I began my career as a nurse practitioner in primary care, where patient visits are often limited to 15 or 20 minutes to manage complex conditions like hypertension, diabetes, and COPD. What struck me was how often these medical issues came with a psychological overlay like depression, anxiety, panic attacks, and trauma. That shaped the course of treatment as much as lab results or medications. The pace of primary care leaves little room to explore those layers, and that’s what led me back for additional training in psychiatry. I wanted to spend more time with patients, to listen deeply, hear their stories, and sort through the nuances that lead to an accurate diagnosis and meaningful care.

After completing a second master’s program and taking on even more student loan debt, I thought I’d finally have the time to sit with patients. Instead, I discovered that drive-thru medicine had crept into psychiatry. Insurance companies taking in hundreds of billions in revenue each year (United Healthcare’s net earnings in 2023 were $22.4 billion) reimburse at rates so low that some plans pay less than Medicare. Most insurers tie their rates to Medicare, which itself cuts payments by 2-3 percent annually. Meanwhile, the cost of living and running a practice keeps climbing: 7 percent inflation in 2021 and 6.5 percent in 2022. I remember when 150 percent of Medicare was considered poor reimbursement in the 1990s; today, both providers and health care corporations are expected to survive on far less.

At the same time, the administrative burden has exploded. Clinicians now spend as much time on documentation, billing codes, and prior authorizations as they do with the patient in front of them. Clinics run perpetually short-staffed, with fewer people doing more work. And the decisions about how we deliver care are increasingly dictated by people who have never sat with a patient: insurance executives, corporate managers, and algorithm designers. The result is a system that prizes efficiency metrics over human connection, where clinicians practice with one hand tied behind their backs. When cost-cutting and red tape push us to compromise care, the wound is not just professional; it is psychologically distressing. For many, it feels like death by a thousand cuts.

I will never forget one of my early patients with an A1C of 11.1. His insurance would not cover the long-acting insulin he desperately needed. That was the moment I knew the system was broken beyond repair. At the same time, many of us are buried in six-figure student loan debt while being asked to sacrifice our health and integrity to a system that causes moral injury. Moral injury, now formally recognized in the DSM-5, is the psychological harm that occurs when people are forced to act against their values or witness suffering they are powerless to prevent. It is an insult that health insurance companies reap staggering profits while patients suffer. UnitedHealthcare alone reported $22 billion in profits in 2023 while patients are routinely denied essential care. Meanwhile, many physicians in areas where there is a higher cost of living cannot afford to buy a home as their pay continues to shrink, saddled with student debt that may take a lifetime to repay. Layered on top of that is the crushing burden of unpaid administrative work, what medicine ironically calls “pajama time.” This is the late-night slog of electronic health record documentation, chart notes, reviewing labs, and responding to patient messages after clinic hours. It erodes well-being and fuels burnout, leaving providers with no time to sit at the family dinner table, exercise, cheer at a child’s sports game, or tuck their kids into bed. These problems are not accidental. They are baked into the design of American health care, a system that prioritizes profit and bureaucracy over patients and the people who care for them.

So I decided to build something different. A little over a year ago, I opened a private, out-of-network practice in functional and integrative psychiatry. My intake sessions often last three hours, allowing me to understand both body and mind, each shaping the other. With that time, focus, and attention, I have been able to catch what the system missed.

Taking the time for a thorough history, listening deeply, and ordering the right labs can change everything. One 28-year-old woman had been told for five years that her neurological symptoms were “all in her head.” When we ran the appropriate labs, we discovered she had hemochromatosis, a genetic iron overload disorder. Left untreated, it can cause serious organ damage and even be life-threatening. An 85-year-old woman came to me with what she had been told were panic attacks. For two years she had been treated for anxiety, but something about her description did not sit right. I asked her to walk me carefully, step by step, through what each episode felt like. The more I listened, the less convinced I was that these were panic attacks at all. They sounded more like near syncope events, episodes of almost fainting. I referred her to a cardiologist, and within a week she was scheduled for a pacemaker to treat a serious arrhythmia. A 67-year-old man came to me with chronic migraine headaches and severe anxiety. He was already on the maximum dose of Effexor, yet his anxiety remained overwhelming. After taking a thorough psychiatric and medical history, I discovered that he was using his albuterol inhaler five to six times a day for asthma. What he really needed was an inhaled corticosteroid and an asthma action plan, rather than relying almost entirely on a rescue inhaler. His overuse of albuterol was not only worsening his anxiety but also driving up his blood pressure. I sent him back to his primary care provider with recommendations for daily inhaled corticosteroids and the goal of using his rescue inhaler no more than twice a week. Once his asthma was properly managed, his anxiety went from daily and severe to mild and occasional. A 37-year-old man had lived with daily suicidal thoughts for more than 20 years. He had tried multiple SSRIs and SNRIs but struggled to tolerate the side effects, and even at low doses the benefits were minimal. Within two weeks of starting him on low-dose lithium, his suicidal ideation disappeared. It has been absent for more than a year and counting, giving him back not just relief from symptoms but the possibility of a life he once thought was out of reach.

These are not outliers. They are what happens when you are given the time and space to practice the art of medicine, listening deeply, thinking critically, and treating the whole patient. Too often, our current system strips that away. It rushes clinicians, rewards throughput over thought, runs on algorithms, and discourages the very kind of careful reasoning that saves lives.

For the past year I balanced my newly budding private practice with the security of a 20-hour-a-week job (not counting pajama time). It was safe and predictable, until my employer demanded I see significantly more patients in less time. They wanted to push my load to unsafe levels. My body and mind rejected it outright. Two weeks ago, I walked away.

Yes, finances are uncertain, and yes, there is fear. But fear is not the whole story. On the other side of fear is relief, faith, and trust. Relief that I no longer have to be a cog in the wheel of a dysfunctional health care system, pushed to my limits with nothing left to give myself or my family at the end of the day. Faith that patients will always find their way to the places where they are truly seen, heard, and cared for with skill and compassion. And trust that if I continue to build a practice grounded in integrity and healing, people will come. It may not happen overnight, but I know this kind of medicine is what people are longing for, and what our communities desperately need.

I am not alone in walking away. Across the country, doctors, physician assistants, and nurse practitioners are making the same calculation. Some are leaving medicine altogether. Others are shifting to concierge practices, hoping that fewer patients will mean more time and less burnout. Some are moving into administrative or consulting work, and many are quietly retiring early. At the same time, the pipeline of young clinicians is shrinking, as crushing student debt and a broken system make this once-vital calling feel less and less sustainable. The human cost is devastating. Each year, between 300-400 physicians die by suicide. Medical students have depression rates 15-30 percent higher than the general population. I personally know three physician colleagues who have died by suicide. It is heartbreaking to see brilliant, compassionate people driven to such despair, and in at least one case I know for certain that burnout was a central factor. Burnout is not just stealing lives. It is taking our healers from us, the very people we rely on to care for the sick and suffering.

This is what patients need to understand: We love medicine. We love caring for people, listening to their stories, and helping them heal. What we are leaving behind is not medicine itself but a broken system that delivers soul-crushing consequences for providers and patients alike. Moral injury has become a silent epidemic, hollowing out clinicians who still know what to do and how to help but are prevented from doing so.

We are not leaving medicine. We are leaving the machine that has corrupted it. Doctors, physician assistants, and nurse practitioners are not walking away from our patients. We are walking toward spaces where the art and science of healing can still exist. But the loss of so many good clinicians should be a warning. A country that spends more on health care than any other yet fails to protect its patients or its providers has reached a crisis point. Until policymakers stop scapegoating and start fixing health care, Americans will keep asking the same question: Where did all the good doctors and nurse practitioners go? And the answer will be: They were driven out by a system that refused to change.

Carrie Friedman is a dual board-certified psychiatric and family nurse practitioner and the founder of Brain Garden Psychiatry in California. She integrates evidence-based psychopharmacology with functional and integrative psychiatry, emphasizing root-cause approaches that connect neuro-nutrition and gut–brain science, metabolic psychiatry, immunology, endocrinology, and mind–body lifestyle medicine. Carrie’s clinical focus bridges conventional psychiatry with holistic strategies to support mental health through nutrition, physiology, and sustainable lifestyle interventions. Her professional writing explores topics such as functional medicine, autism, provider well-being, and medical ethics.