Insurers are popular villains — and they have definitely earned their reputation by employing underhanded tactics to restrict benefits. But other observers have recently pointed to doctors as the underlying driver of the US health care crisis because of the prices charged for their services, the highest in the world on average; hospital and physician spending account for most of the system’s costs.

That has in turn drawn backlash from doctors who, as the clinicians who actually care for patients, felt unfairly maligned for the system’s problems.

It was the latest round of a blame game that obstructs our ability to meaningfully change the health care system. Much has been written recently on the aggregate contributions of health insurers and providers — hospitals, doctors, nurses — to the collective crisis. But what doctors argued, and with some justification, was that the conversation was missing the experiences of the individual physicians who don’t feel our system works well, either, and who routinely feel worn down by it.

Even the medical profession’s critics understand the American health care system will need an engaged and committed workforce to thrive. If the US is to mend it, we must figure out how to contain costs while also improving the experience for the people practicing medicine. Those goals have sometimes been pitted against each other, but they can be complementary — and pursuing both of them would invite doctors to be a part of the solution to our health care crisis.

We need to better understand not only how the providers are contributing to the system’s problems, but also how the system is failing them.

Many US physicians are tired and stressed

The American doctor was once an important fulcrum of the community, a self-starting entrepreneur who also served as connective tissue among neighbors, somebody who would care for their patients from birth to death. As society and medicine changed, the doctor’s individual primacy was lost. More and more are now employees, not business owners, and the doctor-patient relationship is fraying.

I have written in the past about doctors’ discontent. There is a real sense among some young physicians that they have missed out on something. One study that tracked the same individual practitioners over several years found that the number of them who reported feeling burned out grew from 44 percent in 2017 to more than 50 percent in 2021. Primary care doctors in particular experienced high burnout rates.

It is one more piece of evidence that America’s doctors are not all right. But while some of the problems they face are unique to their nation’s health care system, others are not. No matter where you practice, being a doctor can be tough.

I have traveled to other countries and talked to physicians about working under genuinely universal health care systems. They face some of the same challenges with burnout and stress that US doctors do. They wish they were paid more like their American peers. But some of the issues that wear down the US medical workforce, such as navigating claims and denials from private insurers, would be foreign to clinicians in other countries.

The reality is frustratingly complex, and the experiences of US doctors are not monolithic. A rural primary care doctor in Montana does not necessarily share much in common with a neurosurgeon in New York City, even if people call them both doctors. Based on my conversations with health care workforce experts, the US probably has too many surgeons and not enough family doctors. It doesn’t pay the latter enough for the value they provide in preventing costly illnesses.

That kind of misallocation can be traced back to one of those problems that is unique to American medicine: the high cost of a medical education. When you have six figures in medical debt, a surgeon’s salary is more appealing than that of a family doctor. Even before new doctors get their MDs, the US health system starts putting obstacles in front of them.

Medical education in the US is really expensive

Medical professional societies in the US have been global pioneers in their requirements for training and licensing, which helped make the quality of American health care the envy of the world for much of the 20th century. Yet that has also made it very expensive to become a doctor here.

Part of it is the length of training: US doctors attend four years of undergraduate college and four years of medical school, then they have a required residency period of three to seven years during which they do not earn a full-time salary. It can take up to 15 years to become a properly licensed physician. In that time, doctors in training can spend up to $500,000 on tuition, and most of them will graduate with more than $200,000 in education-related debt.

Physicians elsewhere do not bear the same financial burden. I traveled in 2019 to the Netherlands, Australia, and Taiwan, which have three distinct health care systems that still manage to cover all of their citizens: universal private insurance, a public-private hybrid, and single payer, respectively.

In the Netherlands, physicians take three years of undergraduate studies, three years of master’s studies, and complete a one- to two-year internship before being licensed; certain specialties then require further training. Dutch university students typically graduate with much less debt (less than 25,000 euros on average, or about US$26,200) than their American counterparts. In Australia, the training requirements would look familiar to US doctors — a decade or so of education and then on-the-job training — but the tuition would not, with annual medical school costs capped at less than $10,000 per year. Taiwanese doctors likewise spend significantly less money on their education, even relative to differences in cost of living, than US doctors.

What all of those countries have in common is more robust public support for higher education and generous loan repayment programs. The high cost of college is a longstanding issue in the US, and that contributes to the prohibitive cost of a medical education for reasons that have little to do with health care itself.

The US health system forces doctors to do so much paperwork

There is another way in which the US health system places an unusual burden on doctors: the headaches of health insurance paperwork. As left-leaning policy analyst Matt Bruenig wrote on the recent brouhaha over insurers and doctors after the killing of Brian Thompson, at least some of the excess pricing of US medical services can be attributed to the administrative costs that providers incur while dealing with private insurers.

The demands of insurance claims on doctors’ time and attention not only make for a less pleasant working experience, they also take them away from patients, which can contribute to worse health outcomes.

Here is perhaps the most telling statistic, from the Commonwealth Fund’s 2024 international survey of doctors: 20 percent of US doctors said they spend “a lot” of time on paperwork or disputes over medical bills. That was nearly double the rate in the country with the next highest share; 12 percent of Swiss doctors said the same working in their country’s system, which also relies on private insurers to oversee benefits.

Only 5 percent of Dutch doctors and 9 percent of Australian doctors said that paperwork and billing took up a large chunk of their time.

This wasteful activity affects both the cost and quality of our health system. Among wealthy countries, US patients have the fewest number of consultations with a doctor in a given year, with the exception of Sweden, and spend the least time with their physicians. Time and money spent on administrative work, for both insurers and providers, account for about 30 percent of the excess medical spending in the United States.

American doctors do make a lot of money

Fixing college and post-college education costs is maybe as challenging as cutting health care costs. So America’s blunt solution to the doctor debt problem is: Sure, you will accumulate a lot of debt, but at least you’ll make a lot of dough.

And it’s true. The average physician salary in the US ranges from about $260,000 (for endocrinologists and pediatricians) to $550,000 (for certain surgeons). The most elite providers earn more than $1 million annually.

Dutch general practitioners, by contrast, make about 120,000 euros (US$126,000). Even senior hospital surgeons typically earn about 250,000 euros. Australia, with a more robust private market, can be more generous: While primary care doctors earn between AUS$100,000 and $150,000 (US$60,000 to US$93,000) on average, senior practitioners make more and specialized surgeons can rake in as much as AUS$750,000 (US$460,000) — much closer to the American norms.

Doctors in Taiwan — where, it should be noted, nationwide average incomes are about half of what you find in the United States — can make between US$60,000 and $100,000 per year. The policy experts I spoke to there agreed that doctors are underpaid relative to the high number of patients they see, substantially more than a typical American physician will see in a day.

Whatever complaints American physicians may have, doctors in those countries feel undercompensated. Dutch primary care doctors have gone on strike multiple times to call for better pay and more manageable patient loads. Australian physicians describe being torn between their altruistic sense of duty to the country’s public health care system and the money they can make in the private sector.

A plurality of Taiwanese doctors say they are neutral on the country’s national health care program, far below the sky-high approval ratings among patients. I spoke with one Taiwanese doctor who had been drifting from pediatrics to plastic surgery because of the better salary and schedule. He exclaimed in exasperation during our interview: “We are not the Avengers!” They feel patients expect them to be superheroes under the universal health system, where there are few financial barriers to seeking care, while accepting low pay.

Doctors can help make a better health care system

The blame game between insurers and doctors is ultimately a distraction. Other countries have private health plans and private providers and yet don’t experience nearly the same waste and out-of-control price increases as the US has. The whole system — the prices and how they’re paid — will need to be addressed in the long run. As one landmark health economics paper put it 20 years ago: “It’s the prices, stupid.”

US physicians do have legitimate gripes, however. It’s expensive to become a doctor, you have to deal with a lot of administrative hassle, and the system’s response to these frustrations is the same as Don Draper to Peggy Olsen in Mad Men: That’s what the money is for.

You just have to keep the condition of the US health care workforce in context. In the Commonwealth Fund’s international surveys, American physicians report high levels of stress and burnout, but the doctors in Germany and France and Switzerland feel much the same. Being a doctor is tough, no matter what. But burnout among US physicians has dropped a bit since 2021, per the American Medical Association’s annual survey. Their job satisfaction has actually been rising. In an informal poll from MedScape, American doctors said they were paid fairly at a much higher rate than their peers in other countries.

The US will need doctors to build the kind of health care system people seem to want. They should be allies for reformers, not adversaries. Changes to health care reimbursement, prioritizing preventive primary care in the same way the system does complex surgeries, could help steer more aspiring doctors into specialties where they are most needed.

At the same time, the profession will need to accept some changes if the US is going to be able to afford universal health care. If lawmakers let non-MD clinicians handle more basic care, the system can probably save money without sacrificing quality, as leading policy experts have argued. They charge less money for the same services in part because they don’t carry the same (expensive) credentials.

But physician trade associations typically oppose expanding “scope of practice” policies. That kind of protectionism is an example of how providers do actively help preserve some flaws in the current system.

The path forward could be some combination of making it less prohibitive to practice certain kinds of medicine in the first place, while also attempting to curb some of the inflationary pricing of the past few decades. Make it easier for doctors to charge affordable prices for their services.

In the past, doctors have been defenders of the status quo; they helped create the system of private insurance that many of them now condemn. Both sides of the clinical relationship — the providers and the patients — have grown sick of how screwed up our health care is. The US must find the opportunities to fix both sets of problems and make the system less maddening for everyone.

Nobody seems to care much for that kind of nuance in the wake of the brazen killing of a health insurance CEO. But comparing the experiences of US doctors to those in other wealthy countries reveals there is no clean narrative here. In some ways, they have it harder; in others, they have it better. There isn’t one problem to fix. The system needs comprehensive change.