Both settings require a master’s degree and the CCC-SLP certification from ASHA, but offer distinctly different experiences. School SLPs work with children on education-focused communication goals, enjoy summers off, and earn median salaries of around $75,000 for 9-10-month contracts. Medical SLPs work across the lifespan in hospitals and skilled nursing facilities, often focusing on dysphagia, and earn $95,000-$114,000 annually while working year-round.
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Choosing between school-based and medical speech-language pathology is one of the most significant career decisions you’ll make as an SLP. Both paths lead from the same master’s degree and CCC-SLP certification, yet they offer vastly different daily experiences, patient populations, and lifestyle tradeoffs.
This guide breaks down the key differences between these two career paths using current salary data, caseload research, and insights from practicing SLPs. Whether you’re a graduate student planning your clinical fellowship or an experienced SLP considering a change, you’ll find the information you need to make an informed decision.
The good news? Neither path is objectively “better.” The right choice depends entirely on your clinical interests, personality, and life priorities.
Understanding the Core Differences
The fundamental distinction between school and medical SLP practice comes down to focus and philosophy of care. School-based SLPs work within the framework of the Individuals with Disabilities Education Act (IDEA) to address how communication disorders affect a child’s ability to access education. Medical SLPs focus on restoring function, preventing complications, and maximizing quality of life for patients facing acute or chronic health conditions.
A school SLP might spend the morning helping a second-grader improve articulation clarity for classroom participation. During that same time, a medical SLP could be conducting a bedside swallow evaluation for a stroke patient, determining whether they can safely eat—same profession, completely different clinical realities.
| Factor | School SLP | Medical SLP |
|---|---|---|
| Primary Focus | Educational access | Medical restoration |
| Legal Framework | IDEA, IEPs | Healthcare regulations |
| Primary Population | Children and adolescents | Adults and geriatrics |
| Relationship Length | Months to years | Days to weeks |
| Work Calendar | 9-10 months typical | Year-round |
Patient Populations and Clinical Focus
School SLP Populations and Disorders
School-based SLPs work primarily with children from preschool through high school. The clinical focus centers on communication challenges that affect academic performance and social participation.
Articulation and phonological disorders remain the most common issues school SLPs encounter, followed closely by language impairments affecting vocabulary, grammar, and comprehension. Fluency disorders, such as stuttering, require specialized intervention techniques. Social communication challenges are increasingly common, particularly for students on the autism spectrum. Many school SLPs also work extensively with augmentative and alternative communication (AAC), helping students with complex communication needs access speech-generating devices.
Medical SLP Populations and Disorders
Medical SLPs work across the lifespan but predominantly serve adult populations in hospitals, rehabilitation centers, skilled nursing facilities, and outpatient clinics. The clinical scope differs significantly from school-based practice.
Dysphagia (swallowing disorders) represents the cornerstone of medical SLP practice. Clinicians conduct bedside swallow evaluations, modified barium swallow studies, and fiberoptic endoscopic assessments. Aphasia and other neurogenic communication disorders following strokes or traumatic brain injuries require specialized assessment and treatment. Cognitive-communication disorders and voice disorders round out the medical SLP’s scope. In acute care settings, you’ll encounter complex, medically fragile patients requiring rapid clinical decision-making.
Salary and Compensation Comparison
Compensation differs notably between settings, though the gap isn’t as straightforward as raw numbers suggest.
| Setting | Median/Average Salary | Source |
|---|---|---|
| School (9-10 month contract) | $75,000 | ASHA 2024 Schools Survey |
| School (11-12 month contract) | $86,000 | ASHA 2024 Schools Survey |
| General Hospital | $100,990 | BLS 2024 |
| Skilled Nursing Facility | $113,590 | BLS 2024 |
| Home Health | $121,220 | BLS 2024 |
Geographic variation matters significantly. California school SLPs report the highest median academic-year salary at $110,000, while Louisiana reports the lowest at around $58,000. Medical SLPs typically work year-round without extended breaks, so when calculated on a per-diem basis, accounting for time off, many school SLPs argue the compensation gap narrows considerably.
School SLPs on contracted positions through staffing agencies often receive higher hourly rates (around $52-55 median) but may lack the benefits and job security of direct-hire positions. Direct-hire school employees typically benefit from step increases, pension plans, and comprehensive benefits packages. For a detailed breakdown, see our complete SLP salary guide.
Caseload and Workload Realities
School SLP Caseloads
Caseload size represents one of the most challenging aspects of school-based practice. According to ASHA’s 2024 Schools Survey, the median caseload for school-based SLPs is 48 students, though this varies dramatically by state and region. Some states, like Indiana, report caseloads reaching 72-80 students at the upper ranges, while New England states average around 36.
Many states lack enforceable caseload caps. The “manageable caseload” SLPs themselves identify is 40 students, significantly lower than the caseload many actually carry. Beyond raw numbers, school SLPs manage extensive paperwork demands, including IEPs, progress reports, evaluation write-ups, and Medicaid billing documentation. This administrative burden often extends beyond contracted hours.
Medical SLP Caseloads
Medical caseloads are measured in daily patient encounters rather than monthly totals. Inpatient rehabilitation SLPs commonly see 6-8 patients daily for 60-minute sessions. Acute care SLPs may evaluate 7-10 or more patients per day, with shorter sessions focused on assessment and immediate intervention.
SNF SLPs often face productivity expectations requiring 75-90% of their time to be spent in billable patient contact. The nature of medical caseloads differs fundamentally from schools. Patients are discharged, and new ones arrive, providing constant variety but requiring rapid adaptation to new cases and care teams.
Work-Life Balance and Schedule Considerations
School SLP Schedule Benefits
The school schedule represents one of the most compelling advantages of school-based practice. School SLPs typically work regular hours from around 7:30 AM to 3:30 PM with predictable daily schedules. Nine to ten-month contracts allow extended summer breaks, with the option for Extended School Year work for additional income.
Winter break, spring break, and federal holidays align with family schedules. There’s no weekend or holiday work required. For SLPs with school-age children, this schedule alignment is particularly valuable. The tradeoff? You can’t take vacation whenever you want during the school year.
Medical SLP Schedule Considerations
Medical schedules vary significantly by setting. Acute care positions may include weekends, holidays, and on-call requirements. Inpatient rehabilitation offers more predictable schedules, typically 8:00 AM to 4:30 PM. Outpatient clinics maintain regular hours with occasional evening appointments.
Year-round employment means consistent paychecks but no extended breaks. Some medical SLPs value the ability to use PTO flexibly rather than being restricted to school calendar breaks.
Burnout Factors in Each Setting
School SLP Burnout Drivers
Burnout rates among school SLPs are a growing concern. ASHA has identified specific contributing factors, including caseload overload with inadequate administrative support, paperwork that consumes evenings and weekends, role ambiguity around consultative versus direct service expectations, increasingly complex student needs without adequate resources, and the perception that speech services are viewed as “elective” rather than essential.
Research published in Language, Speech, and Hearing Services in Schools found that large caseloads and demanding workloads contribute significantly to occupational stress among school-based SLPs.
Medical SLP Burnout Drivers
Medical settings present different stressors. Productivity demands pressure SNFs to meet billable-hour requirements. The emotional toll of working with critically ill patients, end-of-life situations, and families in crisis weighs heavily. The fast pace leaves limited time for treatment planning and documentation. Some medical SLPs report feeling like “the low person on the totem pole” in medical hierarchies, and ethical conflicts can arise when reimbursement pressures conflict with patient-centered care.
Career Flexibility and Transition Paths
A critical consideration for new SLPs is how their initial setting choice affects future career flexibility. Transitioning from medical to school settings is significantly easier than the reverse.
Moving from medical to school primarily involves learning special education law, IEP processes, and educational vocabulary. Your clinical skills transfer readily. Moving from school to medical requires gaining competency in dysphagia, acute care protocols, and medical terminology. This may require additional continuing education, per diem experience to build skills, or formal mentorship programs.
If you have a genuine interest in both settings, starting in medical does provide more flexibility. That said, don’t choose a setting you’ll dislike just for future optionality. Many SLPs successfully blend both worlds by working full-time in schools while maintaining per diem medical positions, or using school breaks for skilled nursing facility coverage.
Who Thrives in Each Setting?
School SLP Ideal Candidates
School-based practice may be the right fit if you love working with children and adolescents and value predictable schedules with extended breaks. SLPs who thrive in school settings typically enjoy long-term therapeutic relationships and watching student growth over the years. They find satisfaction in collaborating with educational teams and are comfortable managing their own caseload with relative autonomy. The extensive documentation and IEP processes don’t feel burdensome to them.
Medical SLP Ideal Candidates
Medical practice may suit you if you’re drawn to working with adults and complex medical cases. SLPs who thrive in medical settings typically enjoy fast-paced, dynamic environments and find dysphagia and swallowing disorders fascinating. They work well with interdisciplinary medical teams and handle emotional intensity, including in end-of-life care and acute illness. They prefer variety and constant learning over long-term client relationships and are comfortable making critical clinical decisions under pressure.
Job Market and Future Outlook
Both settings face significant workforce shortages, which enhance SLPs’ job security and bargaining power. According to ASHA’s 2024 data, 78.5% of school SLPs report job openings exceeding the number of job seekers in their area, while 55.5% of healthcare SLPs report similar supply-demand imbalances.
The Bureau of Labor Statistics projects 15% employment growth for SLPs from 2024 to 2034, far exceeding the average occupational growth rate. Around 28,000 new positions will be added during this period. Rural areas experience the most acute shortages in both settings. The aging Baby Boomer population drives increasing medical SLP demand for stroke, dementia, and dysphagia services, while expanded early identification of developmental disorders sustains school-based needs.
Frequently Asked Questions
Can I switch from schools to medical later in my career?
Yes, but it requires intentional preparation. You’ll need to take medical-focused continuing education courses, especially in dysphagia. Many SLPs gain experience through per diem positions at SNFs or hospitals during summer breaks. You may need to accept entry-level medical positions initially. The transition is possible but takes more effort than moving from medical to schools.
Is school-based SLP considered “lesser” than medical SLP?
No. This is a persistent but unfounded bias in the field. Both settings require the same credentials and involve sophisticated clinical reasoning. The populations and clinical focus differ, but neither is inherently superior. School SLPs develop deep expertise in pediatric language, literacy, and AAC that medical SLPs often lack.
What’s the real salary difference when accounting for summer breaks?
The gap narrows considerably when calculated per working day. A school SLP earning $75,000 over 10 months may have a similar daily rate to a medical SLP earning $95,000 over 12 months. School SLPs in high-paying districts with strong unions sometimes out-earn medical SLPs when factoring in total compensation, benefits, and time off.
Should I start in medical settings to keep my options open?
If you’re genuinely interested in both settings, starting medical does provide more flexibility since the reverse transition is more complex. Securing a medical clinical fellowship placement can be more challenging, but the experience is valuable for your resume. That said, don’t force yourself into a setting you won’t enjoy just for future flexibility.
How do clinical fellowship placements affect my career path?
Your clinical fellowship setting significantly influences your early career trajectory. Completing a CF in a hospital builds dysphagia skills that are difficult to develop later. A school-based CF develops expertise in IEP processes and pediatric intervention. Many graduate programs offer clinical placements across multiple settings, helping you build diverse skills before committing to a CF.
Can I work in both settings simultaneously?
Many SLPs do precisely this. Common approaches include working full-time in schools while maintaining a per diem position at a local SNF, taking travel or contract positions in medical settings during summer breaks, or building a mobile FEES practice that serves multiple settings. This hybrid approach helps maintain diverse skills and can maximize earning potential.
Key Takeaways
- Both school and medical SLP paths require a master’s degree and the CCC-SLP certification from ASHA, but offer distinctly different daily experiences and patient populations.
- School SLPs earn lower annual salaries (a median of around $75,000 for 9-10 months) but work fewer months, with summers and holidays off.
- Medical SLPs face productivity demands (75-90% billable time in SNFs) while school SLPs manage large caseloads averaging 48 students.
- Transitioning from medical to school settings is easier than the reverse, so starting medical provides more career flexibility.
- Neither path is objectively “better.” The right choice depends on your clinical interests, personality, and lifestyle priorities.
- Both settings face significant workforce shortages, with 15% projected job growth through 2034.
Ready to explore your options? Find accredited SLP graduate programs that offer clinical placements in both school and medical settings to maximize your career flexibility.
2024 US Bureau of Labor Statistics salary and job market figures for Speech-Language Pathologists reflect state and national data, not school-specific information. Conditions in your area may vary. Data accessed November 2025.