As an established, solo practice millennial physician, I grapple with the reality that the promise of a fulfilling career remains unsatisfactory amid today's challenges. Our generation faced a multitude of crises — 9/11, the 2008 financial collapse, the COVID-19 pandemic, wars, climate change, student debt, and persistent economic instability. These challenges, coupled with corporate medicine’s expansion, have eroded the security associated with medical careers in generations past.
Traditional private practice is dying due to untenable costs and administrative burdens associated with it. Instead, I built a solo, home-based practice that leverages technology, travel, and flexibility while retaining the autonomy and ethical-based practice I value. Physicians in the traditional model burn out and end up selling to private equity, become medical directors for consolidated healthcare organizations, or exit the field altogether. Reasons cited by physicians to do so include reduced reimbursement rates, increased overhead costs, fiscal uncertainty, and complex regulatory frameworks. Burnout rates among young physicians in primary care have translated into chronic physical and emotional distress with plans to exit the career sooner than previous generations. Many U.S. physicians, mostly employed, risk losing sight of their intrinsic value to effectively advocate for themselves and our profession. Our intrinsic value is reflected in our extensive education, clinical training, certifications, humanistic values (our care, bedside manner, and advocacy for patient welfare), and leadership experiences. Ultimately, intrinsic value means acknowledging all the skills, responsibilities, and contributions physicians bring to the healthcare system as a group. I discovered it through leadership roles in organized medicine, advocacy, business courses, and network building with those who challenge the status quo. What chipped it away in modern medicine?
The root cause of physician devaluation lies in our medical training. The hierarchical training process conditions physicians to compete, rather than collaborate, using fear and individual milestones as metrics to advance. It encourages a mindset that divides us, a convenient way to keep us controlled by administrators. They fail to teach us essential business skills. They train us to be obedient despite the poor working conditions. It fosters compliance even at the expense of patient care. Trainees and practicing doctors who defy systemic inequities frequently face retaliation, reinforcing a culture of silence. Medical directors serve administrative interests over patient or physician welfare.
But we can fix it. To counter these issues, nonconforming physicians must engage in collective unity through coaching, mentorship, and apprenticeship programs leveraging greater autonomy and awareness of our true value. I have done this, for example, by mentoring trainees on the business aspects of medicine, advocating for self-employed and small-business practice models over traditional employment. My guidance addresses newer physicians’ priorities — work-life balance, fair compensation, and reduced administrative burden — offering perspectives often unavailable from academic faculty with limited business experience.
Collective unity can change the situation and reflect on the priorities of the next generation. Early data suggest that Gen Z physicians continue to experience insurmountable debt, burnout, and career dissatisfaction; they prioritize enhanced work-life balance, mental well-being, high ethical/moral standards, and personal life fulfillment. Their goals can be achieved through alternative models of practice and physician unionization. As a union delegate during residency, I advocated for critical issues like COVID-19 hazard pay, parental leave, patient quality improvement funds, anti-racism in medicine, accountability for duty hour violations, enhanced non-pay benefits, etc. These changes improved residents' well-being and steered toward the provision of ethical healthcare delivery. The future generations can advocate for changes that mold to their own core values and priorities, instead of following directives imposed by others. They can pursue alternative self-employed models that provide more flexibility. Collective advocacy around patient care, scope of practice, reimbursement reform, staffing standards, physician autonomy, and healthcare policy is vital to reestablish our professional value.
Systemic interventions by collective action are needed. First, medical educators and leaders must prioritize curricula that foster advocacy, enhancing physician value, well-being, and financial literacy. This may include establishing a LCME/ACGME-mandated curriculum that focuses on the business of medicine and teaching students how to enhance their professional value collectively. Topics of relevance include clinical microeconomics (e.g., patient financial advocacy/navigation, contract negotiation), legal advocacy (e.g., risk management, patient and physician rights), and operational technology (e.g., AI, workflow optimization). Second, healthcare administrators and health systems can no longer be the primary stewards of the business of medicine. The Affordable Care Act directive that physicians cannot own or operate hospitals should be rescinded. This will allow doctors to build competing, ethical physician-led clinical infrastructure. Structural changes are needed to uncouple physician compensation from purely RVU-based, assembly line volume-based metrics. Instead, value-based metrics that are achievable should be implemented. Mandated ancillary staffing ratios can ease the dreaded inbox messages, requests, prior authorizations, etc., that lead to moral injury.
Finally, policymakers and professional societies must address structural drivers such as private equity encroachment, reimbursement, graduate medical education funds, student loan reform, and capping medical education costs. Specialty medical societies have the responsibility of engaging physicians with policymakers, providing advocacy training, and participating in public health campaigns to help restore trust in physicians as the gatekeepers of health. Instead, we have seen them sell us out, claiming they represent us when in reality they cozy up to third-party industry interests that annually sponsor their conferences.
In summary, we must reclaim leadership, recover our professional self-esteem, and reject the medical industrial complex. Unionization, alternative practice models, curriculum changes, apprenticeship models, and accreditation enforcement are some of the solutions proposed. Fostering a culture of collaboration that uplifts our colleagues is the only viable path to counteract corporate health systems. Our survival depends on reclaiming leadership with unity, integrity, and collective action to reshape the practice of future generations. Otherwise, they too will encounter a career of clinical subservience. We must push for radical reforms to the current model of practice — or knock it down completely and form our own.
