At the peak of COVID-19, I was on call in the NICU with a medical student, an aspiring pediatrician. Watching Dr. Fauci on the news, she asked me about a career in pediatric infectious diseases. I told her about the clinical, research, and administrative aspects of the position. She asked me a question no student had asked me before: “How much does a pediatric infectious disease doctor make after fellowship?”

I was surprised by this direct question and checked a national salary database. She was shocked to learn that the base salary for an assistant professor of pediatric infectious disease ranges from $147K to $158K (blended average data from Association of Administrators in Academic Pediatrics).

She said that her brother, a recent computer science graduate, made a starting salary of $160K. “Why would I spend four more years in medical school, three years in a pediatric residency, and three more in a pediatric infectious disease fellowship with call at nights, weekends, and holidays for such a low salary?” she asked me. “I love caring for children, but my student debts won’t pay themselves.”

She went on to match into anesthesia. This anecdote is emblematic of the factors resulting in our ongoing pediatric subspecialty workforce shortage in the U.S. In the recent 2023 November NRMP, 51.9% of pediatric infectious disease fellowships were unfilled.

Eight outpatient-based, non-procedural pediatric specialties (mnemonic “READING”) have assistant professor salary benchmarks below that of general pediatrics in the AAMC benchmarks.

• Rheumatology
• Endocrinology
• Adolescent Medicine
• Developmental Behavioral Pediatrics
• Infectious Disease
• Nephrology
• Genetics

Economic factors (high student debt and relatively low salaries) dampen interest in a career as a pediatric subspecialist. Three factors contribute to low compensation of pediatric medical subspecialists in the U.S.:

• Medicaid reimbursement varies between states, and is often lower than Medicare values.
• The productivity value (work relative value units, or wRVUs) for non-procedural, outpatient pediatric care is not commensurate with the time and effort needed for high quality family-centered care.
• Gender inequity in physician salaries persists, with a high proportion of female pediatricians in subspecialties (e.g., 76.4% of pediatric endocrinology fellows in 2022 are female).

“The Diaper Phenomenon”

Geriatrics is facing a similar crisis. In "Being Mortal," Atul Gawande, MD points out that a geriatrician fine-tunes and simplifies medications, adjusts diet and exercise, looks for signs of isolation, and works with social work to make sure the home is safe while providing age-appropriate care. Senior citizens receiving care from a specialized geriatric team are less likely to become disabled, develop depression, and receive home health services. However, a geriatrician does not insert expensive devices resulting in high contribution margin like an interventional cardiologist. The starting median academic salary of ~$210,000 in geriatrics (compared to $415,000 for interventional cardiology) has resulted in the highest rate of unfilled internal medicine fellowship positions in the recently concluded 2023 NRMP match (58.5%, compared to 0.3% unfilled positions in cardiology). Clinicians at extremes of the age spectrum (“diaper” patients) struggle with similar issues – need for “indirect” care (discussing care with a caregiver, often requiring more time), low compensation, low productivity (a geriatrician generates 46% fewer wRVUs than a general cardiologist), and gender inequity.

How to Make Pediatric Subspecialty Pay Fair

The 2025 Pediatrics Workforce Initiative by the Association of Medical School Pediatric Department Chairs (AMSPDC) and the report of the National Academies of Sciences, Engineering, and Medicine (NASEM) outline immediate steps to sustain the future of pediatric subspecialist workforce. For more information, access the full report.

The majority of the pediatric subspecialty workforce in the outpatient, non-procedural domain (the “READING” subspecialty workforce) resides in academic pediatric departments. These departments are financially stressed and need additional support. The following changes are needed to support pediatric departments:

• Increase Medicaid reimbursement equal to or higher than Medicare
• Aligned funds flow approach with the health system: The health system’s mission is aligned with the pediatric department and support for programs is provided by the health system.
• Raising the bar: Adoption of a financial approach so that all pediatric subspecialist academic benchmarks are at or above that of a general pediatrician.
• Higher initial salaries: Recruiting graduating fellows as assistant professors at median benchmarks for “total” and not “base” compensation will result in higher starting salary and attract more pediatric residents into subspecialties.
• Pediatric wRVU booster: Caring for children takes longer due to need for indirect history taking from parents and guardians, and innovative techniques needed for examination. A 10-20% additional revenue with the use of a “pediatric conversion or boost factor” to all CPT codes for children will enhance revenue for pediatric services. The use of time-based evaluation and management (E&M) codes by CMS in 2021 has been beneficial to pediatric outpatient specialists.
• Current Procedure Terminology (CPT) codes unique to pediatrics with higher wRVU assignments.

In conclusion, the shortage of pediatric subspecialists endangers the future of American children. Pediatricians enter their subspecialty field because of compassion and a love of improving the lives of children, and should not be penalized economically for pursuing this goal.

Dr. Satyan Lakshminrusimha is the Chair of the Department of Pediatrics and Pediatrician-in-Chief at UC Davis Health. He is a physician scientist and medical illustrator interested in neonatal resuscitation, oxygen, pulmonary hypertension and economics of physician compensation and productivity. Special thanks to Dr. David Lubarsky for his guidance. Dr. Lubarsky is the Vice Chancellor and CEO of UC Davis Health. He is also a Professor of Anesthesia and Pain Medicine with expertise in behavioral economics in health care.

Image: Oksana Latysheva / gettyimages