According to a Commonwealth Fund report, the US ranks last among high-income countries in healthcare access, efficiency, and equity. Our health system has vast potential and can achieve Moonshot-like outcomes, but it still struggles to address people’s day-to-day needs.

The world’s largest health ecosystem comprises five fundamental stakeholders — patients, payers, product innovators, policymakers, and providers. And while they should work in harmony, they remain primarily disconnected, operating in silos with financial performance as the measure of success. With the fear of economic failure nipping its leaders’ heels, the system prioritizes fiscal responsibility over patients’ healthy longevity. It leads to a “sick-are” over healthcare strategic mindset.

A System Disconnected

While medicine is a “team-support,” the health industry positions its sectors like boxers — each pitted against the other. The concept of a fragmented health system is not new. Nearly 20 years ago, Dr. Alain C. Enthoven, a renowned health economist, argued that the US health sector suffered from a fundamental lack of coordination and misaligned incentives, leading to inefficiencies that primarily burden patients.

In her book Fragmented, Ilana Yurkiewicz, MD, illustrates the real-world consequences of this disconnect. Patients often find themselves bouncing between specialists dedicated to one piece of their patient’s anatomy, grappling with conflicting medical advice, and navigating a bureaucratic maze that often results in disparate, delayed, or denied care.

Economic pressures fueling consolidations and layoffs have led major players to go slow on much-needed ambitious health information initiatives. The much-heralded digital transformation, which promises AI-driven operational efficiency, seamless data exchange, and improved patient outcomes, remains unrealized.

Meanwhile, patients are finding themselves trapped in a complex, hard-to-navigate medical maze where medical records are often inaccessible, treatment plans are inconsistent, payer decisions feel opaque, and pricing remains elusive. The effect is profoundly dehumanizing.

The Patient is Out of the Picture

Financial pressures outweigh the fundamental goal of healing, and the loss of patient focus and a significant decline in empathy remain the system’s most glaring obstacles. This absurd reality is captured in a satirical moment from Yes Minister, where a lawmaker appointed by the UK Prime Minister visits an award-winning hospital — shockingly operating without patients. While comedic, the scene reflects an all-too-real aspect of modern health systems. Administrative structures, insurance approvals, and reimbursement models dictate operations, often sidelining the very individuals who seek care and healing.

As economic priorities continue to reshape industry, hospitals that once promised solutions struggle to sustain themselves, leaving patients increasingly marginalized. While improving patient outcomes should be the central focus of government policymakers, they too often become secondary considerations.

As the US Congress considers budget decisions, cutting Medicaid state subsidies does not mean economically struggling patients will be denied urgent care. Instead, when they seek treatment in the ER, hospitals will absorb the cost. This shifts the financial burden, further straining healthcare systems already operating on razor-thin margins.

Doctor Burnout: Primary Symptom of a Broken System

Physicians enter medicine purpose-centered with a desire to heal, yet the system relentlessly applies administrative and financial pressures that shift their attention elsewhere. Many doctors experience burnout, driven by excessive paperwork, prior authorization hurdles, and unrealistic patient quotas. According to a Mayo Clinic Proceedings study, nearly 63% of physicians report signs of burnout, including emotional exhaustion and depersonalization.

Designed to streamline care, electronic medical records (EMRs) are still a significant source of frustration. Physicians spend hours dealing with complex interfaces rather than engaging with patients. The demand to see more patients in less time — dictated by billing and reimbursement structures — further erodes the doctor-patient relationship, leading to dissatisfaction on both sides.

A 2023 survey by the Primary Care Collaborative and the Larry A. Green Center found that 62% of primary care physicians report not having enough time to adequately meet patients’ needs, which impacts treatment and preventive care discussions.

This dissatisfaction manifests as a breakdown in communication. While effective dialogue between providers and patients across specialties and within the broader health ecosystem is essential for treatment and prevention, patients and physicians struggle to find time to connect.

Burnout is not simply a professional hurdle; it’s a crisis that directly affects patient outcomes. Overworked, exhausted doctors are likelier to make errors, experience lower job satisfaction, and even leave the profession altogether. If the system fails to address professional despair and its causes, the shortage of health professionals will only worsen, limiting access and compromising care.

The Business of Health Over the Health of People

While business considerations shouldn’t take precedence over people, the financial structures underpinning the health sector drive decision-making that deemphasizes people’s health. The silos within the health ecosystem exacerbate this issue, preventing a shared understanding of economic and operational realities, limiting coordinated action and shifting the focus away from the patient.

Insurers prioritize cost control without recognizing the pressures this places on providers. Pharmaceutical companies innovate without fully considering how reimbursement models shape prescribing behaviors. Policymakers create regulations with a limited understanding of their clinical innovation impact. This lack of cross-sector awareness perpetuates fragmentation and inefficiency, and patients ultimately pay the price.

Digital health companies, once hailed as the future of care efficiency and effectiveness, are struggling with financial sustainability, forcing many to pivot or shut down entirely. Biopharmaceutical companies triage drug development pipelines, looking for future medicines with a high probability of regulatory success rather than encouraging research that may fail but illuminate a pathway to even more significant discoveries. Again, it is the patient who pays the price.

The Cost of Failing to Invest in Care and Caring

There is enough blame to go around, and we must stop looking for a convenient villain. If we attack one piece of the ecosystem rather than look at the totality of our problem, we will fail to make meaningful changes.

We can’t throw our health system out and start from scratch; we must find a way to work within and through it effectively. The primary lever that will drive reform of the health system and improve its functioning is bringing everything back into empathetic focus, with the patient at the center of care. Whether we are payers, product innovators, policymakers or providers, we must ask if our actions are built on a foundation of empathy — from heartfelt “care.” First and foremost, we must cooperate in the service of the patient.

The health sector is an industry, but it must be more than that. At its core, it should recognize that we are always people — only sometimes patients. Yet, financial pressures have overtaken its fundamental purpose: healing. This system-wide disconnect erodes trust, drives up costs, and leaves too many without the care they need. Until the key players in the health ecosystem realign around a unified, patient-centered mission, fragmentation will persist, outcomes will fall short, and lives will remain at risk. The stakes are too high to accept anything less.

Unless we build on a foundation based on “how would I feel” empathy, our system will not be built to last. It will be structured to fail.

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CHARLESTON, S.C. — Melanie Gray Miller, a 30-year-old physician, wiped away tears as she described the isolation she felt after losing a beloved patient.

“It was at the end of a night shift, when it seems like bad things always happen,” said Miller, who is training to become a pediatrician.

The infant had been sick for months in the Medical University of South Carolina’s pediatric intensive care unit and the possibility that he might not improve was obvious, Miller recalled during an April meeting with physicians and hospital administrators. But the suddenness of his death still caught her off guard.

“I have family and friends that I talk to about things,” she said. “But no one truly understands.”

Doctors don’t typically take time to grieve at work. But during that recent meeting, Miller and her colleagues opened up about the insomnia, emotional exhaustion, trauma, and burnout they experienced from their time in the pediatric ICU.

“This is not a normal place,” Grant Goodrich, the hospital system’s director of ethics, said to the group, acknowledging an occupational hazard the industry often downplays. “Most people don’t see kids die.”

The recurring conversation, scheduled for early-career doctors coming off monthlong pediatric ICU rotations, is one way the hospital helps staffers cope with stress, according to Alyssa Rheingold, a licensed clinical psychologist who leads its resiliency program.

“Often the focus is to teach somebody how to do yoga and take a bath,” she said. “That’s not at all what well-being is about.”

Burnout in the health care industry is a widespread problem that long predates the covid-19 pandemic, though the chaos introduced by the coronavirus’s spread made things worse, physicians and psychologists said. Health systems across the country are trying to boost morale and keep clinicians from quitting or retiring early, but the stakes are higher than workforce shortages.

Rates of physician suicide, partly fueled by burnout, have been a concern for decades. And while burnout occurs across medical specialties, some studies have shown that primary care doctors, such as pediatricians and family physicians, may run a higher risk.

“Why go into primary care when you can make twice the money doing something with half the stress?” said Daniel Crummett, a retired primary care doctor who lives in North Carolina. “I don’t know why anyone would go into primary care.”

Doctors say they are fed up with demands imposed by hospital administrators and health insurance companies, and they’re concerned about the notoriously grueling shifts assigned to medical residents during the early years of their careers. A long-standing stigma keeps physicians from prioritizing their own mental health, while their jobs require them to routinely grapple with death, grief, and trauma. The culture of medicine encourages them to simply bear it.

“Resiliency is a cringe word for me,” Miller said. “In medicine, we’re just expected to be resilient 24/7. I don’t love that culture.”

And though the pipeline of physicians entering the profession is strong, the ranks of doctors in the U.S. aren’t growing fast enough to meet future demand, according to the American Medical Association. That’s why burnout exacerbates workforce shortages and, if it continues, may limit the ability of some patients to access even basic care. A 2021 report published by the Association of American Medical Colleges projects the U.S. will be short as many as 48,000 primary care physicians by 2034, a higher number than any other single medical specialty.

A survey published last year by The Physicians Foundation, a nonprofit focused on improving health care, found more than half of the 1,501 responding doctors didn’t have positive feelings about the current or future state of the medical profession. More than 20% said they wanted to retire within a year.

Similarly, in a 2022 AMA survey of 11,000 doctors and other medical professionals, more than half reported feeling burned out and indicated they were experiencing a great deal of stress.

Those numbers appear to be even higher in primary care. Even before the pandemic, 70% of primary care providers and 89% of primary care residents reported feelings of burnout.

“Everyone in health care feels overworked,” said Gregg Coodley, a primary care physician in Portland, Oregon, and author of the 2022 book “Patients in Peril: The Demise of Primary Care in America.”

“I’m not saying there aren’t issues for other specialists, too, but in primary care, it’s the worst problem,” he said.

The high level of student debt most medical school graduates carry, combined with salaries more than four times as high as the average, deter many physicians from quitting medicine midcareer. Even primary care doctors, whose salaries are among the lowest of all medical specialties, are paid significantly more than the average American worker. That’s why, instead of leaving the profession in their 30s or 40s, doctors often stay in their jobs but retire early.

“We go into medicine to help people, to take care of people, to do good in the world,” said Crummett, who retired from the Duke University hospital system in 2020 when he turned 65.

Crummett said he would have enjoyed working until he was 70, if not for the bureaucratic burdens of practicing medicine, including needing to get prior authorization from insurance companies before providing care, navigating cumbersome electronic health record platforms, and logging hours of administrative work outside the exam room.

“I enjoyed seeing patients. I really enjoyed my co-workers,” he said. “The administration was certainly a major factor in burnout.”

Jean Antonucci, a primary care doctor in rural Maine who retired from full-time work at 66, said she, too, would have kept working if not for the hassle of dealing with hospital administrators and insurance companies.

Once, Antonucci said, she had to call an insurance company — by landline and cellphone simultaneously, with one phone on each ear — to get prior authorization to conduct a CT scan, while her patient in need of an appendectomy waited in pain. The hospital wouldn’t conduct the scan without insurance approval.

“It was just infuriating,” said Antonucci, who now practices medicine only one day a week. “I could have kept working. I just got tired.”

Providers’ collective exhaustion is a crisis kept hidden by design, said Whitney Marvin, a pediatrician who works in the pediatric ICU at the Medical University of South Carolina. She said hospital culture implicitly teaches doctors to tamp down their emotions and to “keep moving.”

“I’m not supposed to be weak, and I’m not supposed to cry, and I’m not supposed to have all these emotions, because then maybe I’m not good enough at my job,” said Marvin, describing the way doctors have historically thought about their mental health.

This mentality prevents many doctors from seeking the help they need, which can lead to burnout — and much worse. An estimated 300 physicians die by suicide every year, according to the American Foundation for Suicide Prevention. The problem is particularly pronounced among female physicians, who die by suicide at a significantly higher rate than women in other professions.

A March report from Medscape found, of more than 9,000 doctors surveyed, 9% of male physicians and 11% of female physicians said they have had suicidal thoughts. But the problem isn’t new, the report noted. Elevated rates of suicide among physicians have been documented for 150 years.

“Ironically, it’s happening to a group of people who should have the easiest access to mental health care,” said Gary Price, a Connecticut surgeon and president of The Physicians Foundation.

But the reluctance to seek help isn’t unfounded, said Corey Feist, president of the Dr. Lorna Breen Heroes’ Foundation.

“There’s something known in residency as the ‘silent curriculum,’” Feist said in describing an often-unspoken understanding among doctors that seeking mental health treatment could jeopardize their livelihood.

Feist’s sister-in-law, emergency room physician Lorna Breen, died by suicide during the early months of the pandemic. Breen sought inpatient treatment for mental health once, Feist said, but feared that her medical license could be revoked for doing so.

The foundation works to change laws across the country to prohibit medical boards and hospitals from asking doctors invasive mental health questions on employment or license applications.

“These people need to be taken care of by us, because really, no one’s looking out for them,” Feist said.

In Charleston, psychologists are made available to physicians during group meetings like the one Miller attended, as part of the resiliency program.

But fixing the burnout problem also requires a cultural change, especially among older physicians.

“They had it worse and we know that. But it’s still not good,” Miller said. “Until that changes, we’re just going to continue burning out physicians within the first three years of their career.”

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When it comes to buying a household appliance, car, or home, consumers study their options carefully. The customer is conditioned to consider all options when making these major purchases; benefits and costs are mapped out clearly by manufacturers and reality checked by consumer product journalists and other customers who have purchased similar products. 

But what happens when people are confronting cancer, diabetes, or heart disease treatment or prevention? Then, they’re not so sure in their decisions as they confront a lack of authoritative information and a web of conflicting studies and recommendations.

Talya Miron- Shatz, PhD, an expert in medical decision making, and author of a new book titled “Your Life Depends on It: What You Can Do to Make Better Choices About Your Health,” takes a new approach to why physicians and patients need to abandon old behavior patterns that no longer work and learn to help each other make better collaborative choices. 

Dr. Miron-Shatz maintains that consumers must learn to express what they want and become part of the decision-making process as a partner or informed participant.

It’s an intriguing idea whose time, very frankly, is overdue. Doctors can no longer assume treatment decisions are all “their call.” Dr. Miron-Shatz maintains that both doctors and patients must explore what will work best toward the desired outcome and, as an outgrowth of this exploration, health system leaders must recognize that their processes for approvals, prior authorizations, and formulary baffle patients and cloud their understanding of potential outcomes and must change.

The System Rules Itself — Not Patient Input or Outcomes

We make a mistake if we assume that patient care is the system’s priority. When the decision pathway is murky and the consumer’s voice is absent, the system jockeys to make sure “house rules” win. Consumers not only need clarity of information, but they also need to build up their ability to make informed choices. As Dr. Miron-Shatz writes:

“We all make health and medical choices every single day. We choose to take a vitamin supplement, go for a run despite a sore tendon, forgo birth control pills, or have chemotherapy after cancer surgery. The more important these decisions are, the more vulnerable we are, and the tougher choosing becomes. This is why we need to build up skills to deal with these choices.”

It’s a simple yet powerful concept. For years, we in the healthcare ecosystem have heard the seemingly sensible call to “invite patients to the table.” Epidemiologist and decentralized clinical trials leader Craig Lipset, himself a patient with a rare disease, recognizes that assumption is flawed. “It’s their table in the first place,” Lipset says. “Too many fear ‘I don’t know’ as a sign of weakness, rather than a signal of confidence and honesty.” 

Though a response of “I don’t know” from a physician to a patient’s question may not inspire confidence, a provider’s willingness to explore questions with the patient — working as a team — is the foundation for a patient-physician relationship that is a positive force for inspired and trusting care and likely better outcomes.

Time for Shared Decision Making

It’s this working partnership that Dr. Miron-Shatz believes to be foundational for systemic change. However, with payers often making the care decisions, it often seems that the system serves itself. The patient is an afterthought with little influence in the conversation — at best a “junior partner” in their own care decisions. 

Payers often reject medical technologies for reimbursement as “investigational.” They cut physical therapy short, either because “it’s working” or “it’s not working.” Doctors are forced to battle the system, until, exhausted, they follow the path of least resistance. Physicians and patients need to hone their shared decision-making abilities in order to align and direct their combined voice toward better care choices.

Dr. Miron-Shatz knows this must happen. Consumer-patients need to have a larger say in the direction of their care, and they need allies to help them make smart decisions. Sy Syms, the menswear mogul and health philanthropist who founded the SYMS clothing chain in New York City, coined the expression, “An educated consumer is our best customer.” 

It’s a concept that transcends its advertising tagline as it applies to just about every interaction a consumer, even a health consumer, may find themselves in. Consumers entering the health system as patients should remember it, and physicians should listen to their charges. Perhaps the will and needs of the educated (health) consumer can be the foundation of a new alliance that helps healers, too often swimming upstream against the flow of the system, to be better partners and advocates for their patients.

Healthcare professionals that master the patient-care decision-making partnership draw upon emotional intelligence to communicate effectively, empathize with their patients’ struggles, and call upon medical knowledge and research to be better providers. 

But, most physicians are not sufficiently trained to speak with patients and are overwhelmed with the expectations of the system struggling to digitize and integrate technologies to ease their administrative burden. It’s a recipe for making decisions in isolation.

Physicians are Dedicated to Patient Advocacy

Allyson Ocean, MD, a medical oncologist and Associate Professor of Clinical Medicine at Weill Cornell Medicine, is among the founders of a pancreatic cancer health professional and patient advocacy community called Let’s Win for Pancreatic Cancer, that encourages shared decision making, says she is on the phone with insurance companies nearly every day trying to make sure her patients can get the treatment they need, and get it paid for.

“My best advice to work around the system of whether or not drugs or tests can be covered for cancer is to make sure you have an advocate in your field working for you,” says Dr. Allyson Ocean. “The frustrating part for me is that sometimes we even have to educate the insurance companies and say, ‘There’s a reason why I want to use this medicine.’”

In medical school, doctors do not learn how to navigate the medical system. They expect to help patients, to tackle disease — but not how to collaborate to tackle obstacles thrown up by the very system in which they’re preparing to work. Dr. Miron-Shatz, a “medical decision-making scientist,” has researched how doctors, consumers, and health systems need to learn how to collaborate and make better medical choices. 

Her new book is the long-needed guide for physicians, patients, and payers that will help them better navigate today’s care realities and rising consumer expectations. Dr. Miron-Shatz recognizes that what is essential to innovation’s success is having a knowledgeable and engaged customer — the consumer voice — as part of the decision-making conversation. She sums up the challenge facing caregivers and patients in this fragmented health ecosystem:

“Making better health and medical choices is neither intuitive nor easy, especially in the face of a life-threatening decision or despite medical jargon and confusing probabilities. Expecting us to handle these flawlessly is unrealistic and ignores issues of cultural background, a whole slew of cognitive barriers, lack of professional training in how to convey medical information, time constraints, and health-system deficiencies.”

Consumers and providers are at a disadvantage. Patients often feel that medicine employs a secret language requiring a skilled translator, and the range of treatment protocols and care options appear to change constantly. The outlook is daunting; to better make informed decisions, Dr. Miron-Shatz prescribes collaboration. 

That’s the key from her point of view, and ensuring patients sit at the head of the medical decision-making table must become the norm. It’s central to better, informed choices that drive care delivery, and will also influence future drug development and regulatory processes. Our lives depend on it.

[Special thanks to Dr. Elinor D. Bashe and John Bianchi for their contributions and input.]

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