It was two in the morning and I was starting a heparin drip on a patient whose clot was not going to wait for daylight. I typed the order, the electronic health record (EHR) flagged the weight-based dose, and minutes later a nurse hung the bag and programmed the smart infusion pump at the bedside. The pump beeped, the number climbed, and I moved on to the next patient without a single thought about how any of it had reached us.
I did some version of that a few thousand times over my training and early years as a hospitalist. Not once did I stop to ask who invented the pump, who paid to build it, how it got past the U.S. Food and Drug Administration (FDA), how my hospital decided to buy that one, or whether anyone got paid for keeping it running. I knew the drug cold. I knew nothing about the machinery that put it in my hand.
That is not a personal failing. It is the design of the training. We spend a decade learning to deliver care and close to zero hours on how care actually gets built, funded, cleared, priced, and purchased. The tools show up on the unit like weather. You learn to use them, you never learn where they come from.
Walk through that one ordinary moment and the invisible part gets loud.
The heparin I ordered was discovered in 1916 by Jay McLean, a second-year medical student at Johns Hopkins, and did not reach clinical use until the mid-1930s. Twenty years from bench to bedside for a molecule I now order without blinking.
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The pump is a bigger education. Most infusion pumps reach the market through the FDA’s 510(k) pathway, which clears a device by showing it is “substantially equivalent” to one already on the market. Clearance is not proof that the device helps patients. It is proof that it resembles a predecessor closely enough to skip a full efficacy trial. If you have ever cared for a patient on a BD Alaris pump, sit with this one. In 2020, after the FDA linked it to dozens of injuries and a death, the company pulled it under a Class I recall and kept it off the market on a long commercial hold. It did not return to service until 2023, once a reworked version earned a fresh 510(k) clearance. None of that was ours to see, and nobody briefed the nurses and residents relying on it.
Someone funded that pump years before it reached my patient. Engineers, a regulatory team, a sales force, all paid for by capital committed long before the first unit shipped. My hospital did not order it off a shelf either. A value analysis committee, usually some mix of clinical leaders, supply chain, and finance, weighed it against competitors and signed the contract. I have watched plenty of those decisions from the outside, and the clinician who actually lives with the device is often the one voice not in the room.
Then there is the part that surprised me most. Under Medicare’s inpatient prospective payment system, the hospital is paid a fixed amount for the admission based on the patient’s diagnosis-related group, or DRG, a single bundled payment meant to cover the whole stay. The pump, the tubing, most of the drugs, the supplies, all of it is folded into that one number. There is no separate check for running the machine keeping the patient alive. It is a cost buried inside a bundle. New technology can occasionally earn a carve-out through a narrow add-on payment, but the default is bundled, and “we will get our own payment” is a long shot.
Even the screen I typed into has an origin story that has nothing to do with medicine. EHRs are everywhere in American hospitals largely because of the 2009 HITECH Act, which put roughly $27 billion of federal incentives behind certified systems. A law reshaped my daily workflow more than any clinical trial ever did.
To be fair, the training bodies are not silent on money. The 2026 ACGME requirements for internal medicine say the successful internist should “understand and manage the business of medicine to optimize cost-conscious care.” The systems-based practice competency asks residents to weigh “value, cost awareness, delivery and payment” and to understand “health care finances and its impact on individual patients’ health decisions.” Read it closely, though. Every word points at cost-conscious bedside decisions. None of it points at how the device, the drug, or the software got to the bedside. The curriculum teaches you to be a careful spender inside the machine. It never shows you the machine.
The data matches the experience. In a 2025 survey of medical students, residents, and junior hospitalists at an academic program, only 15.6 percent said they had received any formal health care financial education, and the newly minted hospitalists scored no better on the knowledge test than the third-year medical students did. We are not learning this on the job. We are just getting more comfortable not knowing.
I felt that gap sharply when I left the wards to start evaluating health care companies for a living. I finished residency with more than a hundred peer-reviewed publications and no idea what a term sheet was. Nobody had ever taught me. From the capital side, the pattern was almost embarrassing. Physicians are the end users and the real-world validators of nearly every product in medicine, and we are the last people in the chain to learn how our own tools reach us.
None of this requires becoming an investor. It requires refusing to treat the machinery as weather. The next time a new device appears on your unit, you already know the questions. Who cleared it, and what did clearance actually prove? Who paid to build it? Who decided we would buy it, and were any of us asked? Who gets paid when it runs, and who does not? These are not finance questions. They are patient-care questions wearing a suit. The machinery is not magic, and it is not above your pay grade. It was just never on the syllabus, and that is a fixable thing.
And it is worth fixing, because of where we sit. No one in the chain is closer to the patient than we are. We are the ones who watch a clunky interface eat ten minutes we did not have, who can tell within a week whether a new tool helps a patient or just generates a charge. That bedside read is the most valuable input in the whole system, and right now we give it away and let other people decide what gets built. Understand the machinery, and your judgment stops being a vent at the nurses’ station and becomes a lever on what your hospital buys and what reaches your patients. The stakes are not abstract. Tools chosen for better reasons mean fewer complications, shorter stays, and less money burned, which is a colder way of saying patients who live longer and suffer less. We keep a hand on the pulse. It is past time we had a say in what reaches the bedside.
This essay is cited in the KevinMD record on physicians and administrators.
Harsha Moole is an internal medicine-trained physician-scientist with more than 100 peer-reviewed publications, including work featured in the New England Journal of Medicine. After years of clinical practice and gastroenterology outcomes research, he made an unconventional transition from the bedside to the boardroom by founding PhysicianEstate, a health care-focused venture capital firm.
Over the past seven years, Dr. Moole has made 22 early-stage health care investments across digital health, medical devices, biotech, and therapeutics. He has also built a network of more than 200 physicians from institutions such as Johns Hopkins and Stanford who help source opportunities and provide clinical diligence before capital is deployed. His core thesis is that physician-scientists with firsthand clinical experience are uniquely positioned to identify health care investments that generalist investors often miss.
His research background is reflected in his publication record on Google Scholar, and he shares professional updates on LinkedIn.
