In surgery, I wrestle with the fact that we sometimes inherit the decisions of the past. In my subspecialty of minimally invasive abdominal wall reconstruction, hernia recurrences and intraoperative battles with old materials — mesh that’s too small or thick, fractured or misplaced, secured with permanent sutures or metal tacks — are just part of the gig.
While I may lament the materials and techniques of a prior era, I don’t question the intentions of the surgeons who came before me. They made decisions based on what they had, what they knew, and what they believed to be best at that time.
And yet, when I plan a non-redo operation for a patient who needs a hernia repair, those inherited lessons help shape my decisions. I choose modern approaches — robotic techniques, resorbable barbed sutures, macroporous monofilament mesh — not out of superiority, but out of humility. Even through the lens of the all-knowing retrospectoscope, we can recognize that our predecessors were limited by the tools of their time.
But not all decisions we inherit are clinical. Some are structural. Decisions about who owns our practices, who profits from our labor, and who shapes our incentives — these, too, are choices we’ll pass down. If we accept that future surgeons will inherit what we build, then we must ask: What legacy are we leaving when we partner with private equity?
Private equity (PE) has been described as an extreme form of shareholder capitalism in which investors pursue high returns on short timelines, typically aiming to sell off a company, system, or practice within five to 10 years. Proponents say this model generates capital by optimizing efficiency. But over time, critics argue, shareholder primacy has shifted corporate purpose away from long-term innovation and toward short-term gains.
The difference is not just economic — it's philosophical. Some businesses invest to hold and build, like P&G buying paper mills, Tata acquiring Jaguar and Land Rover, and Berkshire Hathaway purchasing Dairy Queen. But PE invests to flip, and in that world, the long-term impact and societal purpose of a corporation become secondary.
With all of this tension in mind, a fundamental question arises: Does a corporation serve society, or its shareholders? And when this corporation operates a hospital, what are the implications of shareholder primacy? In the clinical setting, I know that I can positively impact a patient’s life by building on inherited knowledge. But it’s much harder for me to impact patient health outcomes when they’re tangled in a web of maximized profits and outside investors who are sometimes betting against the house.
A lot has been written about the impact of PE in health care, as a surge in PE investment between 2010 and 2020 has rightfully gained attention. To be sure, health care delivery, especially as it applies to an aging population living with chronic disease, is ripe for monetization. For instance, it’s not hard to imagine the kinds of profits you could earn if you owned multiple ophthalmology practices and operationalized them to specialize in cataract surgery only. Unlike most physician groups, PE firms have the up-front capital required to pursue such a strategy at scale, and leveraged buyouts facilitate their opportunism.
Our system is teeming with opportunities like this: long-term rehabilitation facilities, nursing homes, emergency medicine groups, anesthesia coverage, and even entire hospitals. As PE firms have moved to streamline and scale health care, researchers have found that the patients with more complex pathology and others who simply cannot afford the higher cost of PE-managed care are left behind.
For instance, in the case of ER staffing managed by PE firms, replacing higher-cost physicians with mid-level clinicians makes financial sense. However, complex patients in extremis (a trauma patient with a pneumothorax and flail chest, a pregnant woman in the early stages of a miscarriage, a postoperative cholecystectomy patient with a bile duct injury) require specialized, high-level care that doesn’t fit into this low-cost, high-efficiency model. In the most extreme examples, short-term PE ventures have shuttered entire hospitals, leaving behind underserved communities and orphaned trainees.
As an academic general surgeon, the influence of PE on my daily work isn’t always obvious, but I’ve felt it. A few years ago, our OR access was nearly jeopardized by a stalled negotiation with a PE-managed anesthesia group. The issue was resolved, but in that moment, I saw behind the curtain. The decision to take a patient to the OR — something I had thought of as a purely clinical one — had become subject to external forces I couldn't control. The experience was sobering. I felt both naïve and horrified, like discovering the wizard was not just a man, but a boardroom full of people with money, power, and no medical training.
A colleague who was also affected by this threat to his OR schedule shared an even more damning study by Diaz et al., which suggests that PE-owned hospitals are ill-equipped to care for postoperative complications. In examining postoperative mortality for common inpatient operations and comparing PE-acquired hospitals with non-PE-acquired hospitals, the study found that PE-acquisition of a hospital was associated with a 2.7% increase in 30-day postoperative mortality and a 3.9% increase in failure-to-rescue rates. A subgroup analysis found that this increase in mortality was more pronounced for unplanned and emergency operations, which they interpreted to be a reflection of the hospitals' reduced ability to manage complex care.
Another study by Kannan et al. found that hospital-acquired adverse events such as line infections, surgical site infections, and falls increased at PE-acquired hospitals, despite the fact that fewer lines and operations were performed at these institutions.
Why is this the case? Both groups suggest that their findings are related to PE efficiency strategies for profit maximization, as others have discussed previously. PE acquisition often comes with streamlining systems and reducing redundancy. In health care, this “lean” approach translates into fewer nurses, fewer physicians, and generally fewer safeguards against the bad things that we know can happen in a hospital.
Maximizing profits by widening the holes in the safety net is unethical, and frankly, shortsighted. If the people in the boardroom behind the curtain are real human beings, they or someone they love will eventually need the kind of complex, nuanced care that is usually only found in hospitals rife with redundancies, such as teaching hospitals. Indeed, as someone who trains medical students and residents, I have found a practical truth in the fact that while hospitals with trainees tend to spend more on tests, imaging, and consults, they have a lower failure-to-rescue rate than those without trainees. While I am sure there is an optimal clincian-to-patient ratio, I do not believe that PE firms have figured it out.
My brief peek behind the curtain — and the frantic reading about PE that followed — made me wonder about the cost of progress, both for medicine and for society at large. It’s easy to look back on the history of surgery and point to operative innovations and technological advancements as having had a neat, well-structured gestation period. In reality, it’s more often true that necessity, created by circumstances such as war, plague, natural disasters, and the like, has been the driving force behind innovation. So perhaps the chaotic nature of leveraged PE investments should inspire us to take a long, hard look at our priorities in health care delivery before we surrender the reins to the invisible hand.
Ultimately, PE’s vision of health care is neither one I want to inherit nor leave behind. Their strategy of short-term “flippable” health care opportunities reflects not just a shortcut, but a fatalist view of reality. This is particularly jarring for someone whose livelihood is built on hopefulness for the future: in fixing a hernia, I hope the patient has a better life and never has to see me again. I know the statistics, and yet I work to improve my techniques and choose the materials that may prevent recurrences. I do the operation to last—I’m not investing in failure.
But PE, by contrast, feels built on planned obsolescence — a model that eventually profits when things fall apart. It’s not a legacy I want our patients, our trainees, or even our future selves to inherit.
What is your experience with PE and its effects on your specialty? Share in the comments!
Dr. Priya Rajdev is a surgeon specializing in minimally invasive abdominal wall reconstruction and benign foregut surgery in Phoenix, AZ. She is passionate about medical education, health literacy, and the importance of play in daily life. She enjoys gardening, reading, celebrating everyday absurdities and serendipities, and improv comedy. Dr. Rajdev is a 2024-2025 Doximity Op-Med Fellow.
