The Young Physician Trap

Trading Autonomy for Salary

Medical training is grueling. But during that final year, something changes.
You start interviewing for jobs and for the first time in your adult life, people treat you well.

Health systems wine and dine you. They smile. They tell you how valued you are. Most importantly, they put salary numbers on paper that, compared to a resident’s paycheck, feel like winning the lottery. Then they sweeten the deal: student loan forgiveness, generous benefits, and at some large academic centers, even a special low-interest mortgage for your first home.

After a decade of delayed gratification, it finally feels like the payoff has arrived.

Meanwhile, you interview at a private practice. They can’t match the salary. They certainly can’t offer loan forgiveness. Instead, they talk about building equity, running a business, and slowly developing a patient base.

That’s not what you signed up for. So you take the employed job.

For a few years, it works. You don’t have to build a practice from scratch. Referral streams already exist thanks to the vertically integrated system. The hospital puts you on committees so you feel like part of the team. You’re salaried, insulated, and reassured that you made the “smart” choice.

Then the protected salary period ends.

Your compensation flips to productivity-based pay. Suddenly your income depends on chasing RVUs at a pace that would be aggressive even in a perfectly functioning system. You start learning every CPT loophole. You optimize documentation. You sacrifice weekends and evenings not to care for patients better, but to squeeze out marginal RVUs.

There’s no time for committees anymore. There’s barely time for a home life. Nights are spent finishing notes. If you’re surgeon, you stay late to cram in one more case.

And then comes the pay cut. It’s framed as “efficiency.” Or “underperformance.” The implication is clear: you’re the problem.

By now, the hospital knows they have you.

You bought a home. You structured your life around the salary they dangled. Maybe you counted on loan forgiveness. There might be a non-compete at play. Maybe your spouse’s career is tied to the area. Leaving suddenly isn’t easy.

At the same time, the system begins placing obstacles directly in the path of your productivity.

You’re forced to use an inefficient EHR that doubles documentation time. Clinic support is thin. If you’re a surgeon, the frustration is even worse. You know you could double your output but the operating room can’t turn over in less than three hours. Cases start late. Staff disappears. You operate into the night, not because the work is complex, but because the system is dysfunctional.

None of this counts when RVUs are tallied.

You are, after all, just an employee.

You haven’t built a brand. Patients come to the logo on the building, not the name on your white coat. If you leave, the hospital keeps the referrals, the goodwill, and the market share.

Every year brings more initiatives. More mandatory trainings. More metrics. More performance expectations designed by people who have never taken call, never sat with a dying patient, and never borne the consequences of a medical decision.

And at the bottom of that cliff sits the physician who thought they were choosing safety, not realizing they were signing up for a career where nurse managers, quality officers, and compliance committees dictate the conditions of their professional life.

Meanwhile, training is getting longer. Gap years are now routine. Extended fellowships are common. Many specialists don’t start their first real job until their late 30s. That delay massively increases employer leverage.

Hospitals understand this perfectly. They need a steady pipeline of new doctors willing to trade autonomy for short-term security.

Physicians used to own their profession. They built practices, equity, and reputations. They set schedules, standards, and tone of care. They built wealth not by gaming RVUs, but by serving patients and running businesses that made sense. That ownership mattered for both doctors and patients, containing bureaucracy and forcing administrators to justify themselves.

In the long run, that private practice job would have been more lucrative, too. The established private practice doctor has equity in a business. They may own part of a surgery center or imaging center. Their personal brand has value.

Employment is not always bad. Someone who wants to work at an inner city trauma center benefits from the structure of employment. Yet, all doctors, employed or not, need a thriving private practice ecosystem with solo practices, group practices, specialty-specific models, ASCs, hybrid structures, and cash-friendly care. The persistence of that ecosystem forces hospitals to treat physicians as partners rather than disposable RVU generators. Market forces reassert themselves. Physician labor regains bargaining power.

This is why policies that protect private practice matter for all physicians even those who never plan to leave employment. Things like site of service differential, 340B distortions, certificate of need laws, Stark Law, and tax advantages put independent private practice at a disadvantage over large consolidated systems. They make private practice harder to sustain and by doing so, they make life worse for doctors and patients alike.

And until physicians recognize this trap for what it is, and insist on alternatives, the system will keep doing exactly what it was designed to do.