Valuing Subspecialties within Professions: The Case for Aligning Compensation with Societal Need

By: Elke Zschaebitz, DNP, APRN, FNP-BC, FNAP (she/her)

Would you work in a very rural environment if it compensated you substantially more?

The healthcare workforce faces a paradox: the specialties and settings society needs most urgently are often the least financially rewarded. This misalignment between societal value and economic compensation threatens not only individual professions but the entire interprofessional ecosystem upon which modern healthcare depends. Nowhere is this more evident than in the declining interest in infectious disease fellowships, where physicians who could protect populations from pandemics instead choose more lucrative specialties, or in the persistent shortage of healthcare professionals willing to practice in rural communities. If interprofessional education is to produce a healthcare workforce capable of meeting society’s needs, we must confront an uncomfortable truth: we cannot expect professionals to sacrifice financial security for the common good indefinitely.

The Compensation Crisis in Critical Specialties and Settings

Infectious disease physicians exemplify this crisis. These specialists stand on the front lines of pandemic preparedness, antibiotic stewardship, and global health security. Yet infectious disease fellowships consistently go unfilled, with match rates among the lowest of all medical subspecialties.

Rural healthcare workers face parallel challenges. Rural healthcare professionals must maintain broader clinical skills—managing emergencies, obstetrics, mental health crises, and complex chronic diseases that urban specialists would handle. They work longer hours with less backup, often serving as the sole provider for entire communities. Despite this expanded scope and critical role, rural practitioners typically earn less than their urban counterparts while facing higher malpractice insurance costs, limited continuing education access, and professional isolation. A rural healthcare provider might be the only resource within 50 miles yet earn substantially less than a subspecialist in a metropolitan area who treats a narrow range of conditions.

The same pattern repeats across healthcare professions. Primary care physicians earn less than specialists despite being the foundation of effective healthcare systems. Mental health professionals, social workers, and public health specialists—all essential to interprofessional care teams—face compensation that often doesn’t reflect their educational investment or societal contribution. Rural nurses, pharmacists, and respiratory therapists accept lower wages, fewer professional development opportunities, and geographic isolation to serve communities that desperately need them. We ask these professionals to be more versatile, work longer hours with less support, and serve more vulnerable populations—then compensate them less for doing so.

The Ripple Effects on Interprofessional Care

When we undervalue specific professions or practice settings, we don’t merely create recruitment challenges—we destabilize entire interprofessional teams and leave communities without essential services. An infectious disease physician shortage means hospitalists and emergency physicians must manage complex infections without specialized expertise. It means antimicrobial stewardship programs lack leadership, contributing to resistance patterns that affect all patients. It means fewer researchers investigating novel pathogens, leaving future pandemics without adequate scientific response.

Rural healthcare shortages create even more dramatic ripple effects. When a rural community cannot recruit a family physician, the emergency department becomes the primary care clinic. When there’s no obstetrician, pregnant women drive two hours for prenatal care—or deliver in emergency rooms. When mental health professionals concentrate in urban areas, rural patients present in crisis rather than receiving preventive care, and primary care providers absorb psychiatric emergencies beyond their training. When rural hospitals close due to workforce shortages—over 130 have closed in the past decade—entire communities lose access to emergency services, requiring patients to travel dangerous distances for urgent care.

Each undervalued profession and underserved location creates pressure points throughout the interprofessional network, forcing other team members to operate beyond their scope or leaving patient needs unmet entirely. Rural maternal mortality rates are twice those of urban areas; rural suicide rates are substantially higher; rural residents die younger from treatable conditions. These aren’t inevitable geographic disparities—they’re the predictable consequences of systematically undervaluing rural healthcare work.

Value

Systems reflect societal values. The infectious disease physician who prevents a hospital outbreak through stewardship programs saves millions in treatment costs and immeasurable suffering—yet generates little billable revenue. The rural family physician who maintains obstetric skills to prevent dangerous transfers creates enormous community value—but is compensated far less than the urban subspecialist with a narrower scope. The rural pharmacist who knows every patient personally, catches dangerous drug interactions, and provides medication counseling that prevents hospitalizations creates value that never appears in billing codes.

Rural practice particularly suffers from market distortions. Lower population density means fewer patients per provider, reducing revenue potential. Critical access hospitals operate on thin margins, unable to offer competitive salaries. Yet the skill requirements are higher—rural providers need broader training, more versatility, and greater autonomy.

The Interprofessional Impact of Geographic Maldistribution

Rural healthcare shortages don’t merely affect rural communities—they strain the entire healthcare system. Urban emergency departments absorb rural patients who travel hours for specialty care. Tertiary care centers manage routine cases that rural providers transfer. Medical air transport services—extraordinarily expensive—become routine rather than exceptional. Urban healthcare workers face burnout from absorbing rural overflow.

Moreover, the absence of robust rural healthcare infrastructure limits interprofessional training opportunities. Medical students, nursing students, and allied health trainees who never experience rural practice cannot make informed career decisions about it. Urban-centric training creates urban-centric career expectations. When interprofessional education occurs only in academic medical centers, we train learners to expect subspecialty consultation for every complex decision, immediate imaging availability, and abundant colleague support—expectations rural practice cannot meet.

Rural communities also lose the benefits of interprofessional care itself. While urban academic centers can field teams of physicians, nurses, social workers, pharmacists, dietitians, and mental health professionals, rural areas often struggle to recruit even basic primary care. The interprofessional care model we teach becomes a luxury available only to well-resourced communities, deepening healthcare inequities.

Toward Solutions: Revaluing Critical Professions and Places

Addressing this crisis requires systemic change at multiple levels:

Policy Interventions: Loan forgiveness programs must expand significantly for both shortage specialties and rural practice. Collaborative models (in some countries, include church-government or non-profit government models) should include specialty-specific shortages and higher payouts for truly isolated communities. Reimbursement for cognitive services, rural health clinic designation, and public funding for essential low-revenue specialties could help align compensation with need. Tax incentives, housing assistance, and spousal employment programs could address non-compensation barriers to rural practice.

Institutional Commitments: Academic health centers and hospital systems can create differential compensation models that recognize the value of shortage specialties and rural practice beyond revenue generation. Quality metrics, population health outcomes, and stewardship activities should factor into compensation formulas. Rural hospitals need financial support to offer competitive salaries—perhaps through state rural healthcare funds or federal critical access designations with enhanced reimbursement.

Educational Pipeline Development: Interprofessional education must include substantial rural clinical experiences. Students who train in rural settings are significantly more likely to practice there. Rural medical schools, distributed nursing education models, and intentional programming should receive increased funding. We cannot recruit for settings that students have never experienced.

Professional Society Advocacy: Interprofessional organizations must advocate collectively for policies that value all team members and all practice settings appropriately. When professional societies compete for relative compensation, patients and the healthcare system lose. Rural health professional organizations need stronger voices in policy discussions that often center on urban academic medicine.

Telehealth and Technology Integration: Strategic investment in telehealth infrastructure can reduce rural professional isolation, enable specialist consultation, and create hybrid practice models. However, technology cannot substitute for an adequate local healthcare workforce presence—it should supplement, not replace, rural professionals.

Cultural Transformation: Interprofessional education must prepare students to advocate for systemic change, not merely adapt to existing inequities. Future healthcare leaders need skills in health policy, economics, and advocacy alongside clinical competencies. We must also address cultural biases that portray rural practice as professionally inferior rather than recognizing it as requiring superior breadth of skills and clinical judgment.

Conclusion: A Moral and Practical Imperative

Valuing essential professions and practice settings through adequate compensation is not merely a recruitment strategy—it is a moral imperative and a practical necessity. We cannot ask individuals to choose between financial security and serving society’s most pressing healthcare needs. We cannot build robust interprofessional teams when some team members are systematically undervalued because of their specialty choice or geographic service. And we cannot claim to prioritize pandemic preparedness, antimicrobial stewardship, mental health, primary care, or rural health access while compensating these professions and settings as though they were optional luxuries rather than essential services. Finding creative solutions for varying environments can lead to improvements within a system that can be short-sighted instead of working the long game for all citizens of a nation in need.

Photo curtesy of ISTOCK

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About the author:

For more about Dr. Elke Zschaebitz please read our welcome post or the Editors page.

References

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