It's About the Doctors, Stupid

Close your eyes for a moment and think about your last visit to the doctor.

Why did you schedule it? What were you worried about? How long did it take to get an appointment with the person you actually wanted to see — and did that wait matter to you? How long did you sit in the waiting room? At check-in? In the exam room? In testing?

What was the bedside manner? Did they take their time, or did you feel rushed? Were all of your questions answered? How did you feel walking out? Was the reason you went actually addressed? Are you going to go back, or follow up on that referral?

And the one underneath all of them: do you trust your doctor?

The trust data — and the number almost everyone gets wrong

The honest answer, in the aggregate, is that trust is falling. It is falling as part of a broader erosion of confidence in institutions, but the size of the drop in medicine specifically is larger than most people realize.

The best evidence comes from a 50-state survey study published in JAMA Network Open in July 2024 by Perlis and colleagues. Across 24 survey waves and 443,455 unique respondents, the proportion of U.S. adults reporting a lot of trust in physicians and hospitals fell from 71.5% in April 2020 to 40.1% in January 2024. A 31-point collapse in under four years.

A word on a statistic you have probably seen quoted alongside this one: the claim that trust in doctors "plummeted by 75%." It is wrong, and it is worth correcting, because a number that does not survive scrutiny gives people an excuse to dismiss the finding underneath it.

That 75% is a misread of a much older and entirely different measure. Writing in the New England Journal of Medicine in 2014, Blendon, Benson and Hero reported that in 1966, nearly three-fourths — 73% — of Americans said they had great confidence in the leaders of the medical profession, and that by 2012 only 34% still expressed that view. The three-quarters figure was the starting point, not the size of the decline. The real numbers are bad enough on their own. They do not need help.

Now the part that matters more than either headline. In that same analysis, citing Gallup polling, 69% of the public rated the honesty and ethical standards of physicians as a group as "very high" or "high." And in a 2021 NORC survey conducted for the ABIM Foundation, 78% of Americans said they trusted their own primary care doctor, against 64% for the health care system as a whole.

Read those together and the picture is specific rather than gloomy: the institution is losing the room, but the relationship in the exam room is holding. That relationship is the asset — and it is not a soft one. A systematic review in BMJ Open (2018) screened 726 studies, found 22 that met its criteria, and reported that 18 of them found significantly lower mortality among patients with greater continuity of care with their doctor. Its conclusion is worth quoting plainly: increased continuity of care by doctors is associated with lower death rates.

Continuity is not a nicety. It is a clinical outcome. And it is precisely what every trend in this industry is currently grinding down.

Now flip the experience on its head

Run the same exercise, but imagine your physician's day rather than your own.

Personnel turnover and wage inflation. Vendor ordering and payment. Rising regulatory and documentation burden. Consolidation pressure from private equity and hospital systems. Succession planning nobody has started. Insurance contracting. Prior authorization. Data breaches and cyber liability. A never-ending list, layered on top of every personal responsibility they carry outside of work — and layered on top of the actual practice of medicine.

It is no wonder that, in The Physicians Foundation's 2024 survey of current and future physicians, roughly six in ten physicians reported frequent feelings of burnout — with residents and medical students reporting higher rates still. The people we are counting on to replace the current generation are arriving already exhausted.

Burnout is the symptom. The job we built is the disease.

Burnout gets discussed as though it were a resilience problem — as though the answer were a wellness webinar and a better yoga schedule. The evidence points somewhere much less flattering to the rest of us.

A landmark time-and-motion study published in the Annals of Internal Medicine observed physicians in family medicine, internal medicine, cardiology and orthopedics across 430 hours of clinic time. It found that physicians spent 27.0% of their office day on direct clinical face time with patients, and 49.2% on electronic health records and desk work — nearly two hours of administrative work for every hour spent with a patient, plus another one to two hours of documentation at home in the evening.

Read that again. We took the most expensively trained professionals in the economy and arranged their working day so that the majority of it is spent not doing the thing they trained for.

Now put a name on the single most resented piece of that burden. In the American Medical Association's 2023 prior authorization physician survey of 1,000 practicing physicians, respondents reported completing an average of 43 prior authorizations per physician per week, consuming roughly 12 hours of physician and staff time. 94% said prior authorization delays access to necessary care. And nearly one in four — 24% — reported that prior authorization had led to a serious adverse event for a patient in their care.

That is the arithmetic behind the burnout number. It is not that physicians have become fragile. It is that we have built a job in which the highest-frequency activity is adversarial paperwork, and in which that paperwork demonstrably harms the patients it is nominally there to protect.

Then consider what it costs in supply: the AAMC's 2024 workforce projections anticipate a shortage of between 13,500 and 86,000 physicians by 2036. We cannot train or recruit our way out of the wave of care coming over the next fifteen to twenty years if we keep burning out the people already in the building.

So where do we go from here?

Private equity, Amazon, insurers, politicians, banks, health systems — everyone has an opinion about how to fix physician practice. As they say, opinions are like a certain thing that everybody has. I will stop there.

Perhaps instead of trying to reinvent the wheel, it is worth stopping and listening. To the doctors.

The next time you see your physician, try starting with a different question: why did you join this profession in the first place? These are people who invested a decade or more of study and training in order to serve patients and their community. Very few of them will tell you that what drew them in was the deep personal fulfillment of arguing with an insurance company.

Then ask the follow-up that actually matters: does your daily work still line up with that answer?

We are increasingly disenchanted with our experience of our doctors, while simultaneously asking those same doctors to spend most of their day on work that has nothing to do with why they became doctors. Both of those things are true at once, and the second one causes the first.

It's about the doctors, stupid

As we come to the end of a long, exhausting, and frustrating political season, allow me to invoke a kinder, gentler time. When I was all of seven years old, Bill Clinton built an entire presidential campaign around the Ragin' Cajun James Carville's slogan: "It's the economy, stupid."

Might I suggest the healthcare equivalent. If we, as patients, want to rebuild trust with our physicians so they can deliver the care we so desperately need, then we, as healthcare leaders, have to give those physicians every possible tool to find the fulfillment they came looking for.

In other words: it's about the doctors, stupid.

Why I started by listening

I did not start this practice to prescribe a better model of physician practice management. There is no shortage of those. I started it to listen.

The people on the front lines of patient care understand the issues better than any of us on the outside possibly could. The job is to understand those issues deeply, in the context of the physicians' own goals, and then — through rigorous debate and honest financial analysis — lay out the strategic options that actually align with their "why."

Healthcare is not "just business." It is a greater calling. Every interaction between a physician and a patient is an opportunity to build trust. Every chance to make that interaction more fulfilling for the physician is a chance to be a force for good in a world that could use one.

So: we listen first, then we serve the physicians' needs rather than our own — to help build the practices they actually want, not the ones everyone else is telling them to build.

What that looks like in practice

Once the "why" and the strategic plan are clear, the work is concrete. We manage the practice's financial strategy while complementing and enhancing the physicians' existing advisors, practice managers, and staff — coordinating the interested parties so the doctors do not have to, which relieves pressure and returns time to what matters most to them.

• Fractional and outsourced CFO services — senior financial leadership embedded in the practice, without the cost of a full-time hire.
• Project management — strategic planning, transaction advisory, accounting and finance process optimization, capital expenditure planning and financing, budgeting and forecasting, payor analysis and negotiation, vendor management and negotiation, treasury strategy, and lease negotiation and structuring.
• Educational lectures and workshops on the financial topics and challenges physicians specifically face.

As part of Inglewood, this work also draws on four decades of the firm's experience and its professionals across business performance advisory, transaction advisory and valuation, interim management, and expert witness and litigation support when a situation calls for it.

An invitation

Over the coming months and, I hope, years, I look forward to sharing more thinking and inviting conversation about how we raise the standard of excellence in serving our physicians — so that they, in turn, can deliver the best possible patient care.

I would genuinely like your thoughts and your experience along the way, so we learn from each other. Why? Because we are all patients too, and we all want the best for our families and ourselves.

If you know independent physician groups — particularly in Ohio — who are frustrated with their current situation, or employed physicians considering striking out on their own, I welcome warm introductions to talk through their purpose and their options. Not sure where you stand? That is usually the most useful first conversation, and it costs nothing. We also welcome partnerships, especially with operational expertise that complements ours.

Please do not hesitate to share your comments, or topics you would like me to take on next.

With gratitude and appreciation,
Mike Ferkovic