatrics, neonatal care, behavioral/developmental pediatrics, quality improvement, or leadership in children’s hospitals.
• Psychiatry: addiction psychiatry, consultation-liaison, forensics, reproductive psychiatry, or telepsychiatry.
• Internal medicine: hospital medicine, palliative care, medical informatics, quality and safety leadership.

4. Plan for Financial Wellness Proactively

If you choose an underpaid specialty, intentional financial planning is critical:

• Live below your means for the first several attending years.
• Prioritize high-interest debt repayment.
• Automate retirement contributions early, even if modest.
• Consider disability and life insurance tailored to your income and specialty.

Aligning your lifestyle expectations with your chosen field early on can significantly reduce stress and improve long-term satisfaction.

5. Engage in Advocacy and System Improvement

Underpaid specialties will not become better supported without physician voices:

• Join your specialty society’s advocacy efforts around payment reform and primary care investment.
• Participate in quality improvement, clinic redesign, or value-based care initiatives that can reallocate resources toward primary care and prevention.
• Educate policymakers and the public on the critical role of these specialties in health system sustainability.

Your generation of trainees and early-career physicians can help reshape the narrative—and the economics—around underpaid medicine.

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FAQ: Underpaid Specialties, Career Planning, and Physician Compensation

1. Why are some medical specialties considered underpaid when physicians still earn six-figure salaries?

Underpaid, in this context, is relative. Many underpaid specialties require:

• 7–10+ years of post-secondary training
• Significant responsibility for life-and-death decisions
• Management of complex, high-risk conditions

Yet their compensation is markedly lower than other physician specialties with similar training demands. The issue is not that these physicians are “poor,” but that the healthcare system structurally undervalues cognitive, preventive, and primary care relative to procedural work.

2. How should student loan debt influence my specialty choice?

Debt is a genuine factor, but it doesn’t have to dictate your entire career:

• Run realistic projections for different specialties and practice settings.
• Investigate loan repayment options (PSLF, state programs, NHSC, employer-based repayment).
• If you are passionate about an underpaid specialty, strategic planning—geography, practice type, lifestyle—can still make it financially sustainable.

Choosing a specialty solely for income, without regard to fit, often leads to burnout or regret.

3. Are underpaid specialties actually in high demand?

Yes—many underpaid specialties face significant workforce shortages, particularly:

• Family medicine and general internal medicine (especially in primary care roles).
• General pediatrics in certain regions.
• Psychiatry nationwide, including child and adolescent psychiatry.

Demand is driven by aging populations, increased mental health needs, and ongoing gaps in access to primary and preventive care.

4. Can lifestyle benefits offset lower pay in some specialties?

Sometimes, but not always. Some underpaid specialties can offer:

• More predictable hours
• Less frequent in-hospital call
• Greater flexibility with part-time or outpatient-only schedules

However:

• Administrative tasks and after-hours charting can still be heavy.
• Burnout rates in some underpaid fields (especially primary care) are high due to workload and systemic pressures.

Lifestyle advantages are real but not guaranteed; they depend heavily on your specific job and system.

5. What can be done at the system level to improve compensation in underpaid specialties?

Meaningful change will likely require:

• Payment reform that better rewards cognitive work, care coordination, and prevention.
• Increased investment in primary care infrastructure by payers and health systems.
• Expansion of loan repayment and scholarship programs for shortage areas and underpaid specialties.
• Continued advocacy for mental health parity, fair Medicaid rates, and value-based care models that explicitly fund primary care and prevention.

Physicians in all specialties can support these efforts, but those in underpaid fields are particularly powerful advocates because they see the impact on patients and communities daily.

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Underpaid specialties in medicine are the backbone of a functioning healthcare system. If you are drawn to these fields, you are not making a mistake—you are stepping into roles that are critically needed. With clear understanding, strategic planning, and ongoing advocacy, it is possible to build a fulfilling, sustainable career in these essential, if undercompensated, corners of medicine.