Doctors Aren’t Unable to Treat Their Patients. They’re Being Blocked.

Patients experience denials, delays and administrative barriers from one side of American healthcare. Increasingly, physicians are encountering the same machinery from the other.

There was a moment during my recent conversation with Dr. Will Flanary and Kristin Flanary when Kristin interrupted her husband over a verb.

Will was talking about what has happened to physicians inside American healthcare and said that doctors increasingly know how they want to treat their patients but are not able to do it. Kristin corrected him. Doctors are able to do it. They have the training, judgment and skills. They are being blocked from doing it.

I have spent 30 years as a patient and nearly two decades in patient advocacy on the other side of that sentence, and somehow I had never heard the problem expressed quite that way.

Jen Singer and I recently joined Will and Kristin on their podcast, Knock Knock, Hi!, ostensibly to talk about our book, We the Patients: Understanding, Navigating, and Surviving America’s Healthcare Nightmare. There was already a ridiculous amount of connective tissue among the four of us before anyone turned on a microphone. All four of us have lived through serious illness. Jen and I met through the cancer world years ago. Will and I are both young adult cancer survivors. Will, Kristin and I later appeared in Suck It Up, Buttercup, the documentary about physician burnout that unexpectedly pulled me into a crisis inside medicine I had understood far less than I thought.

Before the interview really got going, Will added another connection I had not fully appreciated. He told listeners that he had directly benefited from the young adult cancer advocacy movement I helped build.

When I founded Stupid Cancer in 2007, adolescent and young adult cancer barely existed as a coherent field. I had been diagnosed with brain cancer at 21 in 1995 and went seven years before meeting another young adult brain cancer survivor. I met him by accident. His name was Craig, he was also a bald Jewish guy from New York, and naturally we had somehow managed to attend the same college and sing in the same a cappella group without discovering that we shared the small inconvenience of having survived brain tumors.

That encounter helped redirect my life. Young adults with cancer needed something medicine and traditional cancer organizations had largely failed to provide. We needed other people our age. We needed information about fertility, careers, relationships, survivorship and the peculiar experience of receiving a catastrophic diagnosis while everyone else we knew was worrying about first jobs and terrible apartments. We also needed permission to talk about cancer in language that belonged to us.

Over time, an actual young adult cancer ecosystem emerged. Organizations grew, research followed, programs developed and communities formed. First Descents became one of them, and Kristin found it for Will after his second cancer. She knew her husband well enough to understand that sitting in a circle discussing his feelings was probably not going to happen. First Descents offered another way in: go do something difficult with other young adults who had been through cancer and let the human part happen on its own. Will told us it became a lifeline.

At the end of our interview, Kristin said, “You paved a trail that we walked on.”

I have received plenty of lovely acknowledgments over the years, but this one felt different. Advocacy rarely gives you a reliable view of causality. You launch programs, raise money, fight institutions, build organizations, annoy important people and accumulate enough PowerPoint decks to constitute an environmental hazard. You can measure participation and growth, but you rarely get to follow an invisible line across 20 years and discover where it ended up.

This particular line ended up with an ophthalmologist who survived cancer, became Dr. Glaucomflecken and built an enormous audience by exposing the absurdities of American healthcare through comedy. Years later, our paths crossed because he and Kristin had begun talking publicly about another population getting ground down by the healthcare system: doctors.

My involvement with Suck It Up, Buttercup forced me to confront a blind spot I had carried through decades of patient advocacy. I knew physicians were burned out. Everyone knew physicians were burned out. The phrase had become so familiar that I had stopped interrogating what it actually concealed. “Burnout” sounded like an unfortunate occupational consequence of practicing difficult medicine, perhaps exacerbated by a pandemic, long hours and the emotional weight of caring for sick people.

Then I started listening to physicians describe their lives.

They talked about losing clinical autonomy, about insurers overriding treatment decisions and prior authorizations consuming hours that should have belonged to patients. They talked about corporate consolidation, productivity requirements, private equity and administrative work following them home at night. They described knowing what a patient needed and having to negotiate with people and institutions that had never examined the patient before they could provide it.

I recognized the machinery immediately. I had simply spent my career looking at it from the other side.

Patients know the denial letter. Physicians know the prior authorization process that produced it. Patients know the medication their insurance suddenly refuses to cover. Physicians know the formulary that changed what they could prescribe. Patients know the specialist they cannot see, the bill they cannot decipher and the treatment they cannot get approved. Their doctors increasingly know the administrative architecture standing between their medical judgment and the human being sitting in front of them.

Jen and I encountered this repeatedly while writing We the Patients. One of the central arguments of the book is that the complexity patients experience did not simply materialize because American healthcare accidentally became too complicated. Over decades, we created financial and administrative incentives that can reward delay, obscurity and friction. When a legitimate claim goes unpaid because someone gives up on an appeal, for example, the cost does not disappear. It remains with the patient while the party that would otherwise have paid it retains the money. Multiply variations of that dynamic across a healthcare economy measured in trillions of dollars and friction stops being merely inconvenient. It has economic value.

This is one of the central contradictions of American medicine. We can produce extraordinary scientific advances while simultaneously constructing administrative barriers between those advances and the people who need them.

For most of my career, patient advocacy responded to those barriers by teaching patients to fight harder. Learn the terminology. Get your records. Appeal the denial. Ask for the supervisor. Find the navigator. Bring somebody to the appointment. Understand your benefits. Become an educated consumer of a product whose price you frequently cannot know beforehand, whose quality you may not be qualified to judge and which you would generally prefer never to need.

All of that advice remains useful. I have given it myself for years. I have also become increasingly uncomfortable with the premise underneath it. At some point, congratulating people for becoming exceptionally skilled at surviving unnecessary obstacles starts to look a lot like accepting the obstacles.

Medicine has developed its own version of the same accommodation. Physicians get resilience training while many of the conditions eroding their resilience remain intact. A doctor buried under administrative work can learn mindfulness. A patient buried under insurance paperwork can learn self-advocacy. Both interventions may genuinely help the individual cope, but neither necessarily alters the institution creating the burden in the first place. We have become remarkably good at teaching people how to adapt to dysfunction without requiring the dysfunction to adapt to them.

This is why Kristin’s correction stayed with me.

“Blocked” assigns agency to what “unable” can make sound inevitable. Prior authorization requirements do not descend from the atmosphere. Formularies, reimbursement structures, network restrictions, productivity requirements and corporate policies are designed by people and institutions pursuing particular economic and operational objectives. Some of those controls exist for legitimate reasons, including cost management, patient safety and the prevention of unnecessary care. Others can create delays, administrative burdens and incentives that work against the interests of patients and the clinicians trying to treat them. Once those choices become visible, physician burnout and patient frustration stop looking like unrelated occupational and consumer problems and start looking like different consequences of the same system of incentives.

Will made another observation near the end of our conversation that I have been thinking about ever since. If patients ever organize around healthcare as a genuine political constituency, physicians and other healthcare workers belong in that arithmetic too. He was speaking from inside a profession that increasingly understands itself as losing power to the institutions surrounding medicine.

That creates an alliance I did not foresee when I entered patient advocacy nearly 20 years ago. Back then, I was trying to get young adults with cancer recognized as people with distinct needs. Today I am much more interested in what happens when patients stop organizing exclusively around diagnoses and begin organizing around the forces that affect nearly everyone who becomes sick. The physician who wants to provide appropriate care and the patient who wants to receive it have considerably more in common than our healthcare politics generally acknowledge.

There are legitimate conflicts between patients and medicine, and any serious patient movement has to retain the freedom to confront physicians, hospitals and professional institutions when they cause harm. Solidarity cannot require selective amnesia. Nor should physicians be romanticized as powerless participants in a system in which they still possess considerable authority. The point is not that every doctor and every patient share identical interests. They plainly do not.

The more consequential point is that the growth of corporate medicine, administrative control and insurer influence has altered the balance of power inside the exam room. Patients and physicians can argue with each other forever about what happens there while decisions made far outside that room increasingly determine what either of them can do.

For decades, patient advocacy has been extraordinarily good at organizing people around what happened to them. Cancer. Diabetes. Rare disease. Disability. Medical debt. A denied claim. A devastating diagnosis. Those communities have accomplished remarkable things, including the young adult cancer movement that eventually found its way to Will Flanary.

What we have been less successful at doing is organizing people around why so many of those experiences keep happening across diseases, institutions and populations. The diagnosis changes. The administrative machinery often does not.

That distinction matters because stories can generate sympathy, but constituencies generate political consequences. Patients have enormous numbers but remarkably little organized power as patients. Physicians have professional authority but increasingly find themselves constrained by institutions with far greater economic leverage. Employers spend staggering amounts on healthcare while their workers struggle to use the benefits being purchased for them. Each group experiences a different part of the same system, and each has traditionally organized around its own piece of the problem.

The possibility that interests me now is what happens when those pieces begin to connect.

Nearly 20 years ago, a community of advocates built something because young adults with cancer were isolated and largely invisible. Somewhere downstream, a young doctor with cancer found his way into that world. He survived, kept practicing medicine, became one of the most recognizable physician voices in the country and started using comedy to show millions of people what healthcare looks like from behind the curtain.

I eventually wandered behind that curtain myself and discovered physicians describing a system I already knew intimately.

Kristin was right about the verb.

The more interesting question now is what happens when the people on both sides of the exam room finally recognize who keeps blocking the door.