The lowest-paid doctors in the United States are pediatric subspecialists. Pediatric endocrinologists earn an average of $230,426 per year, making it the lowest-compensated physician specialty, according to the Doximity 2025 Physician Compensation Report. That figure is roughly half what many surgical specialists take home, and understanding why the gap exists reveals a lot about how physician pay actually works in America.
The Five Lowest-Paid Specialties
Every specialty on the bottom of the pay scale shares one thing in common: pediatrics. The five lowest-compensated physician specialties and their average annual salaries are:
- Pediatric Endocrinology: $230,426
- Pediatric Rheumatology: $231,574
- Pediatric Infectious Disease: $248,322
- Pediatric Hematology and Oncology: $255,733
- Pediatric Nephrology: $263,013
These doctors complete four years of medical school, three years of pediatric residency, and then an additional two to three years of fellowship training in their subspecialty. That means roughly 13 to 14 years of education and training after high school, yet their compensation sits well below the physician average.
Why Pediatric Specialists Earn Less
The pay gap comes down to how doctors get reimbursed. Medicare and most private insurers base physician payments on a system called the Resource-Based Relative Value Scale (RBRVS), which assigns a dollar value to every medical service. That system has long been weighted in favor of procedures, meaning a surgeon who performs a 45-minute operation is reimbursed at a much higher rate than a pediatric endocrinologist who spends an hour diagnosing and managing a child’s growth disorder.
The committee that recommends updates to these valuations, known as the RUC, has faced persistent criticism for specialty bias. Primary care physicians hold only 19 percent of the seats on that committee despite handling about 35 percent of all patient visits. The valuations the RUC recommends are based on small, self-reported surveys from specialty societies, and members vote by secret ballot under nondisclosure agreements. The result is a system that consistently places higher value on procedures and specialized treatments than on diagnosis, care coordination, and long-term patient management.
Pediatric subspecialists face an added disadvantage: their patient population is smaller than the adult equivalent. A pediatric rheumatologist treats far fewer patients than an adult rheumatologist simply because fewer children have rheumatic diseases. Lower patient volume means lower revenue for the practice, which directly limits what these doctors can earn. Insurance reimbursement rates for children’s care also tend to be lower, partly because Medicaid covers a large share of pediatric patients and pays less than private insurance.
How Residency Pay Factors In
Before any doctor reaches attending-level compensation, they spend three to seven years in residency earning a fraction of their eventual salary. First-year residents earn an average of $68,166, with pay rising modestly each year to about $89,187 by the seventh year of training. Those figures come from the 2025 AAMC survey of resident stipends.
Regional differences affect resident pay significantly. First-year residents in the Western and Northeastern parts of the country average $77,649 and $74,994 respectively, while those in Southern states average $65,076. By the eighth year of training, the gap widens further, with residents in the Northeast and West earning over $107,000 compared to roughly $87,000 in the South.
When you factor in that pediatric subspecialists complete some of the longest training pipelines in medicine, their effective lifetime earnings look even lower. A pediatric endocrinologist who finishes fellowship at age 32 or 33 has spent a decade earning resident-level wages while accumulating interest on medical school debt that averages over $200,000. The relatively modest attending salary that follows makes the financial math considerably worse than it looks on paper.
The Role of Practice Setting
Where a doctor works matters almost as much as what specialty they practice. Physicians in government and public health roles earn substantially less than those in the private sector. A Columbia University analysis of federal wage data found that 30 out of 44 health-related occupations paid at least 5 percent less in government than in private industry, with some roles paying 20 to 47 percent less. Doctors who work at academic medical centers, community health clinics, or government hospitals often fall on the lower end of the compensation range for their specialty.
Geographic location also shifts pay in meaningful ways. After adjusting for cost of living, physician wages vary considerably across the country. High cost-of-living areas can erode a nominally high salary, while doctors in lower-cost regions may come out ahead in purchasing power even with a smaller paycheck. According to Advisory Board data, the gap between the best and worst locations for cost-adjusted physician pay is significant enough to change a doctor’s financial picture entirely.
What “Low Pay” Means in Context
It’s worth putting these numbers in perspective. A pediatric endocrinologist earning $230,000 is still well above the median U.S. household income. But physician compensation needs to be weighed against the cost of becoming a doctor: a decade or more of post-college training, six-figure student debt, and years of earning below minimum wage on an hourly basis during residency. When researchers calculate an effective hourly rate for the lowest-paid specialties and compare it to other professions with similar training lengths, the gap narrows considerably.
The financial reality shapes who enters these fields. Pediatric subspecialties already face workforce shortages, and compensation is a major reason. Medical students carrying heavy debt loads are steered, sometimes consciously and sometimes by financial gravity, toward higher-paying procedural specialties. The doctors who do choose pediatric endocrinology or pediatric rheumatology tend to do so out of deep commitment to the work, knowing the pay trade-off going in.