I just watched The Backrooms and now I can't stop thinking about hospital liminal spaces. The basement. The pathology lab. The OR at 2 AM when you're going in for an open globe. We start there.

Then a great Spotify question pulls me into ophthalmology boards, what the written test is like, the oral exam I took inside an examiner's actual hotel room (with their luggage in the corner) during a hotel workers' strike in San Francisco, the $2,000 fee, and why the whole recertification industry feels like a money grab. Also a quick rant about why physicians start their careers $400K in the hole and a decade behind everyone else.

The main event is a tale of two health systems. You already know PeaceHealth in Eugene, where the emergency physicians fought back, used Oregon's corporate practice of medicine law, and took it to court. Now meet Valley Health in Virginia's Shenandoah Valley, where CEO Mark Nance just cancelled the contract for EMBER (Emergency Medicine of Blue Ridge) and handed it to SCP Healthm a private equity outfit backed by Canada's Onex Corporation. Same Apollo MD playbook. Same damage. But Virginia has no corporate practice of medicine law, no physician union, and no nurses' union, and Valley Health is flush with cash while blaming Medicaid cuts. I'm fed up, and I'm going to keep making this content as long as people keep sending it to me.

Takeaways:

Valley Health in Virginia's Shenandoah Valley cancelled its 20-plus-year contract with EMBER (Emergency Medicine of Blue Ridge) and handed it to SCP Health, a private equity-backed corporation owned by Canada's Onex Corporation, mirroring the Apollo MD/PeaceHealth situation in Eugene

Despite blaming Medicaid cuts from the "Big Beautiful Bill," Valley Health holds over $1 billion in assets, $700 million in cash reserves, and reported $100 million in net profit in 2024 and continues to build new facilities

Valley Health has also forced out Front Royal Family Practice under CEO Mark Nance, revealing a broader pattern of consolidating independent groups and eliminating physician autonomy

Virginia has no corporate practice of medicine law, no physician union, and no nurses' union, leaving healthcare workers without the legal and organizational protections that allowed the Eugene physicians to fight back successfully

Ophthalmology board recertification, board exam fees, and roughly $400K in training debt mean most physicians don't start meaningful earnings until age 31 or later, a financial reality often missing from broader debates about physician pay

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