The demoralization of America’s doctors

Christie Mulholland’s patient was dying. 

As a palliative care physician at Mount Sinai Hospital in New York, most of her patients come to her in the final stretches of their lives, looking for comfort and a painless end. 

Mulholland’s patient wanted to leave the hospital and spend her final days in a hospice facility, a specialized, home-like setting designed for end-of-life care. 

But the patient’s insurance would not approve the move. 

Mulholland and her team called repeatedly, trying to reverse the decision. Days passed. Finally, a physician at the insurance company tasked with reviewing coverage decisions answered.

“Oh,” the doctor told Mulholland over the phone. “She didn’t die yet?”

The remark laid bare a system in which financial calculus can eclipse patient needs.

“Like the strategy of the insurance company was, they weren’t going to allow her to go to this hospice facility and pay for it,” Mulholland said. “They were hoping that they would drag their feet long enough that she would die in the hospital.”

That phone call has etched itself in Mulholland’s memory.

“Experiences like that accumulate.” 

Are doctors OK?

Mulholland’s story is not unique. Across the country, health care workers face similar experiences: A patient denied care, a nurse juggling too many patients, a physician caught between best practice and what insurance covers.

About a third of physicians plan to leave medicine due to working conditions and a loss of professional autonomy. 

Some call it burnout, others moral injury — a term popularized during the pandemic that describes the ethical distress people experience when they cannot provide the care they believe patients need.

“Over time, it has felt to me more that my efforts are benefiting patients less and benefiting corporations and for-profit entities more,” Mulholland said. 

Over the past two decades, U.S. health care has undergone a profound transformation.

Insurance companies play a central role in shaping care, dictating which treatments will be covered, when and for whom. For-profit corporations and private equity firms — which own a growing share of American health facilities — have cut staff and increased patient volume to meet financial targets. Federal policies designed to expand access and improve accountability have added layers of documentation and reporting, contributing to an increasingly complex, costly and burdensome system. And, in recent years, misinformation and politicization of health and science has fueled distrust and hostility, further eroding the doctor-patient relationship.

The consequences are evident: Americans spend double those in other high-income countries, yet maternal and infant mortality rates remain higher in the U.S., and preventable deaths are more common. Tens of millions delay or skip care because of cost. Meanwhile, health care workers face the highest rates of workplace violence of any private industry, and physicians die by suicide at roughly twice the rate of the general population.

Fueled by a system many say no longer works in the best interest of patients, physicians and nurses are leaving medicine faster than new ones are taking up the torch, deepening an already dire shortage and hurtling the U.S. health care system toward collapse.

Code and bill and code and bill 

Corina Fratila attended medical school in her home country, Romania, where, after six years, students must pass one final exam to become a doctor. 

“It’s the most important exam in medical school,” Fratila explained. “I focused on it my whole life.” 

After taking the test, Fratila learned from a friend that she could have simply purchased the answers, as half of her classmates had done.

“I was so frustrated and upset by the system that I decided to leave,” she said. “The rumors back in the day were that the United States was the place to be if you wanted to escape corruption.” 

Fratila learned English; she flew to Budapest and then to the U.S. for more exams. In 1999, she earned a spot in a New York City residency program. For three years, Fratila regularly worked 120 hours a week. She was exhausted but passionate.

After residency, Fratila specialized in endocrinology and joined a private practice in Maryland. There, she began to sense something wasn’t quite right: Despite her years of schooling and training, doctors were not in charge. Insurance companies dictated how Fratila spent her time, how she was paid and even what procedures or medications her patients could receive.

Fratila was shocked; she thought she had left behind rampant corruption when she fled Romania.

A punch press

Doctors spend on average about 15 minutes with a patient, during which time they must document every detail of the visit: symptoms, diagnoses, tests and treatment plans.

Those notes become part of the patient’s medical record, but they are also translated into billing codes, which insurers use to determine how much a doctor or hospital is paid. Every decision, every moment of a physician’s time has to be justified. 

“There needs to be particular wording explaining why it took me 75 minutes to treat a patient in a pain crisis, and also have a goal of care discussion with them and their family,” said Mulholland. “I have to write a lot of words in the chart explaining why I took that much time.”

If the documentation is incomplete, or the coding doesn’t meet an insurer’s criteria, the claim can be denied, and the provider may not be paid for care they have already delivered. Even when everything is documented correctly, payment is not guaranteed. Many medications, scans and procedures require prior authorization — forcing doctors or staff to submit additional paperwork and, in cases like Mulholland’s hospice patient, to argue directly with insurance companies before moving forward.

“When you have this insurance maze to navigate, when the medical visit revolves around the doctor being on the defensive, documenting symptoms, documenting codes, the doctor is not really, at that point, focusing on what the person in front of them really needs,” Fratila said. 

“Doctors are basically line employees now,” said Dike Drummond, a former family physician who coaches clinicians experiencing burnout. 

“They might as well be a punch press.”

Researchers estimate that, today, for every hour a doctor spends with a patient, they spend one to two additional hours on documentation.

“You are just a glorified data-entry monkey in a Kafkaesque insurance labyrinth, legally obligated to spend more time clicking boxes in Epic than making eye contact with another human,” Fratila wrote earlier this month in a blog post. 

The outsized role of insurance has stripped physicians of their autonomy to practice medicine based on their training, expertise and best available evidence.

Insurers push back on this claim.  

“It’s likely not your health insurer deciding what care is covered by your plan,” a spokesperson from UnitedHealth Group, the largest health insurance company in the country, told SAN by email. “UnitedHealthcare’s claims approval rate stands at 98% for claims for eligible members, when submitted in a timely manner with complete information, and after duplicate claims are removed.” 

Independent analysis conducted by the health policy organization KFF found that UnitedHealth Group’s average denial rate was 19% in 2024 for Americans who purchased plans through Affordable Care Act marketplaces. 

Physicians can recite dozens of instances where insurance coverage did not align with their recommended treatment.

“I run into situations where a patient will benefit from this medication, but because their disease is ‘well managed’ they’re not going to cover it,” said Tomi Mitchell, a family physician and certified wellness coach who trained in the U.S. but now works in Canada.

“What are we trying to do? Are we trying to keep people chronically sick?” she said. “As health care professionals, we should be the ones making the final clinical decision when it’s grounded in evidence, rooted in science and ultimately compassion.”

Over the years, as insurers tightened their grip on clinical decision-making and the federal government passed complex health care laws, the administrative burden and financial pressure on physicians grew. By some estimates, administrative costs account for more than 40% of total health care expenditure today. As a result, it has become increasingly untenable for many physicians to keep practices afloat — creating an opening for other outside actors to acquire practices and further wrest control from health care workers.

Exploiting altruism

In the 1980s, almost 80% of U.S. health facilities were owned by doctors. That number fell through the early 2000s, as running a medical practice became increasingly complex and as insurance payments for many services — particularly in primary care — failed to keep pace with inflation and rising administrative costs.

As independent practices and smaller hospitals struggled under this system, large hospital systems and insurance-backed networks bought them up. More recently, private equity firms have accelerated that trend, consolidating and restructuring practices to maximize profitability.

“There’s been more and more pressure to make money, and now that private equity is involved, that’s the whole point,” said Diane Shannon, a former primary care physician who now works as a career coach. 

“We’ve seen that here in Boston where private equity firms bought a whole bunch of hospitals, ran them into the ground because they were sucking out the profits,” Shannon said. “The governor had to step in, because hospitals were closing in these communities.”

Today, only about a quarter of health facilities are doctor-owned.

Instead of running their own practices and making autonomous decisions, the remaining 75% of doctors are now employees — “subservient to the business of medicine,” as Drummond put it — required to hit financial targets and productivity benchmarks.

Most physicians today are paid, in part, based on output — often tied to the number of patients they see and the services they provide. Because more complex or severely ill patients generate higher reimbursement, the system incentivizes treatment and sickness over prevention and health. 

When profit drives health care, “the only possible outcome is abuse of the customer, the patient, abuse of the workers, the doctors, the nurses and everybody else in the system,” Drummond said.

America’s health workforce is showing signs of cracking. About 50% of physicians report feeling symptoms of burnout, according to the American Medical Association, with many citing a loss of autonomy, chaotic workplace environments and the pressure to see as many patients as possible as key drivers. Shannon herself left medicine because of burnout, though she didn’t learn about this term until years later.

Fratila rejects the term burnout, saying it suggests physicians simply couldn’t handle the demands of medicine. 

“We did residency on three hours of sleep a night while being verbally abused,” she said. “We have been gaslit.”

She prefers the term “moral injury” to describe what happens when doctors and nurses enter medicine to help people, only to find themselves working in a system that too often prioritizes profits.

Profit over patients

For-profit health systems deploy a wide range of tactics to boost profits. 

Insurance companies, including Medicaid and Medicare, increasingly refuse to cover certain services, like the case with Mulholland’s hospice patient. 

By some estimates, insurers now deny roughly one in five medical claims, with higher rates in some states. Professional health organizations and patient advocacy groups say those rejections have increased in recent years. When insurance denies claims, patients either go without doctor-recommended treatment while they appeal to their insurer or pay out-of-pocket. And while patients wait, and physicians watch, top insurance CEOs earn roughly between $15 and $20 million dollars each year.

Some hospitals exploit insurance loopholes that allow them to charge higher prices for providing a service in-hospital, versus an outpatient clinic, Drummond said. 

Others prioritize higher-reimbursing procedures, such as surgeries and imaging, or invest in specialty services such as orthopedics or cardiology over less profitable primary or preventive care. Facilities might outsource departments such as emergency medicine or anesthesia to staffing firms, or rely on temporary contract workers to manage labor costs, a shift that can lead to less continuity of care, weaker ties between clinicians and hospitals and less stability for patients and staff.

Some health systems also reduce staffing levels to cut costs. That was the final straw for Debbie Moore-Black, a former registered nurse who worked for 30 years in the intensive care unit in Raleigh, North Carolina. 

Typically, ICU nurses care for only two patients at a time because they have such intense medical needs. After years of working in ICUs with a typical two-to-one ratio, Moore-Black said her hospital began assigning three critically ill patients to a single nurse in 2022.

“It was very dangerous,” she said. “You could lose your license if something happened, because you just couldn’t keep up with everything.” 

Studies have long reported that when nurses are assigned more patients, complications, infections and deaths increase. 

When Moore-Black’s hospital started assigning ICU nurses three patients, she left her unit for a psychiatric ward. There, she said was struck by a patient on two separate occasions, the second leaving her with a concussion. When the facility declined to provide dedicated security staff for the unit, Moore-Black retired.

Hostile environment

A growing number of doctors and nurses report being accosted by patients and family members over vaccine advocacy or when their care recommendations conflict with AI’s. 

Health care workers already experience the highest rates of workplace violence of any other private industry sector. In 2021 and 2022, there were 41,960 incidents serious enough to require time off work, job restrictions or reassignment — accounting for nearly 73% of all such cases across private industry, up from 28,310 in 2017 and 2018, according to the U.S. Bureau of Labor Statistics. 

Some studies suggest that aggression toward health care workers spiked during the pandemic. Researchers reported that 66% of scientists and physicians were harassed during COVID-19, up from around 23% in prior years. 

Even during non-pandemic times, patients often wait weeks for an appointment only to get limited face time with their provider who is rushing to fulfill productivity quotas, frustrating patients and straining the doctor-patient relationship. On top of that, in the years since the pandemic, trust in health care workers has declined.

This is also driving health care workers from the field.

“When COVID hit, it was a time when a lot of us felt really connected to the calling, because it was a crisis and patients were sick and they needed us. There was a whole health care heroes narrative that sustained a lot of us,” said Mulholland. 

That good will has since morphed into public distrust. 

“That felt like a slap in the face,” Mulholland said.

More recently, several physicians said patients are increasingly echoing messaging from senior health officials in the Trump administration, further fueling distrust.

Rana Alissa, a pediatrician and head of the American Academy of Pediatric’s Florida chapter, said parents are not only refusing medical advice but have become increasingly hostile. 

“We’re seeing more and more, a change of tone of our parents, especially the disrespect and the distrust,” she said.

Mitchell sees it, too. 

“We’re seeing people in positions of power saying they don’t trust the doctor,” Mitchell said. “They’re saying that vaccines are terrible, that doctors are just in it for money. The messaging is so obvious: We’re the bad guys, right?”

Hurtling toward collapse

Dozens of doctors, including Shannon and Drummond, have left medicine for a growing niche industry of physician coaching to address burnout, moral injury and the unsustainable pressures of the health care system. Mulholland and Mitchell, who both still practice medicine, also teach others small ways to cope or regain some control. For instance, Mulholland said she encouraged a physician to use clinical notes to more accurately capture the reality of patient cases. Rather than labeling a patient as “noncompliant” for not taking recommended medications, Mulholland suggested writing the truth: The patient didn’t take the medication because insurance didn’t cover it.

Tech companies and some physicians tout new AI tools called ambient scribe, which transcribe doctor–patient conversations and automatically generate clinical notes, as a solution to reduce administrative load for doctors and to trim “as much as 60%” of costs. 

But ambient scribes are not free, and hospitals and clinics look for ways to recoup those costs, Mulholland said.

“That might mean that each doctor would have to see more patients in order to pay for the AI technology to write their progress notes for them,” she said.

That’s typical. “Anytime a health system invests any money in a wellness program, they are looking for an ROI in that same year,” Mulholland said. 

She recognizes that even thoughtfully designed wellness programs and modest changes in documentation practices can only go so far. The system, in her view, needs broader reforms that restore empathy, respect expertise and prioritize patients.

Many physicians and policy analysts say there is no easy fix — in part because meaningful change threatens powerful interests across the industry. Insurers, hospital systems, pharmaceutical companies and private equity firms all generate billions of dollars from the current structure, and even incremental reforms can trigger fierce political and legal resistance. 

Politicians have repeatedly stalled or scaled back efforts to lower drug prices, expand Medicare or limit billing practices. Even modest changes have proven difficult. Last year, a congressional standoff over extending enhanced Affordable Care Act subsidies forced a government shutdown. Lawmakers compromised to reopen the government, but subsidies were not extended. A handful of other proposed bills to lower health care costs have been rejected.

In the absence of sweeping change, a growing number of physicians are opening cash-based or direct primary care practices that operate outside the traditional insurance system altogether. 

“They just don’t deal with the insurance companies at all, and therefore, there’s no friction. The treatment that the doctors recommend is what the patient can get if the patient agrees,” Mulholland said. 

That’s a bright spot in an otherwise dark outlook. When Drummond surveyed 10,000 of his physician followers last year, he asked whether the system can be saved. The vast majority said no.

“It’s obvious the system is collapsing,” Drummond said. 

If there is a silver lining, it is that in recent years it has become less taboo for physicians to talk about burnout, moral injury and demoralization, according to Mulholland. 

“There has been a cultural shift where at least in rhetoric, the health care system is more open to having programs for physician well-being.” Short of systemic reform, what physicians need next is for hospitals and clinics to invest in long-term programs that keep physicians in their jobs, she said.

Ella Rae Greene, Editor In Chief