The Forge: How Doctors Get Made
Becoming a primary care physician is a demanding enterprise.
You need the undergraduate degree, of course — four years for most people, unless you're like me and majored in English because you thought it would make you a better songwriter, in which case add two and a half more years to go back and knock out biology, physics, chemistry, and calculus.
Then there's medical school: an immersive baptism by firehose into the culture of medicine, a crucible where the heat of the new environment vaporizes your hobbies, your free time, and your sleep schedule. Over four arduous years everything you were gets liquified, and what's left is raw, unrefined potential — which then gets fed, if you're lucky enough to match, into the forge of residency. There, across eighty to a hundred and twenty hour weeks, you are repeatedly struck, shaped, and tempered into a functioning blade.
Three years of residency is the minimum to make a pediatrician, a family doctor, or an internist. Med-peds takes four. These are your primary care doctors.
The transformation is profound enough that it reorganizes people's lives around it. Relationships end during medical school and new ones form inside it, forged in the shared experience of meeting unprecedented challenges at an unprecedented rate. Spouses routinely remark that medical school turned their partner into a completely different person.
Who gets selected
From the very beginning, the process favors people who excel within a system.
Think about your friend in undergrad who was set on becoming a doctor. They studied. They volunteered. They got the grades. Then they went off to medical school and you didn't see them for a while. Admissions committees select for students who excel at compliance, and the application process filters out nonconformity in favor of predictability and reliability.
At my own interview, I was asked to stand at a whiteboard and convince a physician that my desire to become a doctor was "more than the passing fancy of a flighty musician who is down on his luck and motivated by the promise of financial gain." The applicant before me told me afterward that he and his interviewer had cried together about their dogs dying. He was accepted the next day. I got in off the waitlist and heard back six months later.
That system persists all the way through training. Clinical experience runs on hierarchy: attending physicians at the top, maybe some fellows beneath them, then residents ranked by year with interns at the bottom, and medical students running around underneath trying to keep up with everyone. Challenging authority or deviating from an established protocol is punished. And because mistakes cause patient harm, you're simply not allowed to make them — everything you do in training has to follow a standardized, evidence-based guideline.
I'll never forget the day my attending physician called me out in front of her entire clinic for telling a patient with a leg-length discrepancy that whatever relief he was getting from reiki wasn't going to fix his hip pain. My intention was to explain that a lift in his left shoe would make the relief he was already getting last longer. My error was acknowledging that the reiki had offered him any relief at all.
When your attending yells at you, you freeze. You know that talking back gets you more yelling, or worse, a failing grade. I remember the faces of the nurses who pretended not to notice that my teacher was chastising me for saying something that wasn't backed by evidence.
That was 2013. A quick search while writing this turned up Immediate Symptom Relief After a First Session of Massage Therapy or Reiki in Hospitalized Patients: A 5-Year Clinical Experience from a Rural Academic Medical Center. Where were you when I was getting shouted at in a federally qualified health center, Vergo et al?
What happens after the forge
These doctors stay inside the system long after their training ends. More than 80% of American physicians are now employed — meaning they work for someone else, usually a hospital or a corporate entity.
It makes sense when you look at the position they're in. They've deferred personal freedom to a hierarchy for almost a decade. They carry roughly $200,000 in medical debt. They have received no training whatsoever in healthcare billing, insurance, or practice management. So newly minted attendings follow the high starting salaries and the signing bonuses offered by large groups and hospital systems, and they become highly skilled cogs in a much larger machine.
Their voices are then absent from the tables where healthcare policy gets decided.
In these environments the toxicity of subservience keeps forcing clinicians to trade autonomy for financial security. When sick leave and vacation are merged into a single Paid Time Off bank and pitched as "flexibility," your doctor is perversely incentivized to come to work sick. When last-minute encounters are added to a physician's schedule without their consent — which happens constantly in corporate medicine — your doctor becomes less of a clinician and more of an assembly line. Empty slots and cancellations get labeled "unutilized capacity."
And despite our insisting for years that complex human beings cannot be safely assessed and treated in a fifteen- to twenty-minute slot, roughly half of corporate-employed physicians report intense pressure to prioritize volume over optimal care. Because their schedules are packed by administrators, doctors then get forced into hours of "pajama time" — charting at home, at night, just to satisfy the payor-mandated documentation requirements needed to get reimbursed for work they already did.
I remember one of my bosses telling me at orientation, when I started my corporate job, that anyone in primary care should expect their workday to begin one to two hours before their first patient and end one to two hours after their last. She put in eleven-hour days for every eight hours she was scheduled in clinic: records open around seven, first patient at eight, last at four, home around six.
I remember thinking, that will never be me. Then I pulled my pajama time report — yes, there is an actual report for this — and found I was logged into the system for an average of two hours a day outside my scheduled hours.
What insurance does with your doctor's expertise
In many modern healthcare environments, insurance companies exert significant control over clinical decision-making, administrative workflow, and finances. So all that hard-won experience your doctor accumulated across four years of undergrad, four years of medical school, and three or more years of residency? It has to contend with corporate policy, cost-containment strategy, and bureaucracy.
Delays pile up as physicians justify their clinical decisions to insurance companies in order to obtain prior authorization. Even now, any time I order testosterone for a woman, like clockwork I receive a fax inviting me to about an hour of sparring with an insurer to get it approved — only for it to be denied anyway, when we could skip the entire process and use a GoodRx coupon to get a six-month supply for about forty dollars.
And when a doctor asks an insurance company to pay for work already performed, large networks will often unilaterally reduce the payment, or deny the claim outright after the procedure is done.
It's worth noticing the asymmetry here. Public awareness of prior authorization — which lets insurance companies with no medical training influence clinical decisions without any malpractice exposure — has grown enormously. Public awareness of denials has not. Denials shift the burden of getting an insurance company to pay from the patient to the doctor: a doctor who is already overworked, who depends on shrinking insurance payments to keep the lights on, and who is therefore likely either to let it go or to employ a full-time person whose entire job is chasing money already earned.
Even with that person on staff, doctors spend enormous time meticulously managing the special codes attached to every little thing they do. Ladies and gentlemen, I offer for your consideration:
V97.33XD — Sucked into jet engine, subsequent encounter
W61.62XD — Struck by a duck, subsequent encounter
V91.07XA — Burn due to water-skis on fire, initial encounter
W59.22XA — Struck by a turtle, initial encounter
X52.XXXA — Prolonged stay in a weightless environment
R46.1 — Bizarre personal appearance
Z63.1 — Problems in relationship with in-laws
Then there are the "peer to peer" calls, where your doctor argues with a doctor employed by the insurance company to get a service covered. Often these "peers" are designated as such by a shared doctorate rather than a shared residency — they practice in an unrelated field, and they carry no malpractice liability while steering a clinical decision. So when a pediatric neurosurgeon is stopped from operating after a conversation with a retired OB-GYN who works for the insurer, there is very little recourse.
Insurers also maintain lists of preferred drugs, and pharmacy benefit managers are not helping. Patients are routinely required to try and fail several medications before qualifying for the one their doctor knew would work. For any of my patients to get a $500-a-month weight loss medication approved, they first have to fail a series of drugs that clinical experience has taught me are frequently ineffective and often come with side effects nobody wants.
Three rooms we weren't in
Ridiculous decisions about how medicine gets practiced in this country have been made, over and over, by people who do not see patients.
The Balanced Budget Act of 1997 sidelined frontline clinician voices in favor of actuarial projections. Operating on top-down mathematical models, Congress anticipated a coming surplus of physicians. Without meaningful input from working doctors who understood the baseline demands of a growing and aging Baby Boomer population, the BBA froze federal funding for Graduate Medical Education and placed a hard cap on Medicare-supported residency slots. It fueled the chronic physician shortage we now live with in primary care, behavioral health, and general surgery. Today that shows up as long waits, delayed diagnoses, and medical deserts in rural and underserved urban communities.
The HITECH Act of 2009 tried to modernize American healthcare by moving us from paper charts to electronic records, and implemented a program called Meaningful Use to prove we were using them "meaningfully." Clinicians had to satisfy rigid, phased criteria — structured data entry, e-prescribing, drug-interaction alerts.
Meaningful Use heavily prioritized discrete, structured data (checkboxes, dropdowns) because that is what's easy to report administratively. It stripped away the clinical nuance of a patient's story. Clinicians were left reading and writing fragmented, auto-generated note bloat that made it harder, not easier, to tell what was actually happening to a person. Because the systems were clunky and unintuitive, the EHR became a third party in the exam room: the doctor staring at a monitor, clicking boxes to avoid financial penalties, instead of making eye contact and listening to the human being in front of them.
Rather than streamlining anything, it added hours of data entry to the day. Clinicians now routinely spend a third to a half of their workday managing electronic documentation. Many felt reduced to highly paid data-entry clerks, trapped inside software designed for billing compliance rather than for healing. Unwilling or unable to sacrifice their personal lives to master deeply frustrating software, thousands chose early retirement — deepening the staffing crisis we're still in.
That was the consequence of listening to policymakers and software developers instead of patient-facing clinicians.
The RUC is the third room, and the exclusion does not apply to doctors here - but to primary care doctors, who are a minority on the Relative Value Scale Update Committee : a private, highly influential panel of about thirty physicians that advises the federal government on what Medicare should pay for nearly every medical service. The vast majority of its seats are assigned to delegates from specialty societies — orthopedic surgery, cardiology, radiology. Primary care specialties have historically held only a tiny fraction of the voting power.
Technically the RUC is only advisory. It hands its recommended values to the Centers for Medicare & Medicaid Services. In practice, CMS has historically accepted the large majority of those recommendations without change. And because private insurers and state Medicaid programs almost always follow Medicare's rates, the RUC's decisions effectively set prices for the entire American healthcare market Whoever controls the RUC controls where trillions of healthcare dollars flow.
This hurts primary care, and it hurts patients, through a straightforward chain reaction. The RUC's valuation system treats healthcare like a factory line: it rewards procedural volume — doing things to a patient — while penalizing cognitive care, which is thinking about a patient.
When a doctor has twelve minutes with you, they are forced to focus entirely on your chief complaint. My knee hurts. They lose the time it takes to notice early cognitive decline, to ask about a dangerous home situation, to untangle a mental health crisis that's just beginning. Important diagnoses get missed until they become emergencies.
To survive a packed schedule, a rushed primary care physician becomes a referral mechanism. If a problem takes longer than ten minutes to think through, the only way to keep the clinic moving is to send it to a specialist. That fragments care, produces redundant and expensive testing, and drives up total cost.
And the conditions that actually determine how long people live — diabetes, hypertension, heart failure — are not cured by an operation. They're managed through trust, education, medication adjustment, and lifestyle change, over decades. When a patient has no consistent, unhurried relationship with a primary care team, those conditions destabilize, and the destabilization shows up as avoidable emergency visits and hospitalizations.
The system waits for you to get sick enough to require a well-reimbursed procedure, instead of keeping you well in the first place.
The counterculture
Is it any wonder Direct Primary Care has become a counterculture inside American medicine, stuffed to the gills with revolutionaries, cutting insurance out of routine care entirely? This is the model where the voices of primary care physicians — long minimized by the people making policy — finally get to decide how the work is done. You come to us for oil changes and fill-ups. We can't plan for every emergency, but we will do everything we can to keep you from depending on the broken and breaking machine.
We reject the assembly line. My visits don't run the handful of minutes of real face time that gets squeezed into a twenty-minute slot after you've been roomed and your doctor comes in frazzled, ready to address one concern. Over thirty, sixty, or ninety minutes at my clinic, I actually want you to bring "the list" — the one that makes fee-for-service doctors groan, because even explaining that they can't get through it will put them behind for the rest of the day and put them at risk of a one-star review.
We've also reclaimed our independence as clinicians and as business owners. We decide what we will and won't treat. (Not all of us remove toenails. But when it's the right thing to do, just try and hold me back.) We decide what our EMR looks like. We decide how much AI helps us and where. We pull these businesses together despite the fact that most of us have no MBA and no business experience at all.
Business, it turns out, is where a lot of doctors first encounter permission to fail.
That deserves some precision, because of course we fail constantly, and some of it we can talk about openly. The patient I alienated by pushing too hard for a colonoscopy. The intern I never managed to reach, who never really accepted me as a teacher. Those are instructive, and they're safe to discuss, precisely because nobody was harmed.
The other category is entirely different. Failure that harms a patient does not teach you anything — it ends you. With one exception: if you followed evidence-based practice exactly, and the harm came from the guideline rather than from your departure from it, you are protected. The protocol absorbs it. Sit with what that teaches a person over seven years. The lesson is not don't be wrong. The lesson is be wrong in the approved way. Compliance isn't only how you protect the patient. It's how you protect yourself. Which is exactly why deviating feels dangerous even when deviating is right — and why an attending physician will raise her voice at a student in front of a full clinic for acknowledging that reiki helped somebody's hip.
Business has none of that architecture. Ordering a thousand dollars of medication that expires before anyone uses it. Botching a pitch and losing a prospective patient. Taking out a loan I didn't need. These cost me real money and harm nobody, which makes them the first failures of my career that were purely instructive. I own them, and I own the fix.
Every one of us went through the machine that melted us into white-hot liquid and hammered us into functioning blades. None of us set out to be radicals. The disillusionment that permeated the jobs we had was simply the last piece to fall into place — the one that unlocked the creation of something beautiful. So in the end I suppose the broken system is owed its own dram of gratitude. Without every one of the problems plaguing employed, systems-based medicine, the answer of direct care might never have risen to the prominence it has — and continues to gain.
Look up Direct Primary Care near you, if you haven't already. Open enrollment is coming, and your chance to join the revolution and get better care for yourself and your family is right now.
In Colorado? Call me: 720-856-4058.
Dr. Brian Juan is a board-certified family physician and the founder of Metronome Family Medicine, a Direct Primary Care practice in Longmont, Colorado. Learn more at metronomemd.com or book a free consult at metronomemd.hint.com/booking.
