Doctors and Patients Have Identified the Problem: American Healthcare

I recently had the pleasure of being invited onto Kim Downey’s Stand Up (for) Doctors! podcast with my friend Dr. MaryAnn Wilbur for a conversation called “Doctors & Patients: Catalyzing Positive Change Together.”

This meant I had the unusual privilege of being the resident Y chromosome in a conversation among extremely accomplished women, a position for which I remain uniquely qualified. MaryAnn has an MD, an MPH, several other letters I’m probably forgetting, and decades of experience as a physician and physician advocate. Kim has built an entire community around supporting doctors and restoring the humanity of medicine. I brought 30 years of being a patient, a book, a microphone, and the confidence of a middle-aged bald man who has somehow wandered into health policy without anyone checking his credentials. It was delightful and, in the way so many conversations about American healthcare have become, completely insane.

MaryAnn told the story of a patient with endometrial cancer for whom she recommended the standard of care: a minimally invasive hysterectomy with sentinel lymph node dissection. This was not some experimental moonshot she had discovered on TikTok. It was the standard of care for a disease she treats for a living. But the patient had commercial insurance, which meant MaryAnn had to obtain prior authorization and then endure not 1 but 2 peer-to-peer reviews, explaining gynecologic oncology to physicians working on behalf of the insurance company who were not gynecologic oncologists. After roughly 10 weeks of fighting, the patient finally got to surgery, where MaryAnn discovered metastatic disease she had not anticipated.

There is a point at which terminology becomes complicity. We call this “utilization management,” which sounds like something involving forklifts at Costco. We call it “administrative burden,” as though MaryAnn had neglected to submit her expense report before the end of the quarter. We call it a “peer-to-peer,” which is particularly magnificent because the peer may practice an entirely different kind of medicine and is nevertheless participating in a conversation about whether the specialist treating the patient should be permitted to provide the established treatment for the cancer sitting inside her. Meanwhile, we have an entire national conversation about physician burnout. I assume there are PowerPoints.

This is what I kept thinking about after talking with Kim and MaryAnn. Not whether doctors need patients on their side, or patients need doctors on theirs. That framing gets the relationship wrong. Doctors and patients were never supposed to be competing constituencies negotiating a strategic alliance. They are the 2 people at the center of the transaction, and nearly everything else in healthcare was ostensibly invented to help one of them care for the other. Somehow, the supporting infrastructure became the plot.

Insurance companies, hospital systems, pharmacy benefit managers, benefit consultants, prior authorization vendors, revenue-cycle operations, quality metrics, formularies, networks, claims systems, electronic health records, accrediting bodies, government programs, employer benefits departments and an administrative ecosystem so vast that somewhere there is probably a Vice President of Vice Presidents have accumulated around the exam room. Some of those things are necessary. Some are useful. Some solve real problems. But collectively they have created a remarkable situation in which the doctor can be sitting directly across from the patient, both wanting essentially the same thing, while neither possesses the authority to make it happen.

And then they get frustrated with each other. The patient wonders why the doctor isn’t listening, why the appointment lasted 11 minutes, why the prescription wasn’t covered, why the scan hasn’t been scheduled and why nobody called back. The doctor is staring at an electronic medical record, running 45 minutes behind, answering messages at night, fighting prior authorizations between appointments and explaining to an insurance company why the cancer patient requires cancer treatment. We have somehow managed to put the 2 humans healthcare is supposed to serve into the same room and make each of them feel responsible for a system neither one controls. That may be one of the most impressive accomplishments in modern American management.

Kim understands this better than most, which is why I was grateful she brought MaryAnn and me together for this particular conversation. Her work is called Stand Up (for) Doctors! because the distinction matters: physicians need to stand up and tell these stories, but the rest of us also need to stand up for the people trying to care for us. As she said during our conversation, doctors and patients ultimately want the same thing: good care and a physician-patient relationship that is allowed to function.

MaryAnn described it even more simply. We need to protect “the humans needing care and the humans trying to provide care” from the external pressures interfering with that relationship. I love that phrase because it strips away almost everything we have spent the last half-century piling on top of healthcare: the human needing care and the human trying to provide it. Maybe start there.

For most of my career, I came at this from the patient side because that was the world I knew. I became a cancer patient at 21, which was my extremely inefficient alternative to graduate school, and spent the next 30 years learning American healthcare by repeatedly getting hit in the face with it. MaryAnn came through medicine. Kim came through her own experiences and her commitment to physicians. We arrived at this conversation through different doors and found ourselves standing in roughly the same ridiculous room.

That matters to me now because my own work has moved upstream. I have become increasingly interested not simply in helping people survive American healthcare but in asking why we continue tolerating the conditions that make survival skills necessary in the first place. My work around We The Patients is based on the possibility that patients can become a measurable civic constituency capable of influencing the political incentives that shape healthcare. But the more I think about that constituency, the less interested I am in drawing a moat around the word “patient.” Physicians live here, too.

Not because physicians and patients always agree. Of course they don’t. Doctors are people, patients are people, and people remain one of humanity’s more troublesome inventions. There are bad doctors. There are impossible patients. There are disagreements, mistakes, egos, failures of communication and all the other things that happen whenever Homo sapiens are allowed indoors. But those are human problems. What MaryAnn described is a structural one.

And perhaps that’s where something important is happening. Not a grand new alliance between previously warring tribes, or Doctors and Patients Joining Forces™, soon to be celebrated at a Marriott ballroom near Dulles with lanyards and a chicken lunch. Something much simpler: recognition.

The physician-patient relationship is not one interest among many in healthcare. It is the central relationship around which healthcare is supposed to be organized. When the machinery surrounding it becomes so cumbersome that physicians and patients increasingly recognize themselves as being squeezed by the same machinery, perhaps the question is no longer how we make everyone better at navigating it. Maybe we ask why the machinery gets to behave this way at all.

So thank you, Kim, for inviting me into your community and for creating a place where these conversations can happen without turning doctors into villains, patients into inspirational props or healthcare reform into another beige panel discussion featuring 6 people who all have “innovation” somewhere in their LinkedIn bios. And thank you, MaryAnn, for once again reminding me why physicians need to be part of this conversation, not as another stakeholder group to be managed but as human beings standing on the other side of the same exam room.

I went on a podcast called Stand Up (for) Doctors! expecting to talk about doctors and patients. Instead, I think we identified the problem: healthcare.