The recent murder of a United Healthcare CEO shook the healthcare world. But what struck me even more than the act itself was the reaction. In the days following, I saw an unsettling wave of catharsis ripple through parts of the healthcare community—like the Munchkins in The Wizard of Oz singing "Ding Dong the Witch is Dead." There was a sense that perhaps this was justice, that maybe destruction was the only path to revolution. I recognized the anger and pain driving these responses, but I couldn’t celebrate the violence. It was a wake-up call, not just about the state of our healthcare system, but about the deeper despair within those of us working inside it.
That moment made me pause and reflect: what is the deeper cost of the system we’ve built? And more importantly, how have we, as physicians, participated in sustaining it?
Compliance Complex
Our healthcare system runs on what I’ve come to call the Compliance Complex—the systemic structures and daily practices that demand we optimize, maximize, and comply with the rules of a profit-driven, efficiency-focused machine. These structures are omnipresent: billing systems that reward volume over value, administrative burdens that prioritize documentation over patient care, and workflows that turn physicians into cogs in a relentless production line.
It’s easy to point fingers at the insurance companies, hospital administrators, or policymakers who built this machine. And to some extent, they deserve the blame. But the harder truth is that we’re also players in this game, and in some ways, we’ve learned to benefit from it.
Internalized Machine Mentality
To survive in the Compliance Complex, we’ve internalized its values. This Internalized Machine Mentality shows up in how we measure our success and worth. I see it in myself, in my peers, and in the trainees I’ve mentored.
I remember the pride I felt during my busiest clinic days. Seeing 50 patients in a day at the pediatric office—moving from room to room with two MAs and four exam spaces so I could churn through without a break for hours on end- felt like a badge of honor. My workflow was a well-oiled machine, and I thought I was a real badass. If the sick kids are there, someone has to see them, right? But looking back, I wonder about the deeper cost of that mindset. I didn’t question the system that demanded that pace or the toll it took on me, my patients, or my staff.
Later in my career, I became a slave to the RVU machine. I memorized codes and corresponding wRVUs, knowing exactly how to document to hit each level. I explained it to my trainees as “picking up pennies” and told them, “I didn’t make this game, but I am going to figure out how to win it.” It felt strategic, even righteous. If the system was going to exploit us, I reasoned, we had to fight back by maximizing every cent for the greater good. But was it really a win, or just another way of propping up a system that dehumanized us all?
Pain Points of the Machine
The Compliance Complex and Internalized Machine Mentality leave physicians in a state of disconnection and despair. Here are the pain points I’ve seen most often:
Dehumanization: The relentless focus on metrics—RVUs, patient volume, billing codes—reduces us to numbers, and we start to feel like machines ourselves.
A Sense of Futility: Many physicians feel like their sacrifices don’t matter. They give so much of themselves, but no one loves them back—not the system, not the patients, and certainly not the public.
Scapegoating: Doctors often become the targets of frustration for patients and the public, blamed for the failures of a system we didn’t design but continue to sustain.
The Witch and the System
This brings me back to the recent murder and the reaction it inspired. It reminded me of a line from Wicked, “No one mourns the wicked.” The insurance industry is often cast as the “wicked witch” of healthcare, and for good reason. But just as Wicked asks us to reconsider how the witch got that way, we need to ask hard questions about how systems like these come to be—and what role we’ve played in sustaining them.
Violence and destruction won’t fix the system. Burning it all down may feel satisfying in the moment, but it doesn’t address the deeper dynamics at play. If anything, it risks perpetuating the same cycles of harm. True change starts with recognition. We need to see the water we’re swimming in—the Compliance Complex—and how our Internalized Machine Mentality keeps us tied to it.
A Seeker, Not a Sage
I’m not here to offer easy answers or actionable steps. I don’t have a roadmap for dismantling the Compliance Complex or unlearning the Internalized Machine Mentality. I’m a seeker, not a sage. But I do know that change begins with awareness.
We need to reflect on the ways we’ve internalized the values of a system we claim to despise. We need to ask uncomfortable questions: Are we benefitting from the game? If so, at what cost? And what would it mean to divest—not through destruction, but through conscious, intentional action?
An Invitation
This post is the beginning of a conversation, not the end. I’ll be exploring these themes further in what I’m calling Unpacking the Machine—a series that dives into the belief systems and structures that shape our work and lives as physicians.
For now, I invite you to sit with these questions. Look at the system around you, the one we’ve built together. Look at the thoughts and behaviors you’ve internalized to survive within it. And ask yourself: What would it take to step beyond the machine?
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