Capital Is Not the Problem. Misaligned capital is. And there’s a difference worth fighting for.

The Modern Heretic

Let me say something that might make some of my colleagues uncomfortable: I am not afraid of private equity or venture capital in healthcare. I am afraid of what happens when we refuse to distinguish between capital that extracts and capital that builds. Extractive capital enters a system to take value out of it. This looks like loading practices with debt, cutting costs, hitting margin targets, and selling in five years. Aligned capital builds infrastructure that lets physicians actually practice medicine: the technology, the operations, the compliance backbone that reduces burden instead of adding it. The difference shows up in one question: when the business grows, do physicians practice better or worse?

The reflexive takedown of PE and VC in medicine is understandable because, in fact, there are bad actors. Misaligned and distorted incentives cause harm. I am not here to whitewash that. But the categorical rejection of outside capital is at best naïve and misinformed, and at worst, intellectual laziness. Pretending that the alternative to investment is some kind of physician utopia ignores the actual conditions in which we practice. It ignores what it actually costs to become a doctor, what it costs to leave the institutions that abuse us, and what it takes to build something better on the other side.

I want to talk about the numbers. Because the numbers tell a story that we don’t highlight often enough.

The Cost of Becoming a Doctor

Before we can even talk about building something better, let’s get real about what it costs to get into this profession in the first place. Medical school is not just a choice or even a commitment of time and effort. It is a financial sentence that follows you for decades.

$205,000 the median medical school debt for the Class of 2024, not including undergraduate loans (AAMC)

Source: Association of American Medical Colleges (AAMC), 2024 Medical School Graduation Questionnaire

$227,839 the average debt among 2024 graduates of private medical schools who borrowed (AAMC)

Source: AAMC, 2024

23% of 2024 graduates owed $300,000 or more in total education debt

Source: Education Data Initiative, 2024

$68,166 the average first-year resident salary (AAMC, 2025), while carrying six-figure debt at 8.94% federal interest

Source: AAMC 2025 Report on Residents

Now let’s do the math. A doctor enters her residency - which lasts anywhere from three to seven or more years depending on specialty - earning less than many administrative assistants, while their loans compound at nearly 9% interest. A $200,000 loan accrues approximately $13,000 in interest per year. By the time many physicians complete training, they owe significantly more than they borrowed. I will never forget the night on call that one of my co-residents calculated that our per hour rate ( given our 80 hour work week) was approximately what an employee of Taco Bell made. I also will never forget the day I finally paid off my student loans, at the age of 54, and only because I had inherited some money when my mother passed away.

And then we are expected to just bootstrap our way into independent practice? To take out another personal loan - this time against a house ( if we have been lucky enough to buy one!), savings ( if we have been lucky enough to accrue any!) , our family’s financial security - to build something outside the system that has already extracted so much from us?

We ask physicians to take on the financial risk of a startup founder without ever having been given the resources of one.

The System We Are Trying to Leave

Here is what independent practice looks like for most physicians right now. Hint: it is disappearing.

42.2% of physicians worked in private practice in 2024, down from 60.1% in 2012 (AMA)

Source: AMA Physician Practice Benchmark Survey, 2024

77.6% of physicians were employed by hospitals, health systems, or other corporate entities as of January 2024 (Physicians Advocacy Institute / Avalere)

Source: Physicians Advocacy Institute, commissioned report by Avalere, 2024

80,000 approximate number of private practice physicians lost between 2012 and 2024 (AMA)

Source: AMA Policy Research Perspectives, 2024

Doctors are not leaving independent practice because they want to. They are leaving because the financial architecture of medicine makes it nearly impossible to stay. Inadequate reimbursement rates, crushing administrative burdens, the rising costs of health insurance and other employee benefits , electronic health record demands, and prior authorization requirements have made solo and small group practice economically untenable for the majority of physicians.

And employed physicians are not thriving. According to the Physicians Foundation, employed physicians report higher rates of burnout (62%) than physicians in independent or physician-led settings (53%). A Bain & Company survey found that nearly 25% of physicians in hospital-led organizations are contemplating a change in employers, compared to just 14% in physician-led practices.

Source: Physicians Foundation; Bain & Company Physician Survey

41.9% of physicians reported at least one symptom of burnout in 2025, down from a pandemic peak of 62.8% in 2021, but still a substantial number which appears to be embedded in the profession (AMA)

Source: AMA Organizational Biopsy National Physician Comparison Report, 2025

$4.6 billion annual cost of physician burnout to the US healthcare system, largely driven by turnover and reduced hours (AHA)

Source: American Hospital Association, citing AMA data, 2023

$500,000 to $1 million+ estimated cost to replace a single physician who leaves due to burnout, depending on specialty (AMA, NAM)

Source: AMA; National Academy of Medicine, 2023

OB/GYN and women’s health physicians are, in many ways, among the most exposed. In 2023, OB/GYN ranked second only to our emergency medicine colleagues among all specialties for physician burnout, with 53% reporting burnout.

Source: Medscape National Physician Burnout and Suicide Report, 2024, citing 2023 data

A System Built to Undervalue Women’s Health

This is not simply a story about physician working conditions. It is a story about structural bias encoded into the payment system that governs all of it. I dove into this data in another recent Modern Heretic Substack, but it bears a quick review here.

The Medicare Resource-Based Relative Value Scale (RVU system) has set physician reimbursement since 1992. It determines what your time and clinical expertise are worth. And for women’s health providers, the data is unambiguous: the system undervalues us.

84% of male-specific procedures were compensated at a higher rate than anatomically paired female-specific procedures (2015 analysis of 50 matched CPT code pairs)

Source: Benoit & Upperman, Gynecologic Oncology, 2016 (published in journal Gynecologic Oncology)

27.67% average reimbursement premium for male-specific surgeries over matched female-specific surgeries (2015 CMS data)

Source: Benoit & Upperman, Gynecologic Oncology, 2016

31-34% average RVU premium for male-specific procedures over female-specific procedures from 2003 to 2023. There has been no statistically significant progress in closing the gap over that 20-year period

Source: Health Management Policy and Innovation (HMPI), October 2025

75% of urinary tract procedures performed on male patients received higher RVUs and reimbursement than those performed on female patients, averaging 49.1% higher

Source: HMPI, 2025

Twenty years. No meaningful progress. The bias is a persistent, documented feature of the reimbursement architecture that governs women’s healthcare today.

And it is not limited to procedure codes. The cognitive, relational, time-intensive work that defines women’s midlife health - managing hormonal complexity, perimenopause, chronic conditions, mental health intersections, preventive care - is systematically undervalued in an RVU framework that rewards volume and procedural throughput over the depth of care women actually need and deserve.

The RVU system is not a neutral accounting tool. It is a structural argument about whose health matters. And for 30 years, it has argued against us.

So Who Is Actually Funding Innovation?

This is where the anti-capital argument collapses under its own weight. If we are not going to use outside capital to build physician-led alternatives, what exactly is the plan?

Venture capital investment in women’s health reached $2.6 billion in 2024. This is a 55% increase over 2023, and a record high according to Silicon Valley Bank’s 2025 Innovation in Women’s Health Report. When including funding for diseases that disproportionately affect women, total sector investment rose to $10.7 billion.

Source: Silicon Valley Bank (SVB) 2025 Innovation in Women’s Health Report

$2.6 billion VC investment specifically in women’s health startups in 2024, up 55% year over year (SVB)

Source: SVB 2025 Innovation in Women’s Health Report

$14.8 billion total venture investment in health tech in 2024, up 17% from $12.6 billion in 2023 (HSBC Innovation Banking)

Source: HSBC Innovation Banking Health Tech Report, 2025

That capital is building the technology platforms, the compliance infrastructure, the care coordination tools, and the operational backbone that allow physician-led practices to exist outside of hospital employment. Without it, the only alternatives are the personal loan, the punitive contract, and the slow suffocation of the fee-for-service system.

The femtech sector overall is now valued at approximately $28 billion globally and growing at a rate approximately 160% faster than the broader healthcare market. Sounds incredible and exciting, right? Despite that growth, women’s health still represents only 8.5% of total digital health funding. The opportunity is enormous. The gap is real.

Source: Dealroom Femtech Report, 2024; Jones Day / Galen Growth analysis, 2025

And here is the structural irony: the capital is flowing in spite of, not because of, the existing reimbursement environment. Investors are building around the broken system because reform of the broken system is moving at the pace of a Congress that has spent 30 years not fixing RVU gender bias.

The Actual Question

I want to be precise about what I am arguing and what I am not.

I am not arguing that all PE and VC in healthcare is good. Private equity-backed entities accounted for 7 of the 8 largest healthcare bankruptcies in 2024. The stealth consolidation of physician practices - where PE firms acquire independent groups, strip costs, and then sell - is a real and documented harm and it has destroyed beloved practices in my own community.

Source: Private Equity Stakeholder Project (PESP) Healthcare Report, 2025

I am arguing that the conversation needs to be more precise than ‘capital is bad.’ Because the alternative is a profession where 77% of physicians are employed by hospital systems, where burnout costs the system $4.6 billion a year, where a gynecologist’s work is systematically reimbursed at 28% less than a urologist’s for matched procedures. It is a system where physicians who want to build something different have no option but personal debt and that alternative is not better. It is just a different kind of extraction.

The question is not whether to use capital. The question is who controls clinical decisions. Whether physicians are at the table or being managed by it. Whether the model is designed to serve patients and the physicians who care for them, or to optimize for financial returns at their expense.

Physician-led organizations with aligned capital partners are not a moral compromise. They are the architecture of a better system. The technology to operationalize them exists. The investment appetite is growing. What has been missing is the clinical authority to lead them and the willingness to claim it.

Capital is not the problem. Misaligned capital is. Know the difference. Demand the difference.

Dr. Suzanne Gilberg, MD, is a board-certified OB/GYN, integrative medicine physician, Chief Clinical Officer at Monarch, and founder of the Menopause Boot Camp. She is the author of Menopause Bootcamp and is completing her forthcoming book, Plant Medicine: A Modern, Science-Based Guide to Ancient Wisdom, Medicinal Herbs, and Healing Plants. Follow her at @askdrsuzanne and @themenopausebootcamp. H

CITATIONS AND SOURCES

1. AAMC 2024 Medical School Graduation Questionnaire | medschooldebt.org

2. Education Data Initiative, Average Medical School Debt, 2024

3. AMA Physician Practice Benchmark Survey, 2024

4. Physicians Advocacy Institute / Avalere Report, January 2024

5. AMA Organizational Biopsy National Physician Comparison Report, 2025

6. American Hospital Association, citing AMA burnout cost data, 2023

7. National Academy of Medicine, ‘The Real Driver of Burnout: The 1.2-FTE Problem,’ 2023

8. Medscape National Physician Burnout and Suicide Report, 2024

9. Benoit MF & Upperman BA. ‘Comparison of 2015 Medicare relative value units for gender-specific procedures.’ Gynecologic Oncology, 2016. PMID: 28024653

10. Health Management Policy and Innovation (HMPI), ‘The Price of Care: The Ramifications of Financial Pressures on OB-GYNs and Patients,’ October 2025

11. Silicon Valley Bank (SVB), 2025 Innovation in Women’s Health Report, April 2025

12. HSBC Innovation Banking Health Tech Report, January 2025

13. Dealroom Femtech Report, 2024; Jones Day Analysis, September 2025; Galen Growth, August 2025

14. Private Equity Stakeholder Project (PESP), Healthcare PE Report, 2025

15. Bain & Company Global Healthcare Private Equity Report, 2024

16. Physicians Foundation Survey; MGMA Stat Burnout Poll, 2024