Cut & Tell

How Do Doctors ACTUALLY Get Paid? What Doctors and Residents Need to Know

How does a doctor's visit actually turn into a paycheck? It's more convoluted than how a bill becomes a law — and almost nobody, including most doctors, understands it. In this episode of Cut and Tell, Dr. Liz Malphrus (plastic surgeon, Philadelphia) breaks down the claims-based payment system that runs American healthcare: the five data points that determine every dollar a doctor is paid, why a "clearinghouse" still charges $1 per claim in 2026, and how a shadowy 32-person AMA committee called the RUC quietly decides what your appendectomy is worth. We also go back to 1929 to trace how we ended up with employer-based health insurance in the first place — starting with a Baylor University hospital administrator, a group of Dallas schoolteachers, an FDR-era wage freeze, and a 1954 tax law that changed everything. WHAT WE COVER • What's actually in a medical claim (just 5 data points — no clinical detail) • ICD-10 vs. CPT codes, explained simply • Why 10–20% of claims get denied on the first pass • The clearinghouse "middleman" nobody can explain the value of • The AMA's CPT copyright and why it's worth $285M/year to them • RVUs: the fixed "pie" that pits specialties against each other • The RUC — the committee that sets what doctors get paid, and who's on it • The real history: the 1929 Baylor Plan, Blue Cross/Blue Shield, the 1942 wage freeze, and the 1954 tax exemption that built employer-based insurance • Why Medicare (1965) inherited this system rather than designing a new one CHAPTERS 00:00 Intro — why this episode matters 00:00 What is a "claim," really? 00:00 The 5 codes that determine your pay: ICD-10, CPT, place of service, provider, payer 00:00 How a claim moves: coder → clearinghouse → payer → remittance 00:00 The clearinghouse problem 00:00 Claim denials and the appeals process 00:00 A brief history of American health insurance: the 1929 Baylor Plan 00:00 Blue Cross, Blue Shield, and the birth of fee-for-service 00:00 WWII wage freezes and the accident of employer-based insurance 00:00 1954 tax law and 1965 Medicare 00:00 The AMA and the CPT code copyright 00:00 RVUs and the fixed "pie" 00:00 The RUC: who really sets your pay 00:00 Recap and why this matters for doctors and patients [Insert real timestamps after final edit] If this made you mad, good — that's the point. Subscribe, rate us 5 stars, and leave a review; it's the best way to help other clinicians find this show. Share it with a resident, an attending who won't stop complaining about RVUs, or anyone who thinks healthcare billing makes sense. Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

• Transcript
• Chapters

A Noble Profession Tries to Get Paid: The Historical Roots of a Modern Healthcare Crisis

This is Episode 2 of our series on health policy and economics for doctors! This episode is about laying the historical groundwork for the rest of this season, because so many of our modern healthcare problems can be traced back to decisions made WAY in the past that set us on this course. In this episode, Dr. Liz Malphrus digs into the 19th-century roots of American medicine — from home-based house calls and bartered payments to the founding of the American Medical Association in 1847 — to explain how doctors chose to model their profession after clergy instead of lawyers, and why that choice still shapes healthcare's biggest problems today. Drawing on Paul Starr's The Social Transformation of American Medicine, this episode lays the historical foundation for everything Cut & Tell will cover this season: why healthcare is so complicated, why doctors are uncomfortable charging for care, and why patients are too. Referenced: The Social Transformation of American Medicine by Paul Starr Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

• Transcript
• Chapters

Doctors Don't Know How Healthcare Works. Here's Why.

What if doctors understood how the healthcare system actually works? In the first episode of Season 2 of Cut & Tell, Dr. Liz Malphrus kicks off a new series designed to give doctors and residents the health policy knowledge they were never taught in medical school or residency. Liz has a master's degree in public policy and spent five years working in health policy before becoming a physician. Now, after experiencing healthcare from both sides of the system, she's breaking down the forces that shape how medicine works, and why doctors are often left without the knowledge or power to change it. From Medicare and Medicaid to RVUs, CPT codes, claims-based payment, healthcare policy, and the people who make the rules, this season is about understanding the "rules of the game" so physicians can become better advocates for their patients and themselves. Liz also explores the disconnect between health policy and what actually happens at the bedside, why healthcare metrics and reporting requirements don't always improve patient care, and how physicians have gradually lost control over their own profession. And yes, she's here to radicalize you. If you're a medical student, resident, physician, or healthcare professional who has ever wondered Who actually makes these rules? Why does healthcare work this way? And why do doctors have so little control?—this season is for you. In this episode: Why doctors aren't taught healthcare policy How Liz went from health policy to medicine What she learned working at the National Academy of Medicine The disconnect between healthcare policy and clinical practice Why doctors need to understand how healthcare gets paid RVUs, CPT codes, Medicare, Medicaid and claims-based payment Why physicians need to advocate for themselves How healthcare policy affects the doctor-patient relationship Why understanding the system can give doctors more agency Cut & Tell is a Hippocratic Collective podcast about medicine, surgery, residency, and what it really means to be a doctor. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

How to Choose the Right Medical Specialty | My Journey to Plastic Surgery

Choosing a medical specialty is one of the biggest and most stressful decisions in medicine. In this season finale of Cut & Tell, newly graduated plastic surgeon Dr. Liz Malphrus reflects on her own journey from medical student to plastic surgery. Along the way, she seriously considered hospital medicine, urology, interventional specialties, and nearly changed her career path late in medical school after a single reconstructive surgery changed everything. Rather than offering a simple checklist, this episode explores what specialty choice is really about: finding the people, work, and environment where you'll build a fulfilling career. Whether you're a medical student deciding your future or simply curious about how physicians choose their specialties, this episode offers an honest look at one of medicine's most important decisions. Topics discussed: How to choose a medical specialty Why mentorship matters Hospital medicine vs. surgical specialties Why Dr. Malphrus almost chose urology The operation that changed everything What drew her to plastic surgery Personality fit vs. lifestyle considerations Shadowing, networking, and exploring specialties Can you switch specialties later? Advice for medical students who feel uncertain Cut & Tell explores the realities of medical training, surgical careers, and life after residency. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

• Transcript
• Chapters

My First Day as an Attending Plastic Surgeon | Life After Residency

What does the first day as an attending surgeon actually look like? After years of medical school and plastic surgery residency, Dr. Liz Malphrus officially begins her career as an attending plastic surgeon. But instead of jumping straight into the operating room, the reality is far different—and surprisingly emotional. In this episode of Cut & Tell, Liz shares what it's really like to leave residency behind, start building a surgical practice from scratch, earn patients' trust, navigate the business side of medicine, and finally experience something many physicians rarely have: control over their own career. She also reflects on the identity shift from resident to attending, why being called "Doctor" still matters, and how this new chapter has changed the way she thinks about work, purpose, and life outside the hospital. If you're a medical student, resident, fellow, attending physician, or simply curious about what happens after surgical training ends, this is an honest look at one of the biggest transitions in a doctor's career. In this episode: What your first day as an attending is actually like Building a surgical practice from zero patients The emotional transition out of residency Marketing yourself as a new physician Why "Dr." still matters Finding work-life balance after residency Advice for residents approaching graduation Cut & Tell is a candid podcast following Dr. Liz Malphrus as she navigates life after plastic surgery residency—the challenges, career decisions, and realities that medical training rarely prepares you for. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

Starting My First Job as a Plastic Surgeon (What I Had to Buy)

Starting your first attending job means more than just showing up on day one. It means building an entire practice from the ground up. In this episode of Cut & Tell, I take you behind the scenes of what it actually takes to launch a career as a plastic surgeon, from spending nearly $10,000 in a single day on essential equipment to building my website, planning patient workflows, setting up my office, and figuring out how to create a practice that reflects my values. We talk about: • The expensive equipment every plastic surgeon needs (and what's actually worth buying) • Why I invested in a professional camera system and surgical headlight • Building my surgeon website and optimizing it for SEO • Creating a patient experience from the very first visit • Marketing yourself as a new attending physician • Preparing for board certification and practice ownership • The transition from residency to real-world practice Whether you're a medical student, resident, early-career physician, or just curious about what happens after surgical training, this episode offers an honest look at one of the biggest transitions in a surgeon's career. Subscribe for more conversations about medicine, surgery, physician life, and building a career beyond residency. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

How to Find Your First Doctor Job (What Nobody Teaches You)

No one teaches physicians how to find their first job. After years of medical school and residency, new attendings are suddenly expected to navigate networking, interviews, contracts, compensation, and career decisions, often with little guidance. In this episode of Cut & Tell, newly graduated plastic surgeon Dr. Liz Malphrus shares everything she learned during her own physician job search. From building a professional online presence and expanding your network to evaluating job offers, negotiating contracts, and avoiding common mistakes, this is the practical guide she wishes she'd had before starting the process. Whether you're entering residency, fellowship, or preparing for your first attending position, these lessons can help you approach the job search with confidence. Topics discussed: When to start looking for your first physician job Why networking matters more than job boards Building your professional online presence Cold emailing and reaching out to practices Questions to ask during physician interviews Understanding compensation and partnership tracks Why every physician needs a contract attorney Evaluating practice culture and red flags How Dr. Malphrus found her first attending position Making the transition from resident to attending Cut & Tell explores the realities of surgical training, career transitions, and building a meaningful life in medicine. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

Confessions of a Former People-Pleasing Plastic Surgeon | Cut & Tell

After six years of surgical residency, I expected to leave with better technical skills. I didn't expect to leave without one of my defining personality traits. In this episode of Cut & Tell, I share the story of how a formal complaint from a senior resident completely changed how I saw myself, and ultimately forced me to stop trying to make everyone happy. We talk about: Why medicine attracts people pleasers How hierarchy can shape your identity Learning to have difficult conversations with patients The emotional toll of residency politics Why not everyone has to like you How losing my reputation helped me find my voice If you're a resident, medical student, physician, or anyone who's struggled with conflict, perfectionism, or the need for approval, I hope this episode reminds you that sometimes the strongest version of yourself only emerges after disappointing someone else. 🎧 Subscribe for honest conversations about life after residency, surgery, identity, and building a career on your own terms. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

Chief Resident Advice No One Teaches You | How to Lead a Residency Team

What actually makes a great chief resident? After finishing plastic surgery residency, Dr. Liz Malphrus reflects on one of the most important leadership roles in medical training, and the lessons no one formally teaches. From setting expectations and managing team dynamics to giving meaningful feedback and building trust, this episode is a practical guide for anyone preparing to lead in residency. Dr. Malphrus shares the communication strategies that transformed her approach as chief resident, why vague feedback hurts more than it helps, and how supporting curiosity can create stronger teams and better physicians. Whether you're an intern, senior resident, future chief, or attending looking to mentor trainees, these leadership principles extend far beyond medicine. In this episode: How to develop your own leadership style Why communication is the foundation of great teams Setting expectations from day one Giving feedback that's immediate, specific, and actionable Avoiding the biggest mistakes chief residents make Building team morale while maintaining accountability Why curiosity is one of the most important leadership skills If you're navigating residency, preparing for chief year, or interested in leadership in healthcare, this episode offers practical advice you can apply immediately. Subscribe for more honest conversations about residency, surgical training, physician life, and the realities of modern medicine. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

How to Survive (and Thrive) During Intern Year | Advice From a Graduating Resident

Starting residency can feel overwhelming. New city, new hospital, new responsibilities, and suddenly everyone expects you to know what you're doing. In this episode of Cut & Tell, graduating plastic surgery resident Dr. Liz Malphrus shares her most requested advice for incoming interns. Drawing on six years of residency experience, she breaks down the physical, cognitive, and psychological strategies that helped her survive, and ultimately thrive, during training. From building sustainable study habits and protecting your sleep to finding community, seeking therapy, and learning how to navigate the constant feeling of not knowing enough, this episode is a practical guide for anyone beginning residency. Topics discussed: Intern year survival tips Physical readiness: sleep, food, movement, and gear Building effective study habits during residency Learning from your patients How to study when you have no free time Finding community in a new city Managing stress, anxiety, and burnout Why therapy can be an important part of residency Personal mantras that helped through training What every new intern should know Whether you're starting residency this summer or simply remember what it felt like to be an intern, this episode is a reminder that you don't have to figure everything out on day one. Host: Liz Malphrus, MD Connect with Liz: https://www.hippocratic-collective.com/members/liz-malphrus-md IG: @dr.malphrus Produced By: The Hippocratic Collective Subscribe to @hippocraticcollective on Youtube for all of the other shows and content the Hippocratic Collective has to offer.

Why Residency Feels Financially Impossible Today | "Back in My Day", Part 2 | Cut & Tell

Residents today earn roughly the same inflation-adjusted salary as residents did decades ago. So why does training feel so much more financially difficult? In this episode of Cut & Tell, plastic surgery resident Dr. Liz Malphrus explores the economic realities facing modern trainees—from exploding medical school debt and rising housing costs to childcare expenses, delayed financial independence, and the growing gap between resident compensation and the true cost of becoming a physician. This is the second installment in the "Back in My Day" series, examining how residency has changed over time. Rather than debating which generation had it harder, Dr. Malphrus argues that the conditions surrounding medical training have fundamentally changed—and that understanding those changes is essential if we want to improve graduate medical education. Topics discussed: Resident salaries then vs. now Medical school debt and rising education costs GME funding and resident compensation Housing, childcare, and cost-of-living pressures Why many residents struggle financially despite being physicians The changing demographics of residency training Single-parent households and residency Why "back in my day" misses the bigger picture Moving beyond the suffering Olympics in medicine Cut & Tell explores the realities of surgical training, medicine, and the systems shaping physician life today. Subscribe for new episodes and visit the Hippocratic Collective for more conversations about the future of medicine.

"Back In My Day" - Why Today’s Residents Feel Less Prepared Than Ever | Cut & Tell

Attendings often tell stories about residency "back in the day" - more autonomy, more responsibility, more independence. But was training really better, or has the entire system changed? In this episode of Cut & Tell, plastic surgery resident Dr. Liz Malphrus explores why modern residents often report feeling less prepared for independent practice despite performing similar case volumes to previous generations. From duty-hour debates and supervision requirements to RVU-based compensation and the growing pressure for clinical productivity, she examines the structural forces reshaping surgical education. This isn't a conversation about whether residency is easier or harder. It's about understanding how the training environment has changed, and what that means for autonomy, burnout, and the future of medical education. Topics discussed: Why case numbers don't tell the whole story Resident autonomy and surgical confidence The impact of RVU-based compensation on teaching Academic medicine's productivity pressures Why more residents pursue fellowship training The relationship between autonomy and burnout How surgical education has evolved over the past two decades What attendings and residents can learn from each other Cut & Tell is a podcast exploring the realities of surgical training, medicine, and life beyond the operating room. Subscribe for new episodes and visit the Hippocratic Collective for more conversations about the culture of medicine.

The 3 Books Every Resident Should Read Before Graduation | Cut & Tell

What if the most important lessons of residency aren't found in a textbook? With graduation just days away, Liz shares the three pieces of writing that most shaped her understanding of medicine, residency, and life beyond training. From the realities of surgical culture and physician burnout to the hidden history of American healthcare and the power of personal agency, these recommendations offer a framework for understanding not just residency, but your place within the system. In this episode, Liz discusses: - Why Surgeon on the Edge by Frances Mei Hardin is the residency memoir she recommends over The House of God - What The Social Transformation of American Medicine reveals about the forces shaping modern healthcare - Why the essay How to Be More Agentic by Kate Hall may be the most important 10-minute read for physicians - How understanding systems can make you a more effective doctor - The mindset shifts Liz wishes she had before starting residency Whether you're a medical student, resident, attending physician, or simply interested in the realities of modern medicine, this episode offers a practical reading list for anyone trying to make sense of the profession, and build a career with intention. 🎧 New episodes of Cut & Tell every Thursday.

What Actually Makes a Great Resident | Cut & Tell

What makes a good resident? And beyond that — what actually makes someone great? In this episode of Cut & Tell, Dr. Liz Malphrus breaks down the unwritten skills of residency that no one formally teaches: anticipation, adaptability, reading the room, emotional resilience, communication, and learning how to survive medicine without becoming robotic in the process. From OR etiquette and closed-loop communication to social anxiety, burnout, and the strange art of staying positive during training, this is an honest conversation about the human side of becoming a doctor. Whether you’re a medical student, intern, resident, or just trying to survive a high-pressure environment, this episode is a candid look at the traits that actually matter — and why all of them can be learned. Cut & Tell is where medicine gets honest. https://sashachapin.substack.com/p/my-six-stages-of-learning-to-be-a

My Museum of Failures | The Stories Behind Becoming a Surgeon

Cut & Tell is where medicine gets honest. In this episode, Dr. Liz Malphrus opens up about the failures, regrets, rejections, and detours that never make it onto a CV. From getting a C in biology at Columbia, to losing out on a White House job she thought would define her future, to walking away from a career in music — Liz reflects on the moments she once believed had ruined everything. This is a conversation about perfectionism, identity, career pivots, rejection, and the pressure in medicine to package every setback into a clean success story. Instead of a polished resume, this episode is an anti-resume: a candid look at the messy reality behind becoming a doctor. If you’ve ever felt behind, rejected, uncertain, or like your path hasn’t gone according to plan — this one’s for you. 🎧 New episodes of Cut & Tell every Thursday.

Residents Are Being Exploited (And Everyone Knows It) | Cut & Tell with Dr. Liz Malphrus

Cut & Tell is where medicine gets honest. In this episode, Dr. Liz Malphrus gets real about the hidden economics of residency training, and why so many residents feel trapped, undervalued, and burned out before they ever become attendings. With just weeks left before finishing plastic surgery residency, Liz reflects on what she wishes someone had told her on day one: know your worth. She shares: Why residency is a job—not “just training” How the system keeps residents financially powerless The reality of working 80-hour weeks for low pay Why residents can’t simply “leave” like other professionals The emotional and financial cost of medical training How healthcare depends on resident labor Why anger about the system may actually be justified What needs to change for the next generation of physicians From pandemic ICU shifts to the culture of silence in medicine, this is an unfiltered conversation about labor, identity, sacrifice, and the true cost of becoming a doctor. If you’ve ever wondered why residents are burning out, or lived through it yourself, this episode will hit hard. 🎧 New episodes of Cut & Tell every Thursday.

Cut & Tell with Dr. Liz Malphrus | The Truth About Residency (That No One Says Out Loud)

Cut & Tell is where medicine gets honest. In this first episode, Dr. Liz Malphrus, a plastic surgery chief resident, opens up about what residency is actually like, beyond the polished narratives. From the hidden curriculum of training to the emotional weight of becoming a surgeon, this is a candid look at the parts of medicine that are usually left unsaid. She shares: Why residency culture is built on silence The paradox of learning on real patients How competition and comparison evolve over time Why the first year in practice may be the hardest The problem with traditional “advice” And what it means to document this transition in real time This episode sets the tone for the show: unfiltered conversations about training, identity, and the reality of becoming a physician. If you’ve ever wondered what residency is really like—or lived it yourself—this is the conversation you’ve been waiting for. 🎧 New episodes of Cut & Tell every Thursday.