Would I Tell My Kids to Go Into Palliative Care?

The Palliative Lens

By Andrew Esch, MD

I love being a physician. I love palliative care. Let me say that first, because everything that follows only makes sense if you understand that.

This field has given me the most meaningful professional moments of my life, sitting with families in impossible moments, helping patients reclaim control over their story, and reminding medicine what it is supposed to be about: people.

Yet, when my twins, now third-year medical students, asked me if they should follow me into palliative care, I answered, "It’s complicated, but no.”

Not because the work isn’t sacred, because the system surrounding it is increasingly broken.

This is not nihilism. This is what honesty sounds like when you love a field enough to want it to survive. If we want the future of palliative care to be strong, we have to start telling the truth about the forces shaping it, even the parts that make us uncomfortable.

The Financial Reality: Passion Doesn’t Pay Loans

Let’s start with numbers, because today’s trainees don’t have the luxury of ignoring them.

Current workforce and education data show that the average U.S. medical student graduates with roughly $225K–$250K in student loan debt, often at 7–9% interest (AAMC, federal loan rate data, recent workforce finance analyses). Over a standard repayment timeline, that commonly becomes $350K–$400K in total repayment.

Four hundred thousand dollars.

For the privilege of entering a profession that will then ask you to delay earning, delay saving, and delay financial stability.

Meanwhile, compensation data across multiple salary databases place palliative care physician compensation generally in the mid-$200K range:

• ~$240K average compensation (national compensation datasets)

• ~$260K+ average base salary (job-posting aggregation data)

I’ll be honest those numbers feel generous compared to what many clinicians actually experience in employed models.

Compare that to procedural and some subspecialty cognitive fields that often earn substantially more. In real-world terms, many of my classmates in anesthesia, surgery, and other specialties out-earn palliative care physicians by large margins, sometimes multiples, while working similar hours.

That lifetime delta isn’t abstract.

o   That is retirement timing

o   That is college funds

o   That is financial freedom

If you are graduating today and staring at:

• 10–15 years of training

• Delayed retirement investing

• High loan burden

• Lower lifetime earning curve

…it is rational to ask hard questions.

I did and I still chose palliative care, but I trained in a different era than today’s students.

The Corporatization Problem: Medicine Is Becoming Employment, Not a Profession

When I trained, independent practice was still a viable identity. Today in many markets, it’s effectively gone. National physician workforce data show:

• Private practice dropped from ~60% (2012) to ~42% (2024) (AMA workforce tracking)

• Hospital-owned practice and direct employment continue to rise

• Private equity involvement continues expanding in physician practices

This trend is accelerating.

Why does this matter for palliative care? Because our field runs on things the payment system struggles to measure:

o   Time

o   Relationship

o   Trust

o   Team-based care

o   Decision support

o   Longitudinal presence

While corporate medicine rewards:

o   Throughput

o   Margin

o   Productivity metrics

o   Standardization

Those are not neutral differences. Those are philosophical differences. Palliative care often depends (outside of some value-based or integrated models) on deficit funding. Deficit funding usually means employment. Employment usually means less leverage. 

And now we are seeing, increasingly:

o   Non-competes

o   Non-solicits

o   Broad NDAs

In hospice and palliative care!!!  In a field built on patient autonomy and choice???

Let that sink in.

Satisfaction and Burnout: The Complicated Truth

Here is the paradox. Palliative clinicians often love their day-to-day work but system stress is everywhere in medicine. Recent national survey data consistently show ~40–50% of physicians report burnout symptoms (AMA, Medscape, and other workforce surveys).

Palliative care adds something additional:

o   Moral distress

o   Daily exposure to suffering

o   Fighting systems to align care with patient goals

You can love your work deeply…and still feel trapped inside the system delivering it.

Many of us live in that tension.

The Truth I Told My Kids

Here’s the sentence I actually said to them: Pick a specialty that gives you leverage.

Leverage to:

o   Achieve financial freedom ASAP (only two ways to do that: less loans or do a specialty that pays more competitively)

o   Control your schedule

o   Leave bad systems

o   Build something new

o   Practice medicine on your own terms

Because medicine is shifting from:

Profession → Workforce

Autonomy → Employment

Calling → Productivity metric

Pretending otherwise is unfair to trainees.

Final Answer: Would I Tell My Kids to Do What I Did?

No.

Would I be proud if they did anyway? Absolutely.  

Because palliative care is still one of the few places in medicine where humanity reliably wins, even if the system doesn’t reward it.

Why Do I Stay?

Because when palliative care works, it is the best job in medicine. The intrinsic reward is enormous, but intrinsic reward does not pay Sallie Mae and it does not protect you from corporate decision-making.

Unless you truly cannot imagine doing anything else, meaning alone is not enough to sustain a 30-year career in this system.

What Clinicians Can Do Right Now to Protect the Future of Palliative Care and Make It More Attractive

If we want this field to exist, not just be admired, we need to change how we behave collectively.

1. Stop Signing Restrictive Contracts

Non-competes, overly broad NDAs, and non-solicits suppress wages, limit mobility, and reduce leverage in a field that is already workforce constrained.

Palliative care is already:

• Undersupplied

• Underpaid relative to training

• Structurally dependent on employers

Signing restrictive contracts locks that imbalance in place.

2. Start Saying No to Unsustainable Practice Models

• Unsafe consult volumes

• Impossible outpatient panels

• Productivity expectations incompatible with relationship-based care

When we normalize unsustainable workloads, systems scale them.

3. Don’t Be Afraid to Move

Mobility is one of the strongest drivers of compensation, working conditions, and program investment in modern healthcare labor markets. If palliative clinicians want the field to thrive mission alone will not recruit the next generation, structure will

Let’s all start to act like scarce, highly trained experts, not replaceable mission labor.

Because we are not, and the future of the field depends on it.

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