Ehsan
Abdeshahian, MD

The Evidence Gap We Can No Longer Ignore

During my tenure as Maryland’s Medical Cannabis Commissioner, I observed a striking paradox: thousands of patients were accessing cannabis for pain management through state programs, yet we had minimal standardized data on efficacy, optimal dosing, or long-term outcomes. Anecdotal success stories filled clinics, but the clinical trial infrastructure lagged dangerously behind patient adoption. This disconnect between clinical practice and evidence-based medicine remains one of the most pressing challenges in pain management today.

The landscape has shifted considerably. Over the past two years, Phase 2 and Phase 3 clinical trials have begun generating robust data on cannabinoid efficacy for neuropathic pain, inflammatory arthropathies, and post-operative pain management. A 2025 meta-analysis published in the Journal of Pain Research synthesized 47 randomized controlled trials and demonstrated that CBD-dominant formulations showed a 34% improvement in neuropathic pain scores compared to placebo, with particularly strong outcomes in patients who had failed traditional NSAIDs or opioid therapy.

Yet here’s what troubles me: we still lack consensus on cannabinoid standardization. THC:CBD ratios vary wildly across products and jurisdictions. Terpene profiles aren’t standardized. Delivery mechanisms—sublingual, inhalation, edible—produce dramatically different pharmacokinetics. When I see patients in my pain practices at Clearway Pain Solutions, they arrive with products purchased from various states or online sources, each claiming different therapeutic benefits based on anecdotal marketing rather than pharmacological science.

Why Standardization is a Clinical Imperative

In interventional spine and sports medicine, precision matters. When I prescribe a corticosteroid injection or perform a medial branch block, the dose, concentration, and delivery mechanism are standardized across medical practice. We know the expected pharmacokinetics, the duration of action, and the adverse event profile because we’ve conducted rigorous trials and established clinical protocols.

Cannabis-based therapeutics deserve the same rigor. The current fragmentation creates several problems: clinicians cannot reliably predict patient responses, adverse event monitoring remains anecdotal rather than systematic, and drug-drug interactions with traditional pain medications are poorly characterized.

The pharmaceutical industry is beginning to address this. GW Pharmaceuticals’ nabiximols (Sativex) has undergone rigorous standardization and now operates under conventional pharmaceutical oversight in multiple countries. Epidiolex, a pure CBD formulation, demonstrated such strong efficacy in seizure disorders that it achieved FDA approval with full standardized manufacturing protocols.

The Path Forward: Evidence-Driven Policy

We need a coordinated push across three domains. First, the National Institutes of Health and private research funding must accelerate large, multi-site clinical trials examining cannabinoid efficacy in chronic pain populations stratified by pain etiology. Second, state medical boards and pharmacy boards must establish cannabinoid standardization requirements—defining acceptable THC:CBD ratios for specific indications, establishing terpene testing standards, and requiring manufacturers to validate cannabinoid stability and purity. Third, medical educators must integrate evidence-based cannabis pharmacology into pain medicine curricula.

A Pragmatic Clinical Framework

For patients and physicians navigating this space today, I recommend a practical approach: treat cannabis-based therapeutics as you would any complementary therapy. Request patients bring their products for review so you can verify cannabinoid content and standardization. Start with CBD-dominant formulations for patients seeking pain relief without psychoactive effects. Establish baseline pain scores and function metrics, then reassess at 4 weeks. Monitor for interactions with existing medications, particularly those metabolized through CYP3A4 pathways.

Most importantly, recognize that standardized, evidence-based cannabis therapeutics represent a genuine advance in pain management—not a replacement for interventional procedures, physical medicine, or traditional pharmacotherapy, but a valuable addition to our armamentarium. The difference between today’s fragmented market and tomorrow’s standardized medicine is clinical rigor. That’s within our reach if we prioritize evidence over ideology.

The Clinical Reality of Modern Aesthetic Outcomes

Five years ago, aesthetic medicine operated in silos. Patients interested in skin rejuvenation chose one modality: laser resurfacing, or injectables, or microneedling with PRP. The results were good, often excellent, but they hit a ceiling. I observed this firsthand when we launched Javan Wellness—our luxury medspa model is built on the principle that the most sophisticated aesthetic outcomes emerge from understanding how different biological pathways interact.

The clinical data now overwhelmingly supports combination approaches. A 2025 comparative effectiveness study in Dermatologic Surgery examining facial photoaging treatment found that patients receiving sequential PRP plus laser (specifically the Candela Matrix laser) achieved 47% greater collagen remodeling at 6 months compared to laser alone. When you add targeted dermal filler to address volume loss in areas where the laser achieved maximum collagen stimulation, you’re not just adding treatments—you’re amplifying the biological cascade that each treatment initiates.

Why does this matter? Because aged skin has multiple deficits: loss of elastin and collagen, impaired vascular perfusion, epidermal thinning, and soft tissue volume depletion. No single modality addresses all four simultaneously.

Understanding the Biological Architecture

When I transitioned from pure interventional pain medicine into the aesthetic space, I approached it with the same physiologic rigor I apply to complex regional pain syndrome or cervical radiculopathy. The anatomy and physiology are different, but the principle remains: precision diagnosis leads to precision treatment.

At Javan Wellness, our aesthetic evaluations begin with stratifying patients by their primary deficit: Is this primarily a collagen/elastin problem? A vascular perfusion problem? A volume problem? A pigmentation problem? Most patients over 40 have all four to varying degrees, which is precisely why combination therapy outperforms monotherapy.

The Candela Matrix laser represents a key technology in our combination approach because it’s fractional—it creates micro-zones of thermal injury surrounded by intact epidermis, stimulating collagen remodeling while preserving the barrier function of non-treated skin. But the magic happens when you pair it with PRP timing.

If you administer PRP immediately after laser treatment, the growth factors released during the healing phase—VEGF, FGF, PDGF, and TGF-beta—work synergistically with the thermal injury cascade to amplify neocollagenesis. Studies examining PRP timing in fractional laser indicate that immediate application increases type I collagen deposition by approximately 34% compared to laser alone.

Practical Application and Patient Selection

Over the past 18 months at Javan Wellness, we’ve refined a clinical protocol for combination aesthetic rejuvenation that delivers outcomes that surprise patients because they’re more holistic than they expected. Patient satisfaction scores have increased from 82% to 91% across our aesthetic clientele since implementing systematic combination protocols. More importantly, the results look natural—not overdone—because we’re improving underlying skin quality, not just filling lines.

This approach demands more expertise from the practitioner. You need deep anatomic knowledge to understand where volume is truly lost versus where it’s an optical illusion created by lax skin. But that’s precisely why aesthetic medicine, done well, is not a commodity business—it’s a sophisticated medical discipline.

The Business and Clinical Future

Practices that offer only Botox and filler are vulnerable to commoditization. But practices offering sophisticated combination aesthetics with advanced laser technology and evidence-based protocols maintain higher margins, stronger patient loyalty, and the ability to command fees that reflect the true expertise required.

The future of aesthetic medicine isn’t prettier faces from single treatments—it’s genuinely rejuvenated faces from intelligent, biologically-informed combination therapies. That’s what we’re building at Javan Wellness, and it’s what patients increasingly expect.

A Market Opportunity Hiding in Plain Sight

The opioid crisis persists not because we lack effective treatment, but because evidence-based medication-assisted treatment remains criminally under-scaled. In the United States, approximately 2.7 million people have opioid use disorder, yet fewer than 1.2 million receive MAT in any given year. The deficit isn’t treatment efficacy—methadone and buprenorphine have decades of evidence demonstrating 50-70% reduction in illicit drug use and overdose rates. The deficit is access and infrastructure. This is precisely why I became Chairman of Outreach Recovery: addiction treatment represents healthcare’s greatest intersection of clinical necessity and entrepreneurial opportunity.

From a business perspective, the metrics are extraordinary. Medicaid reimburses MAT at rates that support sustainable operational models. Private insurance coverage has expanded significantly with recent regulatory changes mandating parity. And the market dynamics are compelling: patients receiving adequate MAT typically stay in treatment, generating predictable recurring revenue streams unlike episodic care models.

The Clinical Foundation for Scale

Buprenorphine—the medication driving most recent MAT expansion—operates as a partial opioid agonist, maintaining receptor occupancy at 70-80% while producing minimal euphoria and substantially lower overdose risk compared to full opioid agonists. The clinical data is unambiguous: patients maintained on buprenorphine at adequate doses show 50-60% reduction in illicit opioid use and 30-40% reduction in criminogenic behavior. When you couple medication with evidence-based psychosocial interventions—cognitive-behavioral therapy, contingency management, peer recovery support—outcomes improve further.

The regulatory environment has evolved favorably. DEA regulations now permit nurses to prescribe buprenorphine with modest additional training. Telehealth infrastructure allows remote monitoring and prescription management, dramatically expanding access beyond urban centers.

Operational Model Design for Rapid Growth

Building Outreach Recovery taught me the critical distinction between a boutique addiction medicine practice and a scalable MAT platform. The operational architecture I implemented separates clinical decision-making from routine monitoring. Physicians conduct comprehensive intake assessments and manage complex cases. But 70-80% of routine visits are managed by nurses or counselors supervised by physicians. This leverages physician expertise where it’s clinically essential while distributing routine care across mid-level providers, dramatically improving throughput.

Technology amplifies this model. We implemented electronic monitoring for pill-dispensing, randomized toxicology screening protocols, and automated patient communication systems. A physician can now supervise 40-50 MAT patients across multiple sites rather than managing 15-20 in a traditional practice model. That operational leverage is what enables rapid scaling.

Financial modeling confirms the opportunity: At scale, a well-operated MAT program generates 22-28% EBITDA margins when Medicaid comprises 60-70% of payer mix, and 30-35% margins with mixed commercial-Medicaid populations.

The Reimbursement Landscape

Medicaid reimbursement for MAT office visits ranges from $85-$120 per visit depending on state, with additional reimbursement for group therapy and psychosocial interventions. At a conservative estimate, a patient in stable treatment generates $400-$600 monthly in reimbursable services. At scale of 500 patients per program location, monthly revenue approaches $200,000-$300,000 per location.

What makes this economics even more attractive is predictability. Retention rates at high-performing programs exceed 70% annually—meaning patient populations remain stable and revenue forecasting becomes reliable.

The Non-Financial Case

Every patient retained in MAT represents prevented overdose deaths, maintained family relationships, restored employment, and reduced criminal justice involvement. The broader societal impact is profound—addiction disorder costs the United States $300+ billion annually.

But let me be direct: acknowledging the financial opportunity isn’t cynical. Sustainable, growing MAT programs are built by operators who understand metrics, who appreciate operational leverage, and who approach treatment delivery with entrepreneurial discipline. That’s what we’re building at Outreach Recovery, and it’s what I’d recommend to any physician-entrepreneur evaluating their next venture. The opioid crisis will persist until MAT reaches scale. That opportunity is immediate.

For years, the spine world operated in silos. Surgeons handled the operating room; interventional pain physicians handled the fluoroscopy suite. Referral patterns were linear, turf battles were real, and the patient often got caught in between. That era is ending.

At the 2026 Becker's Spine Conference, a striking consensus emerged among industry leaders: the word defining this year is "integration." The most forward-thinking practices are breaking down walls between surgical and interventional disciplines, creating unified care pathways that start with the least invasive option and escalate only when clinically justified.

Why this matters for pain physicians

This convergence isn't a threat to interventional pain — it's a massive opportunity. As evidence mounts that conservative and minimally invasive approaches produce comparable outcomes for many spine conditions, the interventional pain physician becomes the quarterback of the care team, not the backup.

We're also seeing this play out in ASC development. Pain management procedures are increasingly moving to outpatient settings where we control the environment, the patient experience, and the economics. With real-time imaging advances and augmented reality tools now available for percutaneous pedicle screw placement, the technical capabilities in interventional suites are approaching what was once exclusively surgical territory.

What I'm watching

The practices that will thrive are the ones building multidisciplinary teams now — PM&R physicians, interventional pain specialists, orthopedic spine surgeons, physical therapists, and behavioral health providers all under one coordinated umbrella. At Clearway, we've seen firsthand how this model improves outcomes, reduces costs, and drives patient satisfaction.

The question for every pain physician in 2026 is simple: are you building bridges, or are you still guarding your silo?

Patients are already running their doctor's notes through ChatGPT. Hospitals are deploying AI documentation tools that cut charting time in half. Robotic-guided needle placement is achieving sub-millimeter accuracy in spine procedures. The AI revolution in healthcare isn't coming — it's here, and interventional pain is no exception.

The question I hear most from colleagues is: "Will AI replace us?" The answer is unequivocally no. But AI will separate the physicians who leverage it from those who don't.

Where AI is already making an impact

In the procedure suite, AI-powered imaging is allowing us to visualize anatomy in real time with greater precision than traditional fluoroscopy. Robotic arms don't replace the physician's hands — they stabilize and guide them, reducing tissue trauma and radiation exposure for both doctor and patient.

On the administrative side, AI-generated progress notes are on track to be accepted by CMS and major insurers for billing purposes by mid-2026. For a specialty where documentation burden is crushing — physicians spend up to 70% of their time on administrative tasks — this could be transformative. We're talking about reclaiming 15 to 20 hours per week.

The human element remains irreplaceable

What AI cannot do is understand the patient sitting across from you. It can't read the frustration of a construction worker who's been in pain for three years, or calibrate the emotional weight of telling someone their options are narrowing. Pain is inherently subjective, and the physician's ability to interpret that subjectivity alongside objective data is what makes our field both science and art.

My advice to every pain practice: start integrating AI tools into your workflow now. Not because the technology is perfect, but because the learning curve is real, and the practices that build competency today will be the ones leading tomorrow.

Pain management has become one of the fastest-growing targets for private equity investment in healthcare. A JAMA Network Open study revealed that PE-backed groups grew from employing just 0.4% of U.S. pain physicians in 2013 to over 8.2% by 2023. And that number is accelerating.

In January 2026 alone, Resolve Pain Solutions acquired Spine Diagnostic & Pain Treatment Center in Louisiana. KPMG's recent analysis identified Clearway Pain Solutions, National Spine & Pain Centers, and Capitol Pain Institute among the platforms actively expanding through add-on acquisitions. The U.S. pain management market is projected to reach $53.6 billion by 2030.

Why PE loves pain management

The fundamentals are compelling: chronic pain prevalence has risen from 20.4% to 24.3% of the population. The specialty is highly fragmented, with nearly 70% of practices having fewer than 10 providers. And the shift from inpatient to outpatient settings creates margin expansion opportunities that PE firms understand well.

What physicians should consider

If you're a practice owner being approached by PE, understand that you have one shot to choose the right partner. Running a competitive process matters enormously — both for deal economics and for protecting your clinical autonomy post-transaction.

For those already inside a PE-backed platform, the opportunity lies in driving growth through ancillary services, ASC development, and geographic expansion. The physicians who create enterprise value beyond their own production are the ones who benefit most from recapitalization events.

Having navigated this landscape firsthand at Clearway, I can tell you that the key is alignment: finding a partner whose values around physician leadership and patient care match your own. Everything else is negotiable.

Serving as Education Chairman for Maryland's Medical Cannabis Commission for over three years gave me a front-row seat to one of healthcare's most complex regulatory evolutions. We built frameworks from scratch — education standards, provider guidelines, patient safety protocols — in a space where the clinical evidence was still catching up to patient demand.

Now, several years later, the landscape has matured significantly, but the fundamental challenge remains: medical cannabis still lacks the clinical standardization that every other therapeutic modality in medicine takes for granted.

The standardization gap

We can prescribe opioids with precise dosing protocols and well-understood pharmacokinetics. We can titrate anticonvulsants for neuropathic pain with established guidelines. But when it comes to cannabis-based therapies for chronic pain, we're still operating with too much variability — in formulation, dosing, delivery mechanisms, and outcome measurement.

This isn't an argument against medical cannabis. It's an argument for elevating it to the same evidentiary standard we apply to everything else in our toolkit. Patients deserve that rigor.

Where I see opportunity

The states that invested early in robust education and regulatory infrastructure are now best positioned for the next wave: clinical research partnerships, pharmaceutical-grade product development, and integration into multimodal pain management protocols. For physician-entrepreneurs with regulatory experience, the advisory and consulting opportunities in this space are substantial and growing.

The medical aesthetics industry is experiencing explosive growth, and with it, an equally explosive proliferation of unregulated operators. Walk through any major metro area and you'll find storefronts offering injectable treatments, laser procedures, and IV therapies with varying degrees of medical supervision — or none at all.

When my sister Anita and I co-founded Javan Wellness, we built it on a simple premise: advanced aesthetics is medicine, and it should be practiced as such. Licensed professionals, physician oversight, evidence-based protocols, and medical-grade technology aren't differentiators — they're the minimum standard.

The market is self-correcting

As patient education improves and complications from unqualified providers make headlines, the market is beginning to sort itself. Patients are asking better questions: Who is supervising this treatment? What are your credentials? What happens if something goes wrong? The practices that can answer those questions with confidence are winning.

The business case

Physician-led medspas also have a structural advantage in the private equity market. Investors value clinical governance, regulatory compliance, and defensible market positions. A practice with physician leadership, standardized treatment protocols, and a track record of safety commands significantly higher valuations than one built purely on marketing volume.

At Javan, adding advanced technology like the Candela Matrix laser system isn't just a clinical decision — it's a strategic one. Each capability we add deepens our moat and strengthens the case for the physician-led model.

Medication-assisted treatment works. The data is overwhelming: buprenorphine and methadone reduce opioid overdose deaths, improve treatment retention, and support long-term recovery more effectively than abstinence-only approaches. This isn't debatable — it's established science.

And yet, the majority of people with opioid use disorder in the United States still don't have access to MAT. The gap between what the evidence says and what patients can actually receive remains one of the most consequential failures in American healthcare.

Why the gap persists

The barriers are both structural and cultural. On the structural side, there aren't enough providers. Despite regulatory changes making it easier to prescribe buprenorphine, the number of physicians actually doing so remains far below what's needed, particularly in rural areas and underserved communities.

On the cultural side, stigma — both within the medical profession and in society broadly — continues to suppress adoption. Too many treatment programs still operate from ideological frameworks rather than evidence-based ones.

What entrepreneurs can do

This is why I founded Outreach Recovery. The vision wasn't just to provide treatment — it was to build a model that could scale. Evidence-based protocols, compassionate care teams, and operational infrastructure that can be replicated across locations.

Addiction medicine needs more physician-entrepreneurs who are willing to build, not just treat. The clinical evidence is there. The patient need is there. What's been missing is the operational and business sophistication to deliver MAT at the scale the crisis demands.

Every week in my practice, I see patients who have been receiving epidural steroid injections on a recurring schedule — sometimes for years — without anyone having a serious conversation with them about what comes next. Steroids have their place. They are a powerful tool for acute radicular pain, disc herniations with inflammatory components, and diagnostic purposes. But they were never intended to be a long-term management strategy.

The question I get most often from both patients and referring physicians is straightforward: when do you move from steroid injections to radiofrequency ablation?

Understanding the mechanism difference

Epidural steroid injections work by delivering a potent anti-inflammatory directly to the source of irritation — typically an inflamed nerve root. The relief can be dramatic, but it is inherently temporary. You are treating the inflammation, not the underlying pain generator.

Radiofrequency ablation takes a fundamentally different approach. By using thermal energy to create a lesion on the medial branch nerves that transmit pain signals from the facet joints, RFA disrupts the pain pathway itself. The result is often six to eighteen months of significant relief, and in many patients, it is repeatable with consistent outcomes.

My decision framework

I use a fairly structured approach when deciding to escalate. First, if a patient has had two rounds of epidural steroids with only short-lived or diminishing relief, it is time for a different conversation. The evidence does not support unlimited repeat injections, and I believe we owe our patients intellectual honesty about that.

Second, I look at the pain generator. If the clinical picture and imaging point toward facet-mediated pain — axial back or neck pain without a clear radicular component, pain with extension and rotation, tenderness over the facet joints — RFA should be on the table early, not as a last resort.

Third, I consider the patient’s goals. Someone who is active, wants to return to sport, or is losing work productivity deserves a more durable solution than quarterly injections. RFA offers that durability.

The diagnostic block step

Before any RFA, I perform diagnostic medial branch blocks. This is non-negotiable. If a patient gets significant but temporary relief from a medial branch block, it confirms the facet joint as the pain generator and predicts a strong RFA outcome. This step protects both the patient and the physician — you should never ablate a nerve without confirming the diagnosis first.

What I tell my patients

I frame it simply: steroid injections are like applying ice to a bruise. They reduce swelling and make you feel better, but they do not change the underlying condition. RFA is more like flipping a switch — it interrupts the signal that tells your brain to feel pain from that joint. Both have a role, but the goal should always be moving toward the most targeted, durable treatment as efficiently as possible.

If you are a physician still ordering a third or fourth round of epidural steroids for facet-mediated pain, I would encourage you to reconsider the treatment algorithm. Our patients deserve escalation, not repetition.

The conversation around artificial intelligence in medicine has become almost impossible to avoid. Every conference, every trade publication, every investor pitch deck leads with AI. And yet the actual application of AI in the day-to-day pain clinic remains poorly understood by most practicing physicians.

I want to share where I see AI making a real, practical difference right now — and where the hype still outpaces the reality.

Where AI is already working

Imaging analysis and triage. AI-powered tools are getting remarkably good at flagging significant pathology on MRI and CT scans. For a high-volume pain practice, this means faster turnaround on identifying surgical candidates, red-flag conditions, and patients who need immediate intervention versus conservative management. It does not replace the radiologist, but it does help us prioritize.

Prior authorization automation. This is where AI might have the most immediate impact on physician burnout. The prior-auth process in pain management is uniquely punishing — insurers routinely deny first-line interventional procedures, and the appeal cycle consumes hours of staff time. AI systems that can auto-populate clinical documentation, match procedure codes to evidence-based criteria, and generate appeals are already saving practices real money and real time.

Predictive analytics for outcomes. We are beginning to see models that can predict which patients are most likely to respond to specific interventions — spinal cord stimulation, for example — based on a combination of demographic, clinical, and imaging data. This is early-stage, but the potential to reduce trial-and-error treatment is enormous.

Where the hype still exceeds reality

Autonomous diagnosis. No AI system is ready to independently diagnose and develop a treatment plan for a patient with complex chronic pain. Pain is multifactorial — biomechanical, neurological, psychological, social. The clinical interview, the physical exam, the nuance of interpreting imaging in context — these are irreducibly human skills for the foreseeable future.

Robotic-assisted procedures. Surgical robotics in spine are advancing, but for the interventional procedures we do in the pain clinic — needle-based, fluoroscopy-guided, requiring real-time tactile feedback — full autonomy is decades away if it arrives at all. AI may assist with navigation and targeting, but the physician’s hands are not being replaced.

My take

I am a realist about AI, not a skeptic. The practices that embrace these tools thoughtfully — automating the administrative burden, improving diagnostic speed, personalizing treatment selection — will outperform those that do not. But the physicians who abdicate clinical judgment to algorithms will harm patients. The answer, as with most things in medicine, is balance.

Adopt the tools. Automate the tedium. But never stop thinking.

Private equity has transformed the landscape of physician-owned practices. Pain management, anesthesiology, dermatology, ophthalmology, addiction medicine, aesthetics — almost every procedural specialty has seen a wave of consolidation. And the money is real. The multiples being offered to physician-owners are often life-changing.

But I have watched too many colleagues sign deals that looked good on paper and felt terrible eighteen months later. The pattern is almost always the same: the physician is drawn in by the headline number, does not interrogate the structure, and wakes up as an employee of their own practice with diminished autonomy and a management team that does not understand medicine.

The framework I use

When I evaluate a potential PE partnership — whether for one of my own ventures or when advising colleagues — I focus on five things:

1. Clinical autonomy preservation. This is the single most important term in the deal. If you lose the ability to make clinical decisions, hire providers you trust, and control the standard of care in your practice, no amount of money compensates for that. Get it in writing. Get it specific.

2. The management team’s track record in healthcare. Not all PE firms are the same. The ones with healthcare-specific operating partners who have actually built and scaled medical practices are fundamentally different from financial engineers who see your practice as an EBITDA line item. Ask who will be running day-to-day operations. Meet them. Evaluate them the way you would a partner.

3. The equity rollover structure. Most deals require the physician to roll a percentage of proceeds into equity in the new entity. This is where the real wealth creation happens — or does not. Understand the capital structure, the debt load, and the realistic timeline to a second liquidity event. If the firm is loading the platform with debt to finance acquisitions, your rolled equity may be worth less than you think.

4. Non-compete terms. These are often draconian in PE-backed deals. Understand exactly what you are agreeing to: geography, duration, scope. If the deal goes sideways and you want to leave, can you still practice medicine in your market?

5. Cultural alignment. This one is hard to quantify but easy to feel. Does the PE firm understand that healthcare is different from a SaaS company? Do they respect the physician-patient relationship? Are they building for sustainable growth or stripping the practice for a quick flip?

The bottom line

PE capital is not inherently good or bad — it is a tool. The right partnership can accelerate growth, professionalize operations, and give you access to resources you could never build alone. The wrong partnership can destroy what you spent a career building.

Do the diligence. Hire a healthcare M&A attorney. Talk to physicians who have been through the process with that specific firm. And never sign anything out of urgency — the best deals will wait for you to be ready.

Let me start with a confession. Every time I meet someone new and the “so what do you do?” question comes up, I can watch their face do a little calculation. Doctor. Oh. Must be rich. And look, I’m not complaining. I’ve built a good life, I love what I do, and I’d choose medicine again. But somewhere between the white coat and the white-knuckle cost of actually becoming the person wearing it, the financial story we tell young people about this profession stopped being true.

I’ve been thinking about this a lot lately, and not for abstract reasons. I have an 8 year old daughter. She’s starting to ask the big questions. What do you do, Dad? Why do you work so much? Should I be a doctor too? I don’t have a clean answer for her yet, and the honest truth is I’m torn. Part of me wants her to follow this path, because the work is meaningful and the life, despite everything, is good. The other part of me looks at what the next twenty years of medicine actually look like and wonders whether I’m doing her a disservice by pointing her toward a four year college and a healthcare career instead of something with better economics and less institutional punishment baked in.

That tension is the reason I’m writing this.

The pitch for medicine used to be simple. Work your ass off for a decade, come out the other side with job security, respect, and an income that made the sacrifice worth it. In 2026, two of those three still check out. The third is getting quietly gutted every October when CMS drops the new Physician Fee Schedule, and almost nobody outside medicine notices.

The Training Phase: A Financial Death March with Excellent Letterhead

To become a physician in this country, you sign up for a minimum of eleven years of post high school training. Four years of undergrad, four years of med school, and three to seven years of residency and fellowship. For the subspecialty lanes (neurosurgery, interventional cardiology, complex spine, fellowship trained pain), you’re looking at thirteen to fifteen years before you earn a real paycheck. I spent thirteen.

Now the bill. The median four year cost of attendance for the medical school class of 2026 is about $297,745 at a public school and $408,150 at a private school. Average debt at graduation is around $212,000, but that average hides the real story. Roughly 46% of practicing male physicians and 38% of female physicians owe more than $250,000. Federal Grad PLUS loans carry an 8.94% interest rate for the 2025 to 2026 academic year. At that rate, a $200,000 balance paid off over ten years ends up costing you over $303,000 after interest. Congratulations on your new adjustable rate mortgage on a house you can’t live in.

Then comes residency, which is where the real comedy begins. A first year resident in 2026 makes around $67,000 a year working 60 to 80 hours a week. Do that math. That’s a pre tax hourly rate that, in some markets, is straight up lower than what a shift manager at Chipotle is clearing. Except the shift manager gets to go home at night and doesn’t have a quarter million dollars of 8.94% interest compounding on their back like a barnacle of doom.

And the part that really gets me, the part nobody puts on the spreadsheet because it’s invisible, is opportunity cost. While I was eating ketchup sandwiches and drinking Natty Light trying to make rent in med school, my college friends who went into finance, tech, and consulting were stacking 401(k) matches, buying houses, and getting married in backyards they actually owned. By the time the average physician finishes training, they’re in their early thirties, net worth is negative $200,000, and they’re just starting to think about retirement savings their non physician friends have been compounding for eight years.

Meanwhile, the Plumber Is Crushing It

Here’s a comparison nobody wants to make in polite company, so let’s make it anyway.

Take a smart 18 year old who goes to a vocational program to become a plumber or an electrician. Four year apprenticeship, paid while learning, licensed and working independently by age 22. By the time my hypothetical medical counterpart is crawling out of residency at 31, this plumber has been earning a real income for nine years. No student debt. No deferred life. No 80 hour weeks for $67,000.

A journeyman electrician or plumber in 2026 pulls roughly $65,000 to $85,000 starting out. A master tradesman running their own shop routinely clears $150,000 to $300,000 a year. If they plan it right — buy a house at 24, max out a SEP IRA, pick up a rental by 30 — they can build a net worth by their mid forties that would make most attending physicians quietly jealous.

And here’s the kicker. The plumber didn’t miss a single Friday night in their twenties. They weren’t memorizing the Krebs cycle on their birthday. They weren’t scrubbed into a case on their kid’s first Thanksgiving. The lifestyle cost of medicine doesn’t show up in any financial planner’s projection, but it’s real, and you don’t get those years back.

None of this is a knock on the trades. I have massive respect for the people who keep our buildings running. It’s a knock on the myth that medicine is still the obvious financial play. With good planning, a disciplined tradesman who owns their own business can absolutely out earn and out net worth a primary care doc by their late forties. That’s not a joke. That’s just math.

The Reimbursement Reality: Getting Paid in 2001 Dollars

Here’s where it really goes sideways. After you finish training, you finally start practicing. You start billing. And then you discover that Medicare, which sets the reimbursement floor that basically every commercial payor anchors to, pays you roughly the same for a procedure today that it paid in 2001. Literally.

This is not an exaggeration. Adjusted for inflation, Medicare physician payments have declined 33% from 2001 to 2025. Thirty three percent. That is not a rounding error. That is the profession getting financially lobotomized over two decades while every cost input (rent, staff salaries, malpractice, supplies, EMR subscriptions, the cost of the damn printer toner) has gone the other direction.

The really fucking insulting part? Hospitals get an automatic annual inflation adjustment. Physicians do not. Same government, same program, same patients. Hospitals get indexed to inflation by statute. Physicians get whatever Congress feels like giving us, if they feel like it at all, usually as a last minute “fix” tacked onto some unrelated spending bill at 11 p.m. on a Friday in December.

For 2026, Congress passed a one time 2.5% bump through the One Big Beautiful Bill Act. A temporary patch that expires at the end of the year. CMS projects practice costs will grow 2.7% in the same year, so the “raise” doesn’t even cover the increase in overhead. Then CMS finalized a 2.5% “efficiency adjustment” cut applied to about 95% of all physician services, plus a 7% reduction in practice expense for facility based work.

If you’re an office based physician, you’re running as hard as you can just to move backward more slowly than last year.

The Liability Tax Nobody Talks About

Now add the part of the equation that never shows up on a salary comparison website. Liability.

Your friendly neighborhood plumber needs a general liability policy that runs maybe $800 to $2,500 a year. Physicians? Different planet. Depending on your specialty and state, malpractice insurance runs anywhere from $5,000 a year for a low risk cognitive specialty to well over $100,000 a year for OB, neurosurgery, or high acuity interventional work.

By age 65, more than 75% of low risk physicians and over 99% of high risk specialists will have faced a malpractice claim. Not all result in payouts, but every single one eats two to five years of your life, wrecks your sleep, and drags you through depositions and chart reviews on your own time.

And then there’s compliance: HIPAA (penalties up to $1.5 million per violation category per year), Stark Law and Anti Kickback Statute (violations in the millions with criminal exposure), OIG exclusion risk, CMS documentation requirements with RAC audit clawbacks, state medical board reporting, and DEA compliance for controlled substances.

The plumber fixes the leak and invoices the customer. The physician treats the patient, charts in four systems, fights prior auth, documents to CMS audit standard, stays on top of Stark and Anti Kickback, carries a six figure malpractice policy, and prays that a disgruntled patient doesn’t find a plaintiff’s attorney with an appetite. Same hour of work. Very different overhead.

Why I Moved Toward the Business Side

I didn’t set out to become a business guy. I went to medical school to be a doctor, same as everyone else. I did my PM&R residency at SUNY Downstate, my interventional spine fellowship in Birmingham, came home to the DMV, and started practicing. I loved the clinical work and still do.

But at some point, somewhere between my second Medicare rate cut and the tenth time I realized a private equity firm was making more off my RVUs than I was, I had a conversation with myself that I think every physician eventually has, or should.

Your clinical income has a hard ceiling. That ceiling is set by CMS, softened by commercial payors, and it’s moving down in real terms every single year. You can work more hours to earn more money, but your hours are finite and your body isn’t. Linear scaling doesn’t work in this game.

What does scale? Equity. Ownership. Decisions.

That’s the shift. Medicine teaches you to be paid for your hours. Business teaches you to be paid for your decisions. The former is capped by biology. The latter isn’t capped by anything except how good your decisions are.

So I leaned in. I became a partner in Clearway Pain Solutions and took on a Senior VP role in provider relations and business development. I bought into our ASCs, because facility ownership has scaling economics that professional fees never will. I co founded Javan Wellness with my sister because the cash pay, anti aging, and regenerative medicine space operates completely outside the CMS reimbursement swamp. I got involved in commercial real estate. I founded Outreach Recovery to address behavioral health and addiction treatment in a space that desperately needed operators who understood both the clinical and the business sides.

None of this was because I stopped loving clinical medicine. It was because I looked at the math honestly and realized that if I wanted to protect my family, build real wealth, and have any optionality as a physician in 2026 and beyond, I had to stop relying solely on the reimbursement system that was actively devaluing my clinical work. Equity, ownership, partnership, consulting, real estate. Those are the levers that actually compound. Clinical income is the base. It’s not the game.

The Part That Still Matters

I’ve spent this whole piece talking about dollars, and I want to be clear about something before I close it out. I did not become a physician for the money. Almost none of us did.

You don’t sit through organic chemistry, MCATs, third year rotations, and 80 hour resident work weeks because you ran the comp spreadsheet and it was the optimal career path. You do it because something in you wants to take care of people. You do it because the first time you walked into a hospital as a medical student and watched an attending pull a patient back from the edge of something terrible, you thought that’s what I want to do with my life.

It is, genuinely, a privilege to take care of patients. Every time a patient walks back into my office and tells me they’re moving better, sleeping better, living better, I remember why I did all of this. Those are the real compensation of this job, and they don’t show up on any CMS fee schedule.

My frustration with the financial side of medicine isn’t because I think doctors should be the highest paid people in the country. It’s because the system is structured in a way that makes it harder and harder for doctors to keep doing the work we love without breaking ourselves financially, mentally, and emotionally. The critique in this piece is a critique of the system, not of the calling. The calling is still worth answering. It’s the economic scaffolding around the calling that needs fixing.

So What Do I Tell My Daughter?

I keep coming back to that question, and I don’t think there’s a single right answer.

If she tells me at 18 that she wants to be a physician because she wants to take care of people, I’m going to support her. Of course I am. There is nothing in this piece that says medicine isn’t worth it. It is. It’s just not the no brainer financial decision it used to be, and any parent who pretends otherwise isn’t being honest with their kid.

What I will do is make sure she understands the full picture before she signs up. I’ll make sure she knows what thirteen years of training actually costs, in dollars and in time. I’ll make sure she understands that the reimbursement environment is getting worse, not better. And I’ll make sure she understands that if she does choose medicine, she needs to learn the business side early, because the people who own the healthcare infrastructure are going to keep eating the lunch of the people who just work inside it.

Do it because you love it. Do it because you can’t imagine doing anything else, because there’s nothing quite like the moment a patient walks out of your office better than they walked in.

But don’t do it because you think it’s the obvious financial play anymore. It isn’t. Not without a plan.

And if you do become a physician, do yourself a favor. Learn the business side early. Learn what equity is. Learn what ownership is. Learn the difference between being paid for your hours and being paid for your decisions. Build income streams that don’t depend on a CMS conversion factor and a prior authorization clerk at Aetna. Own the building. Own the practice. Own a piece of the facility. Get a stake in the thing you’re already helping to build value in.

The plumber knew this at 22. The physician usually figures it out in their forties, if at all.

You don’t have to wait that long. And neither does my daughter.

Medical Cannabis

The Dumbest Smart Thing Maryland Ever Did: A Cannabis Love Story

April 28, 2026 • 5 min read

Picture this: it's 1999, and a Republican state delegate in Maryland, a law-and-order, tough-on-crime, Reagan-portrait-on-the-wall type, is sitting in his office when a dying veteran walks in and basically says, "Hey man, I have cancer, I'm out of options, and the only thing that helps me eat is illegal. Can you do something about that?"

That delegate was Don Murphy. The veteran was Darrell Putman. And that conversation, not some grand political strategy, not a lobbyist's PowerPoint deck, just a sick dude asking for help, kicked off Maryland's entire cannabis journey.

Murphy went home, apparently had a "what the fuck am I doing with my career" moment, and introduced Maryland's first medical cannabis bill. In 2003, Governor Ehrlich signed the Darrell Putman Compassionate Use Act. And look, "Compassionate Use Act" sounds impressive until you read what it actually did: if you got busted with under an ounce and could prove you were using it for a medical condition, your fine was capped at a hundred bucks. That's it. That was the whole thing. A parking ticket with extra steps.

But here's what nobody expected: that little hundred-dollar speed bump turned into a highway.

The World's Slowest Revolution

Maryland didn't exactly sprint into the cannabis future. They more... ambled. Like a state government going through a Costco on a Saturday.

2011: Legislature finally removes the criminal penalty. Only took eight years. Progress!

2013: They create an actual commission, the Natalie M. LaPrade Medical Cannabis Commission, to build a real regulated program with growers, processors, and dispensaries.

2017: First dispensary finally opens. Four years after passing the law. I've seen hip replacements heal faster than Maryland's regulatory process.

I was on that Cannabis Commission, by the way. And I'll be honest with you: building a state medical cannabis program from scratch is the bureaucratic equivalent of performing open-heart surgery while the patient is arguing with you about their insurance. You've got public health people wanting more restrictions, business people wanting fewer, patients just wanting their damn medicine, and the federal government in the corner pretending the whole thing isn't happening because it's still technically Schedule I. It was chaos. Beautiful, important, soul-crushing chaos.

Show Me the Money (Spoiler: It's a Shitload of Money)

OK let's talk about the part that makes politicians' eyes do that little cartoon dollar-sign thing.

In 2022, Maryland put recreational cannabis on the ballot. 67% of voters said yes. Sixty-seven percent. In a state that can't agree on literally anything else, two-thirds of the population looked at legal weed and said, "Yeah, obviously."

Sales launched July 2023. First full fiscal year? $1.1 billion in revenue. Billion. With a B. In a state with fewer people than the New York City subway system moves on a Tuesday.

By 2025, annual sales hit $1.16 billion. Tax revenue crossed $100 million. The state bumped the tax rate from 9% to 12% and between July and September 2025 alone, Maryland banked $26.8 million in cannabis tax, most of it from the Baltimore metro area, because of course it was.

That money goes to the General Fund, a Community Reinvestment and Repair Fund, county allocations, a public health fund, and a social equity business assistance fund. In other words, legal weed is now funding schools, roads, and programs to help communities that got destroyed by the War on Drugs. If that irony doesn't make you laugh, or cry, I don't know what will.

But Does It Actually Help People? (Asking as a Doctor, Not a Politician)

Here's where I switch from "guy who's entertained by government absurdity" to "physician who actually gives a shit about patient outcomes."

At its peak, Maryland's medical program had over 140,000 registered patients. These weren't college kids trying to get a card so they could buy gummies legally. These were chronic pain patients, cancer patients, PTSD patients, people with seizure disorders. People who'd been buying unregulated product from God-knows-who and were finally able to walk into a licensed dispensary and get something that was actually tested and labeled correctly.

Since recreational went live, the medical patient count dropped about 38%, down to around 87,000. Makes sense. If you can just walk in and buy it without a card, why bother with the medical program? But the patients who stay in the medical program are the ones who really need it. They get the tax break (medical cannabis is exempt from sales tax, and that's real money if you're a chronic pain patient buying regularly), access to higher-potency products, and most importantly, they maintain a relationship with a provider who actually knows what else they're taking.

That last part matters more than people realize. I see patients at Clearway Pain Solutions who are on gabapentin, muscle relaxants, maybe an SSRI, and they're also using cannabis. Cool, but I need to know about it. Drug interactions are a thing. Dosing matters. "I dunno, I just eat a gummy before bed" is not a treatment plan, it's a vibe. Maryland's medical program structure forces that conversation to happen, and that's genuinely good medicine.

Where Maryland Screwed Up (Because of Course They Did)

Look, it's not all billion-dollar high-fives. Maryland issued only 108 dispensary licenses for 4.7 million adults. That's the same ratio as California and Illinois, two states famous for having their legal markets get absolutely bodied by the black market. Legal cannabis is only capturing about 49% of total demand in Maryland right now. Half the state's weed consumers are still buying from their guy. That's not a policy success, that's a participation trophy.

Social equity is another mess. The Community Reinvestment Fund sounds great in press releases, but try actually opening a dispensary if you're from one of the communities that got hammered by prohibition. The capital requirements and regulatory complexity are insane. We built a program that was supposed to help the people most affected by the drug war, and then made the barrier to entry high enough that most of them can't get through the door. Classic government move.

The Point of All This

Here's the thing though. For all its stumbling, Maryland actually proved something important. You can go from "weed will destroy society" to a billion-dollar regulated industry without civilization collapsing. Crime didn't spike. Public health didn't crater. Teenagers didn't suddenly become more likely to use cannabis (the data actually shows youth use has been flat or declining in legalized states).

What did happen is that patients got safe access to medicine, the state got a massive new revenue stream, and communities started getting reinvestment dollars, however imperfectly distributed. For a journey that started with a dying veteran and a hundred-dollar fine, that's a pretty remarkable outcome.

And Darrell Putman? He probably had no idea he was lighting the fuse on a billion-dollar industry when he walked into Don Murphy's office. He just wanted to eat dinner without puking. Sometimes the biggest changes start with the smallest, most human ask.

That's what good policy looks like when you strip away the bullshit. Someone says "I need help." And eventually, sometimes way too slowly, the system actually helps.

Dr. Ehsan Abdeshahian is a physician-executive, former Maryland Medical Cannabis Commissioner, and partner at Clearway Pain Solutions, founder of Rubrica Medical, and co-founder of Javan Wellness and Outreach Recovery. He writes about pain management, healthcare business, and what actually happens when medicine and politics collide, which is usually a mess, but occasionally something useful.

Aesthetic Medicine

The GLP-1 Wars Just Went Nuclear: Foundayo, Retatrutide, and Why Your Aesthetics Practice Won't Look the Same in 18 Months

May 9, 2026 • 6 min read

If you blinked in April, you missed the moment the entire weight loss industry quietly ate itself. The FDA approved Foundayo, Eli Lilly's oral GLP-1 pill, in 50 days. Fifty days. That's faster than most people get their prior authorization for a back MRI. It's the fastest new molecular entity approval since 2002. And it slid through under the new National Priority Voucher pilot program, which is basically the FDA equivalent of saying "fine, take the express lane, we trust you."

Translation: a once-daily pill that you can swallow whenever you want, with or without food, with or without water, no weird thirty-minute timer like the old oral semaglutide, just hit it like a multivitamin and walk on with your day. And the average weight loss on the high dose? Twelve percent over 72 weeks. Insurance copay can drop to twenty five bucks a month with the savings card. Lilly is shipping it directly to your house from LillyDirect. The pharmaceutical industry just turned weight loss into Amazon Prime.

But Foundayo is just the appetizer. The actual main course is retatrutide. And friends, retatrutide is coming for everything.

What the Hell Is Retatrutide?

Retatrutide is what happens when Eli Lilly's chemists decide subtlety is for cowards. It hits three receptors at once: GLP-1, GIP, and glucagon. Semaglutide hits one. Tirzepatide hits two. Retatrutide hits three. It's the metabolic equivalent of a triple espresso, except instead of caffeine it's mainlining the hormones that tell your body to stop eating, burn fat, and improve insulin sensitivity all at the same time.

The Phase 3 TRIUMPH-4 readout that came out earlier this year showed an average weight loss of 71.2 pounds on the 12 mg dose over 68 weeks. Not 71 pounds at the top end. Seventy one pounds on average. That is roughly a quarter of body weight evaporating off a person, which makes Wegovy and Zepbound look like a brisk walk around the block.

Lilly is filing the NDA later this year, so realistically we are looking at FDA approval somewhere in 2027. That gives the rest of us about eighteen months to get our shit together before the floor falls out of the entire weight loss market a second time.

Why This Matters For Aesthetics (And Why Most Practices Are Sleepwalking Into a Wall)

Here is the part nobody in aesthetic medicine wants to hear out loud: GLP-1s are no longer a separate market that lives over in endocrinology and primary care. They are your market now. Your filler patient is on semaglutide. Your laser patient is on tirzepatide. Your "I just want a little tox between the brows" patient lost forty pounds last year and now has a face that looks like it deflated.

Ozempic face was the canary in the coal mine. Foundayo and retatrutide are the entire flock. When you can lose a quarter of your body weight on a pill that costs less than your Spotify subscription, the downstream demand for everything aesthetic medicine sells, volume restoration, skin tightening, body contouring of the loose tissue left behind, absolutely explodes.

The medspas that are going to win the next two years aren't the ones running another tox special on Instagram. They're the ones who:

1. Build a real GLP-1 program in-house. Not a "we sell compounded semaglutide for $199" gas station vibe. A real, physician-supervised, nutrition-backed, lab-monitored program that owns the patient's transformation arc. If you don't, the telehealth GLP-1 mills will, and they'll keep your aesthetic patient downstream too.

2. Reposition aesthetics as the Phase 2 of weight loss. The patient lost the weight. Now they need their face back, their arms back, their chest back. This is the highest-intent, highest-LTV aesthetic patient on planet Earth, and most practices are still pitching them a Hydrafacial.

3. Stop charging for products and start charging for outcomes. The minute Foundayo hits LillyDirect at $25 a month with no friction, the entire margin in "we sell you a compounded GLP-1" disappears. The margin moves to clinical oversight, body composition tracking, sequencing combination treatments, and aftercare. That's a service business. Most medspas are still running a retail business. Guess which one survives.

The Part Nobody Is Saying Out Loud

Here is my actual hot take, and I'll say it as a physician executive who runs a medspa, sits on the board of an addiction recovery company, and watches all of this from inside the machine: GLP-1s are about to do to obesity medicine what statins did to cardiology. They are going to become so cheap, so accessible, and so effective that within five years, treating obesity with diet-and-exercise as a first line will look as quaint as bloodletting.

Retatrutide, in particular, is going to be a watershed. A drug that produces 24% body weight loss with substantial improvements in osteoarthritis pain, A1C, blood pressure, and cardiovascular risk is not a weight loss drug. It's a metabolic disease drug. Pain physicians, orthopedists, cardiologists, hepatologists, psychiatrists, all of us are going to be prescribing this thing for indications we haven't even imagined yet.

And if you're running an aesthetics, addiction, or pain practice and your strategic plan for 2027 doesn't have the word "GLP-1" in it somewhere, you don't have a strategic plan. You have a wish.

What I'm Actually Doing About It

At Javan Wellness, we've been integrating GLP-1 management into our aesthetic patient pathway for about a year. The unlock isn't the drug, it's the wraparound. Real labs. Real body comp scans. Real visits with a physician, not a chatbot. The drug is the cheap part. The clinical infrastructure around it is what patients will pay for, and it's what keeps the outcomes durable instead of yo-yo nightmares.

If you're a physician owner staring at this market wondering whether to lean in or sit it out, I'd offer one piece of advice: don't try to compete with LillyDirect on price. You'll lose. Compete on what an algorithm and a mailbox can never do, which is judgment, sequencing, and accountability.

Foundayo just rewrote the access story. Retatrutide is about to rewrite the efficacy story. The practices that figure out how to ride both waves instead of getting wiped out by them are going to look back on 2026 the same way Amazon looked back on 1999. Ridiculously well positioned, slightly out of breath, and laughing at everyone who didn't see it coming.

Dr. Ehsan Abdeshahian is a physician-executive based in Washington, DC. He is Partner and SVP of Provider Relations at Clearway Pain Solutions, Co-Founder and Medical Director of Javan Wellness, and Chairman of the Board at Outreach Recovery. He writes about pain, business, and the messy intersection of medicine and money.