During Trump’s first address to Congress, he continued to promise economic reform. In the wake of the administration’s brazen attempts to cut costs, we have watched in awe as combat veterans are fired from the VA, lifelong civil servants are left jobless, all while hearing the continuous insistence that the government must become more “efficient,” even in the face of pending lawsuits.

Despite watching from the sidelines and remaining personally unaffected, I cannot help but wonder about the fate of our health care system. As a practicing surgeon, I can confidently say our system is an expensive behemoth that deserves an in-depth analysis, if not a purge, regarding cost. We spend a lot of money on health care, and we don’t have the outcomes to justify it.

But the implementation of cost change remains perplexing. I work as an acute care surgeon at a county hospital. In the middle of the night, when a patient with acute appendicitis needs a surgery and asks how much it will cost, I answer, “I don’t know, and I cannot find out.” The cost of the surgery depends on what their insurance says it should cost, what the hospital says it does cost, and the discrepancy between those numbers. It depends on in-network providers, which may vary based on who is on call that night. It depends on how the hospital adjusts any uncovered amounts, and how that amount gets transferred back to the patient. This can all change if the patient later contacts the hospital, or their insurer, to dispute the bill.

At midnight, I cannot figure out the answer, and neither can the patient. Insurance companies do not provide upfront cost estimates (and neither do hospitals) even when given ample time to plan for elective procedures. Asking for this in the middle of the night, or in an acute setting, makes the request even more implausible.

As a surgeon tending to acutely ill patients, the impending cost has nothing to do with what we offer the patients. If someone needs surgery, we offer it. If a trauma patient is bleeding, we give them blood. There is no pause built into acute patient care that accounts for cost or insurance status, and most of us agree that’s a good thing. It doesn’t matter who you are or where you come from: If you land in the emergency room and need surgery, you will be offered surgery before we know your financial situation. In true emergencies, we provide care before we even know your name.

Acute care surgeons are not fluent in health care costs, and this reflects the complexity of the system. The chore of navigating health care costs is even less appealing to a profession based on extensive training regarding patient physiology, the art of medicine, and the craft of surgery. We spend a decade learning what comes next in the physiologic algorithm to keep a patient alive. Should that decision pathway be contaminated with money, profit, costs, and payments? There is something ideal about the cost unconscious physician in preserving the historically sacrosanct patient-physician relationship. But the financially ignorant surgeon may be leaving this relationship vulnerable to disassembly from the swaths of health care industry that function for profit.

As the Trump administration continues to slash and burn “excess” within the bureaucracy, the administrative arch over health care is ripe for dismantling, or at least querying its output and productivity. Administrative hiring has far outpaced physician hiring, and administrative health care costs continue to bloom. What if the thousands of hospitals that receive Medicare funding need to cut their administration staff in half, or at least justify their productivity like other federal employees are being asked to do?

I imagine the bubble I work in, the bubble of patient care based on their physiologic needs in an acute setting, is safe from being stripped down to less. I already don’t factor costs into care. In a way, I have nothing to offer the financial arm of health care, and I possibly prefer to remain untainted by cost discussions. Either this leaves me safe by being irrelevant, or the first to pay a price. I don’t know the numbers, but the administrators do. But what do the numbers translate in terms of daily functional care? As a surgeon planning urgent operations for the sick, it means nothing.

Similarly to COVID-19, we will continue to show up to work with other core employees, wear trash bags as PPE if that’s all we have, and work to keep the sick alive. We tuned into Zoom hospital updates our administrators hosted from their homes while we huddled in workrooms wearing N95s that hadn’t been cleaned in thirty days, then we continued performing essential labor while they did administrative things. Maybe they ordered more PPE, or strategized what floors to convert to ICUs, but does that really require ten times more administrators than doctors?

Perhaps I am ignorant and there really is some essential element I am not privy to, but must trust, that exists in the C-suite. But how can a foundational member of the health care team, a physician, have little insight, and high skepticism, to the necessity of our administrators?

The boldness of Trump’s reformation attempts may be alarming, but his firm insistence that we waste money is indeed evidenced in the health care system. As he continues his search for spending targets to cull, I can direct him to the top floors of our nation’s hospitals, the place with hardwood floors, big windows, coffee machines, and secretaries, where people are wearing high heels and suits. They are in a different wing than the sick and dying, far from the blood spatter on the floors of the trauma bay. I’ll ask him and Elon Musk to bring their chainsaws up there and dive into the undoubted waste of health care administrative spending.

Christine Ward is a trauma and critical care fellow.