You might be a med student weighing future salaries if you’re asking questions like “What is the most underpaid medical specialty?” However, the answer to this question reveals a deep crack in the foundation of the U.S. healthcare system that’s partly responsible for the current physician shortages you keep hearing about.
The most consistently underpaid roles in the U.S. healthcare system are generalists. While many med school students obsess with searches like “what doctor makes $500,000 a year” or “what doctor makes 700k a year,” the specialties that provide the bedrock of quality care – primary care, pediatrics, and family medicine – are financially penalized for their breadth.
The U.S. healthcare industry has created a system that pays the most to physicians with the narrowest focus, and everyone pays the price.
Doctors who specialize in everything aren’t formally called “generalists” in the U.S. They are known as primary care physicians (PCP), and there are arguably the most in-demand doctors for all the wrong reasons.
Think of them as the central nervous system of patient care, trying to coordinate a body of specialists where each one operates like a separate, hyper-efficient reflex arc with no connection to the brain.
A medical student graduating with staggering debt has a clear financial incentive to hyperspecialize, reducing the pool of generalists. For example, a cardiothoracic surgeon’s salary typically dwarfs that of a family medicine doctor.
The healthcare system’s reimbursement structure rewards procedures over cognitive labor, creating brain drain in the field of comprehensive care. The result has been a crippling shortage of primary care physicians, leaving many of the very doctors we need to coordinate care overwhelmed, underpaid, and at risk of burnout.
The shortage of PCPs in the U.S. reveals a fundamental flaw in the training model used. Doctors in the U.S. are trained in silos from the start of residency. A cardiologist masters the heart, a gastroenterologist the gut, and an endocrinologist learns about hormones.
However, the human body doesn’t care about these bureaucratic divisions, and it often leads to the infamous “specialist carousel,” where patients with complex, multi-system issues bounce from one expert to another.
A cardiologist dismisses their headaches, while the endocrinologist refers them to a gastroenterologist. Each specialist, trained to deal with the organ they specialize in in isolation, declares that the patient’s health issues are outside their scope of practice.
Meanwhile, the patient accumulates thousands in copays and piles of conflicting notes from specialists, while a PCP is left trying to stitch together a coherent treatment plan from the fragments provided by the different specialists. This is inefficiency masquerading as thoroughness.
A story from a physician in Ecuador highlights the different approach to healthcare in many Latin American countries, where specialists are first trained as generalists.
During training, the physician rotated with a podiatrist treating a patient with a diabetic foot ulcer. The patient reported minor throat issues, which would typically trigger a referral to an otolaryngologist in the U.S., leaving the patient waiting weeks for an appointment.
However, the Ecuadorian podiatrist, thanks to his generalist training, simply examined the patient’s throat and immediately provided feedback to the patient.
Imagine that. A single visit. Multiple issues arising organically in conversation, matching the flow of human conversation and connection. Multiple issues resolved.
That’s the advantage of a healthcare system that produces physicians who see the body as an integrated system. These doctors retain the competence needed to handle minor issues outside their primary niche. They understand how a throat infection can impact a diabetic patient’s overall health. Care becomes more connected, more human, and less bureaucratic.
With fragmented care and a focus on hyperspecialists, a healthcare system is created where no one is accountable for patients as a whole. The PCP becomes the default coordinator, a role they aren’t even paid well for.
Many PCPs spend hours on administrative tasks, reconciling one specialist's prescription with another that conflicts and fielding desperate calls from patients lost in the confusion. This fragmentation of care is a root cause of burnout and a leading driver of the U.S. physician shortage.
The healthcare industry doesn’t simply need more doctors; it needs more doctors who are trained to think broadly and collaborate with other physicians.
So what is the most underpaid medical specialty? It’s the one we need the most: the generalist. The financial disincentives to entering and staying in primary care are a direct contributor to systemic bottlenecks. Many medical school students are chasing the "$700k a year" dream while the healthcare system’s foundation crumbles.
The solution isn’t just to pay PCPs more (though that would certainly help). It's to rethink the entire approach to medical education. Medical schools should instill a generalist mindset in every student, regardless of their future specialty. The U.S. needs cardiologists who understand how thyroid function impacts heart rate and endocrinologists who understand the gut-hormone axis.
You don’t have to accept the status quo of a fractured, inefficient system. Sign up for our free monthly newsletter if you’re frustrated by the gaps in U.S. healthcare and want to learn from integrated, global healthcare models.
We break down how medical education and healthcare systems in other countries tackle chronic conditions with food-first, lifestyle-first, and collaborative approaches. Stop wondering why the system is broken and start learning how to fix it.