Who’s in the Room
Two years ago, Urology of Virginia was in trouble.
We’d shrunk from over thirty urologists to roughly half that. Post-COVID instability, retirements, financial pressure. Private equity was circling. A significant chunk of the partnership was seriously considering selling. And I couldn’t tell you, with any confidence, whether the practice would hold together.
Today we have over twenty-five urologists. Nine new hires in two years. Zero debt. This year was a strong year. No outside investors. No capital infusion. Just good people who cared enough to rebuild something that belonged to them.
This is the story of how that happened, and what I think it means for anyone deciding where to spend the next thirty years of their career.
The PE Question
I want to talk about private equity openly, because many of you will face this decision, and the conversation deserves more honesty than it usually gets.
The pitch is always some version of: We won’t touch your clinical decisions. You’ll still run the practice. We’re just a capital partner.Here’s what actually happens.
The physicians present at the time of the deal get a big payout. Enough to make you stop and consider it, even when you sense in your bones it’s not right for the practice long-term. There’s a cognitive dissonance: you’ve put in your sweat equity, the number is real, and nobody in that internal conversation is saying this is good for the future of the group.That’s the dissonance.
In exchange, a meaningful percentage of earnings now flows to the PE firm — permanently. The partners who took the payout can work five more years and leave. They got their money.
Now consider the new graduate you’re trying to recruit. She didn’t get the payout. She’s walking into the same overhead, the same expectations, and a structural deficit baked into every dollar. She looks at the partners who were there for the deal and understandably wonders why the arrangement is equitable. I’ve called it a Ponzi scheme. That may be too strong, but the architecture is similar: early participants benefit at the expense of later ones, and the model depends on speculative growth to paper over the gap.
And here’s the core mismatch — PE is offering a financial solution to a human-resource problem. Capital doesn’t train urologists. You can’t buy more of us. The median age of practicing urologists is in the late fifties. Over sixty percent of U.S. counties lack a single one. Only 385 residency positions were available for the 2025 match. The pipeline cannot keep pace with retirements, let alone rising demand. PE’s growth model breaks when the rate-limiting step is a human being who spent thirteen years in training.
The indirect pressure is real, too. They may not directly meddle with clinical decisions. But when there’s a vice grip on the practice to produce, and resources are constrained, the pressure is there whether it’s spoken or not. One more patient. Faster. Faster. You start to feel less like a physician and more like a number on a spreadsheet. Meanwhile, the parent company answers to private investors whose identities you may never know, and who have no obligation to your patients or to you.
The Three Tensions
I don’t want to be naive about the economics of medicine. I sit on our board. I feel the tension between patient care and profitability every single day.
But I’ve come to believe that the tension itself is the point.
In our boardroom, every significant decision runs through three questions: What’s best for the patient? What keeps the physicians, APPs, and employees — the people who make this thing exist — fulfilled and sustainable? And can we make money doing those two things so the company stays alive?
If you can align those three without too much compromise from any one, you have something real. There’s no simple formula. A lot of what’s good for the patient isn’t reimbursed well. A lot of what’s good for doctors cuts into revenue. The work is finding that balance, honestly and transparently.
In a physician-owned practice, that’s the conversation. Imperfect, but real. In a PE-backed practice, the voice above the room is profit — not because anyone is a bad person, but because that’s the structural reality of what private equity is. Its fiduciary obligation runs to its investors, not to your patients.
Who’s in the room matters.
Rising
Our practice went through a two-year process with PE and said no by a nearly unanimous vote. It was a mature deliberation — we gave it a fair shake, met with the groups, had difficult conversations. The conclusion was that independence gave us more agility, more control over our happiness as providers, and the ability to do what we believed was right for our patients.
Then came the hard part. We shrank. There was real uncertainty. But something interesting happens when you think you’re at the bottom: you’re often about to go up.
The contraction forced us to innovate. We built pathway-driven care models — stone pathways, BPH pathways, overactive bladder pathways — where APPs initiate the workup and guide patients through an algorithm, getting them to the right surgeon at the right time. We built a lecture series, created educational resources, developed AI tools on top of our own content so APPs had faster access to knowledge at the point of care.
And then we recruited. Nine new urologists in two years. We took no bonuses for a year to pay down debt. Came into the next year at zero. Made smart investments, executed well. Because we cared. Because it’s ours.
What I Learned at the Dinner Table
I should tell you where I come from, because it shapes everything I’ve said.
I’m a fifth-generation physician. My parents were both trained in the Soviet Union, where they practiced for nearly thirty years. They emigrated to America, repeated their residencies, rebuilt from nothing, and practiced here for another thirty years. I don’t think many people can offer a more complete comparative perspective on communist versus capitalist medicine.
My mother once shared a framework I’ve never forgotten. She said roughly a third of people are naturally hard workers — put them anywhere and they’ll do their best. Another third are driven by incentives — the more they’re rewarded, the more they produce. And the final third will do the minimum regardless.
If you accept that even loosely, the math of why the Soviet Union failed and America thrived becomes intuitive. In a system with no incentive differentiation, you capture only the intrinsically driven third. Add meaningful incentives and you capture two-thirds. It’s rough math. Economists would poke holes. But as the lived experience of a family that practiced under both systems, it rings true.
I share this because it informs how I think about practice structure — and because I think we’ve actually landed on something at Urology of Virginia that captures the best of both systems.
We run a capitalist business. There is a spreadsheet. There is accountability. But you are more than a spreadsheet. We row together because we know we’re stronger together, and because we’ve seen what happens in medicine when everybody is just getting after it for themselves — weird outcomes. Perverse incentives produce perverse results. At the same time, we’re not an authoritarian state holding you in line. It’s simpler than that: we’ve built a structure where doing good work, together, is what gets rewarded.
PE captures the incentive-driven third but alienates the intrinsically driven — the ones who came to medicine because it’s who they are. Pure socialism captures the missionaries but loses everyone else. What we have is a small, independent group that borrows the best elements of both: the fulfillment of a shared mission, and enough individual accountability that no one is coasting. “Socialist” is usually a dirty word in America, and I get it. But the impulse behind it — that we owe something to each other, that we’re building something collectively — is not a bad impulse. It just needs to be paired with ownership and incentive, or it collapses.
That’s what we have. It’s ours. We care for it differently because of that.
The Room Today
The Harvard Study of Adult Development has followed people for over eighty-five years. The conclusion, after nearly a century of brain scans, blood work, and thousands of interviews, is disarmingly simple: good relationships keep us healthier and happier. Not wealth. Not prestige. Not publications. Relationships.
That’s probably a good place to start when you’re thinking about where to spend the next thirty years of your career. The people you work with are people you spend an enormous portion of your waking life alongside. If those relationships are built on a common mission — a genuine alignment on what you’re trying to accomplish and why — then the hard days become tolerable.
In our room today, it’s the physicians and a handful of long-tenured administrators who know this group and care about it. The conversation is always the same three questions. What’s right for the patient. What keeps the physician’s life reasonable and fulfilling. And can we sustain a business doing those two things.
The path to get here was hard. The PE deliberation, the contraction, the uncertainty. But those hard things are precisely what made it meaningful. I went into medicine because I care about people, I want to challenge myself, and I want to do hard things. Urology of Virginia has given me that opportunity.
Find the right people. Look at who’s in the room. The rest follows.
Well said Ilya!