It starts the same way too often. After months of scheduling hassles, a patient finally gets in front of a doctor, sits down, and unloads all the pent-up frustration: surprise bills, endless hold times, MRI denials, a three-month wait for a ten-minute visit. The conversation goes something like this:
“Why won’t you just order the scan?” I did. Twice. Unfortunately, it was denied by someone you’ll never meet.
“Why is this bill so high?” Because the price was set by people who don’t wear stethoscopes.
“Why did I wait three hours?” Because the hospital scheduled one attending physician when they really needed three.
Doctors are the face of the healthcare system and, increasingly, the public’s punching bag for everything wrong with it. We didn’t design this system, but we confront its failures every day. We are both insiders and victims, asked to comfort the patient, navigate the insurer, appease the metric, and make it all look effortless.
The Illusion of Control
Patients imagine decisions flow from the exam room outward. And perhaps that was the case decades ago when most physicians were in private practice. But in reality, physicians have lost control over nearly everything patients hate most about healthcare. Consider what actually frustrates patients: according to recent surveys, 93% of physicians report that prior authorization for a medication or procedure delays patient care, and more than half of consumers have experienced a prior authorization problem in the past two years. Forty-two percent of patients receive medical bills containing errors. Nearly 40% of Americans delay medical care because of cost concerns.
These aren’t physician failures—they’re system failures we’re powerless to fix. I have physician friends who, despite being doctors themselves, must repeatedly prove to their insurers that their Type 1 diabetes requires insulin for life. One colleague with cancer spent months fighting for coverage of standard chemotherapy while simultaneously treating his own patients navigating the same Byzantine system. The absurdity isn’t lost on us: doctors treating doctors who can’t get their own medically necessary treatments approved.
The numbers reveal where control actually lies. In 2023, physician salaries represented just over 8% of healthcare spending, while the hospital itself, through facility fees and management, consumed 31.2%. But the real story is in administration: the U.S. spends $925 per person annually on health administration compared to $245 in comparable countries. That $680 difference represents the invisible infrastructure engendering/leading to the delays, denials, and confusion patients experience daily.
When researchers analyzed excess U.S. health spending, they found administrative costs account for roughly 30% of the excess, while physician wages account for only 10%. The bureaucracy costs three times what physician labor does, yet physicians bear the blame for the system’s failures.
Consider drug pricing. Pharmaceutical manufacturers set list prices, then Pharmacy Benefit Managers (PBMs) negotiate secret rebates while controlling formularies. The drug passes through wholesalers who add their markup, then pharmacies add theirs, and PBMs pocket the “spread” between what they charge insurers and pay pharmacies. In Ohio, Kentucky, Illinois, and Arkansas alone, PBMs have overcharged state Medicaid programs more than $415 million using this practice. When a patient’s insulin costs $300, their doctor wasn’t responsible for setting its price and certainly doesn’t profit from it. Yet ir is the doctor who the patient sees and blames.
The Human Firewall
James, a patient with advanced cancer, told me: “I was so angry at my oncologist for months. The insurance kept denying the drug he recommended, and I thought he just wasn’t fighting hard enough. Then I found out he’d spent six hours over three weeks on the phone with them, submitted three appeals, and finally got his practice manager involved. Nobody told me. I thought he’d just given up on me.”
This is what buffering looks like. Physicians complete an average of 39 prior authorizations weekly, spending 13 hours on the process. We re-explain denials. We tweak orders to match formularies. We translate billing codes. We open laptops at night to finish notes we couldn’t complete between patients—what we call “pajama time,” those hours in the evenings when the real documentation happens.
We act as the system’s human firewall, absorbing heat so patients don’t get burned worse. But that buffering is unpaid labor: time, cognition, and emotion spent reconciling what’s right for the patient with what’s possible in a structure we don’t control. This isn’t “burnout” as individual failure. It’s moral injury—being compelled to act against professional values by forces outside the room.
The cost manifests everywhere. Twenty-nine percent of physicians report that prior authorization has led to a serious adverse event for a patient in their care. Yet when these delays cause harm, patients see only their doctor’s face, not the anonymous reviewer who denied the treatment.
Strategic Scapegoating
Understanding our actual sphere of influence makes what’s happening now more concerning: physicians are being accused of profiting from services that either lose us money or in which we have zero financial stake.
The current HHS Secretary Robert F. Kennedy, Jr. has publicly claimed that “doctors are being paid to vaccinate, not to evaluate“ and that they’re “pressured to follow the money, not the science.” This narrative has gained traction despite the evidence: pediatric practices often break even or lose money on vaccines after accounting for specialized refrigeration, insurance for vaccine stock, backup generators, and nursing time. As one pediatrician noted, “If it was really about the money, it would be better for kids to be sick.”
Yes, some pediatricians have value-based contracts with insurers that include vaccination rate bonuses for meeting CDC schedule targets. But these are insurer-designed public health incentives, not physician profit schemes. Meanwhile, the person making these accusations earned over $2.4 million in referral fees from law firms suing vaccine manufacturers—a fact worth noting when evaluating motivations.
During COVID-19, physicians faced similar accusations about inflating death counts for profit. The facts: hospitals didn’t receive extra funds when patients die from COVID-19. The CARES Act provided a 20% payment increase for treating COVID patients (not deaths) to cover PPE, isolation procedures, and therapeutics. Moreover, since most hospital physicians are salaried, a COVID diagnosis wouldn’t change personal compensation anyway. Yet the accusation stuck because physicians were visible even as hospitals were losing an estimated $323 billion.
Breaking the Loop
Here’s why these profit accusations aren’t just unfair but strategic. If clinical expertise can be reframed as ideology or self-interest, it becomes easier to sideline physicians from policy decisions. This creates a devastating cycle: distant actors constrain care through denials and staffing cuts. Patients experience real harm owing to delays and bills. Physicians, who are visible and accessible, absorb any and all anger. Trust erodes as patients are told doctors are “In it for the money,” and such erosion further marginalizes physician input to ultimately perpetuate the dysfunction.
Sarah experienced this firsthand when caught between her doctor’s antibiotic recommendation and her insurance’s requirement to “fail first” on a cheaper alternative: “I knew my doctor was trying to help, but the insurance company made it sound like he was just prescribing the expensive thing because he got kickbacks. I ended up in the ER three days later when the cheap antibiotic didn’t work.”
This misdirection serves a clear purpose. If the public believes doctors are the problem, there’s no pressure to reform PBM practices, reduce administrative waste, or regulate hospital pricing. The anger gets absorbed by the firewall, and the dysfunction behind it continues unchanged.
Where Physicians Do Have Agency
Before going further, I need to be clear about where physicians actually hold power and where we contribute to the system’s problems.
We have agency in choosing whether to work for hospitals or remain independent, though market consolidation makes independence increasingly difficult. We make clinical decisions within the confines set by insurers . We could advocate more loudly for systemic change through our professional organizations. Some unnecessary testing is driven by defensive medicine—liability fears rather than insurer demands—though studies suggest this accounts for only 2-3% of spending, not the 10% sometimes claimed.
I don’t claim physicians are underpaid—the median salary of $374,000 is well above most professions. But privilege and being scapegoated aren’t mutually exclusive. The question isn’t whether doctors are comfortable; it’s who’s actually making money from dysfunction and who’s being blamed for it.
The Path Forward
Aspirational calls for “transparency” and “accountability” mean nothing without specifics. Addressing the root causes requires:
1. Prior Authorization Reform: Implement “gold card” programs where physicians with high approval rates get automatic approval for evidence-based care. Texas’s model cut authorization time by 65%. Standardize forms and processes to eliminate the $31 billion currently wasted on variation. Make denials carry institutional liability when they contradict guidelines and cause harm.
2. PBM Transparency: Support requiring disclosure of pricing on every claim and banning retention of manufacturer rebates. Every pharmacy transaction should itemize manufacturer price, wholesaler markup, PBM fees, and insurance processing costs. Patients deserve to see where their money actually goes.
3. Real Accountability: Every denial letter must name the reviewer with credentials, cite the specific policy, and provide clear appeal paths. Hospitals should post real-time staffing ratios the way airports post delays. When the wait is three hours because the ED is short two nurses, everyone should know.
4. Compensate Cognitive Work: Prior authorization time, care coordination, and after-hours documentation are currently undervalued by 40% in the relative value scale. If documentation is required work, it should be compensated as such, not hidden as “pajama time.”
Physicians have work to do, too. Specifically: Document your buffering. Log time spent on prior authorization and appeals not captured in productivity metrics. Explain constraints transparently: “I’m recommending X; insurance may deny it; here’s what we’ll do next.” This turns patients into allies rather than adversaries.
For everyone: When hospitals resist posting prices or insurers fight transparency, make noise during public comment periods. Share accurate information when you see false accusations about physician profits. And support journalists working to make this absurd system more clear: like Heather Knight, now of the New York Times.
A Different Ending
Imagine that exam-room conversation with structural changes in place. The MRI is approved automatically for guideline-concordant indications. When denied, the letter names the reviewer and policy clearly. Staffing levels are posted publicly. The bill itemizes where every dollar goes. Prior authorization time is compensated like the work it is.
In that world, patients still bring fear and frustration - illness is always hard - but they know where to direct their concerns. Clinicians still bear responsibility, but not blame, for decisions they didn’t make. And when someone claims that doctors profit from vaccines or manipulate death certificates, the public knows enough to ask, “Who’s really making money here?”
The physician you share your story with will always be your face of medicine. That’s the privilege of this work. But we shouldn’t be the scapegoat for a system we didn’t design and can’t fix alone.
If doctors seem tired, it isn’t from healing the sick. It’s from absorbing the sickness of the system itself and defending against accusations designed to obscure where real money flows. The cure won’t come from another resilience seminar. It will come when the people who truly profit from dysfunction are finally visible, accountable, and aligned with patients and clinicians—not protected by our visibility while they remain in shadow.