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.