SERIES: THE BILL NO ONE WANTS TO PAY • PART 1 OF 5

Training more menopause-literate clinicians means nothing if the system won’t let them do their jobs

The Modern Heretic

I am going to say something out loud that the menopause awareness movement - for all its momentum, all its well-meaning conferences and CME hours and hashtag campaigns - has been conspicuously reluctant to say:

You cannot train your way out of a broken payment system.

In the last 4 years since the publication of Menopause Bootcamp I’ve spent quite a bit of time in rooms full of brilliant clinicians, impassioned advocates, policy wonks, and research equity champions. We talk about the data gaps, the dismissal of women’s symptoms, the decades lost on HRT, the unconscionable under-representation of midlife women in clinical trials. We are not wrong about any of it. But there is a room adjacent to all of these conversations that we consistently refuse to enter. The room where the money lives.

So I’m going in. And I’m inviting you with me.

The numbers you need to know.

When we talk about why women receive inferior care in midlife, we tend to focus on physician ignorance and cultural bias. Both of these are real issues, both worth addressing. But let’s start with what the structure of payment actually rewards. This will require a bit of a detour through the “sausage factory”, so bear with me.

A brief decoder for the non-clinician reader:

A CPT code (Current Procedural Terminology) is a standardized numerical label assigned to virtually every medical service, procedure, or office visit in the United States. When a doctor sees a patient, examines a lump, performs surgery, or counsels someone about menopause, they assign a CPT code. That code determines how much they get paid. The codes are maintained by the American Medical Association and used by Medicare, Medicaid, and virtually every private insurer in the country. They are, in essence, the price tags of medicine.

RVUs (Relative Value Units ) are the unit of currency attached to each CPT code. The government assigns every clinical service a numerical RVU value meant to represent the complexity, skill, and time required. That number is then multiplied by a dollar conversion factor set annually by CMS (The US federal agency, Centers for Medicare & Medicaid Services) to determine actual reimbursement. A routine office visit might be worth 1.5 RVUs. A complex surgery might be worth 30. The higher the RVU, the higher the paycheck and critically, the more time-intensive, relationship-based work of medicine tends to generate far fewer RVUs than procedures and interventions.

The most common form of physician compensation in the US is a base salary plus a production bonus based largely on RVUs. By 2010, 61% of physicians already had their compensation tied to RVUs and that figure has only grown. Today, RVU-based productivity models dominate physician employment across hospitals and large health systems. The structural biases embedded in how RVUs are assigned ripple directly into what physicians earn, what services they prioritize, and how long they can afford to spend with any one patient. This is not a niche accounting problem. It is the engine that drives most of American medicine.

The numbers are not neutral: gender Bias in price tags.

A 2025 analysis of 110 paired CPT codes found that 75% of procedures performed on female patients carried lower work RVUs than analogous procedures on male patients, with male-specific procedures reimbursed 30% higher on average. RVU analyses from 1997 and 2015 demonstrated that sex-specific procedures for women are undervalued without any surgically justifiable reason. When gynecologic and urologic procedures are matched by complexity and RVUs, male-specific procedures are compensated at a higher rate 84% of the time. Since 1997, these disparities have remained essentially unchanged. We are not talking about a gap that medicine is slowly closing. We are talking about a structural devaluation of care delivered to women’s bodies that has been documented, published, and largely ignored for thirty years.

But this is not only about whose anatomy is on the table. The compounding injustice is this: the physicians most often performing those undervalued procedures on women are themselves women, paid less for the privilege of doing so. A landmark 2023 JAMA Surgery study found that patients treated by female surgeons have lower rates of adverse postoperative long-term outcomes, including death, compared to similar patients treated by male surgeons. A subsequent 2024 meta-analysis of over 5.4 million patients across 15 studies confirmed that patients treated by female surgeons experienced lower postoperative mortality. Female surgeons deliver measurably better outcomes and are paid measurably less to do it. The market does not reward excellence when it is packaged in a woman’s body wearing a white coat.

The system was built with a thumb on the scale. Training more OB/GYNs in menopause medicine and then sending them back into that system does not remove the thumb.

The clinician delivering that care? She’s drowning.

This is where I need to get personal, because I have lived this.

OB/GYN consistently ranks among the highest-burnout specialties in medicine. In Medscape’s 2024 survey, 53% of OB/GYNs reported experiencing burnout - second only to emergency medicine (but you are watching The Pitt, so you already know that). Women physicians are significantly more likely to suffer burnout than their male colleagues -47.2% versus 38.9% - and are less likely to feel valued: 51.6% compared to 58.2% of men.

Think about what this means: the physicians most likely to specialize in women’s midlife health are themselves working in conditions that are literally making them sick. The top drivers of burnout are not clinical complexity. Bureaucratic tasks (62%), excessive work hours (41%), and lack of respect (40%) are the leading factors. We are not burning out because the medicine is hard. We are burning out because the system is designed to extract maximum volume from minimum time while paying us less for doing so.

The top contributors to burnout are not the patients. They are the paperwork. The prior authorizations. The documentation requirements. The denial letters. And increasingly, they are the layer of non-clinical administrators who, despite having no training in the actual delivery of care, hold enormous decision-making power over what care gets authorized, how it gets coded, and how quickly - if ever - it gets paid for. These people are not (all) villains. Many are doing their jobs as designed. But a system that asks a physician to justify a menopause treatment plan to an algorithm, or to spend 40 minutes on a peer-to-peer review with someone who has never examined the patient, is a system that has drifted very far from its stated purpose. When 62% percent of physicians cite bureaucratic burden as the primary driver of their burnout, we have a diagnosis.

The patients feel it too- in rushed visits, long waits, fragmented communication, and the growing sense that their doctor is somewhere else even when sitting in the room.

We are not approaching a crisis. We are in one. And it is getting louder.

Scroll through any physician forum, medical subreddit, or the comment section under any post about healthcare right now and you will find the same thread: doctors of every age, every specialty, every career stage, describing why they are done with clinical medicine. Not burned out in the recoverable sense. Done.

Two in five physicians in AMA survey data said they planned to leave practice within five years. That is a workforce collapse in slow motion.

It is no longer just the exhausted mid-career internist or the OB/GYN who delivered her thousandth baby at 3 am only to spend the next morning fighting a prior auth denial. It is newly minted attending physicians, two years out of residency, already disillusioned. It is experienced specialists with twenty years of expertise who are simply refusing to participate in a system that has made the actual practice of medicine the least valued part of the job. In TikToks, Instagram reels and LinkedIn essays physicians are publicly documenting why they are leaving. They are not being dramatic. They are providing data.

Meanwhile, the United States is projected to face a shortage of between 37,800 and 124,000 physicians by 2034, with the gap most severe in primary care and the specialties most essential to women’s health. HRSA ( Health Resources and Services Administration, a part of the federal Department Health & Human Services) projects a national shortage of 68,020 primary care providers by 2036. This represents more than 80% of the total projected shortage. We are building a crisis on top of a crisis: training physicians at record rates while simultaneously creating conditions that drive experienced clinicians out of the field entirely.

These are not nice-to-have conversations. They are existential ones.

The women who will be in perimenopause five years from now - who are already 27 to 70 days away from their first appointment in major American cities - will be looking for a menopause-literate physician in a healthcare system that has fewer physicians than it does today.

Up next → Part Two: Follow the money — administrative bloat, the AI false promise, and why physicians who left the system are not the problem.

Dr. Suzanne Gilberg is a board-certified OB/GYN, integrative medicine physician, Chief Clinical Officer at MonarchMD, and founder of the Menopause Boot Camp. She is the author of Menopause Bootcamp and the forthcoming Plant Medicine. Find her at @askdrsuzanne and @themenopausebootcamp. Paid subscriptions are coming. Reply to this email if you want founding member pricing.