Written by Dr. Bianca Busch
The healthcare debate often focuses on patient access and affordability, but what about the hidden cost to physicians struggling to survive in a system that overlooks the very people delivering care? As a psychiatrist trained at the University of Chicago, where psychotherapy is as integral as pharmacology, I entered this field with a clear vision: to listen deeply to patients’ stories, offer therapy, and prescribe medication when appropriate. Psychiatry appealed to me because of its time-intensive nature—a rarity in modern medicine. I believed I could build true healing relationships and connect with patients who so desperately want to be cared for by a woman of shared racial identity.
But the reality of practicing medicine in America quickly deflated that dream. In most clinical and academic settings, psychiatrists are expected to “practice to the top of their license,” which often translates to prescribing medication and leaving therapy to social workers, psychologists, and counselors. It’s an efficient system on paper but one that strips away the relationship-driven care that drew me to psychiatry in the first place.
The only way I could fulfill my vision of integrating therapy and medication was by starting my own practice. Even then, I faced a difficult decision: whether to accept insurance. My mentors—seasoned psychiatrists—warned me of the pitfalls: delayed payments,
clawbacks for “unnecessary” care as determined by algorithms or non-medical reviewers, and the insult of being asked to justify deeply personal notes about patients’ lives to secure compensation. Add to this the absurdly low reimbursement rates for therapy compared to medication management, and the choice became clear: I would not take insurance.This decision weighed heavily on me. I entered medicine to serve the underserved, and turning away from insurance felt like turning away from those who couldn’t afford care. Yet, in this system, rejecting insurance became the only way to provide care on my terms. That is, treating the whole person by considering their physical health while observing their economic, social, political, and spiritual environments as I develop plans to treat their mental health. In addition to being able to treat patients with their wellness in mind, I now also have the freedom to offer discounted or pro bono services to those in need without fear of violating insurance contracts. Ironically, by stepping outside the system, I’ve been able to help more people—and deliver the kind of care that restores dignity to the physician-patient relationship.
But the hurdles don’t end with insurance. As physicians, we are burdened by an endless cycle of fees and gatekeeping mechanisms that claim to ensure our competence while actively undermining it. Consider the
cost of board certification: $1,945 for the exam itself, plus $1,000 or more for study materials—not to mention the weeks of unpaid time spent studying. I took my first Adult Psychiatry Board Exam in 2020 while serving as a Chief Fellow, and I was just beyond the fatigue and nausea of the first trimester of pregnancy. I made time to study and covered all of the recommended materials, preparing as well as I could. The demands of medical training do not pause for life’s circumstances. I failed the 2020 board exam by one point. The next year, I passed—but only after enduring the demoralizing realization that had I taken the 2020 exam the year prior, in 2019, my failing score would have been enough to pass.Last fall, while juggling my roles as mother, wife, and founder, I took the Child and Adolescent Psychiatry board exam, only to fall short by 0.4%. That’s right—a fraction of a percent. Meanwhile, I was treating another psychiatrist who had struggled with the same exam. She passed with flying colors under my care. That experience inspired me to write my first book, Test Anxiety No More, a comprehensive guide to overcoming test-related stress and performing at your best. If successfully treating patients doesn’t prove my competence, I don’t know what does.
These stories aren’t
unique. Across specialties, I hear from physicians like myself—particularly women of color and working parents—who miss passing by a hair’s breadth. The process feels rigged against those who already face systemic barriers. And when we complain, the response is often dismissive: “You’ve had plenty of time to prepare.” As if juggling patient care, family responsibilities, and the demands of a broken healthcare system weren’t enough.I joined hundreds of psychiatrists scrambling to meet board recertification requirements. The task? Reading dozens of academic articles—a process so overloaded that the servers crashed multiple times. Many of us completed this work on weekends, sacrificing family time. When asked if extensions would be granted, the answer was a curt no. The system’s lack of empathy is galling, especially in a profession founded on compassion.
The recent death of Dr. Brian Thompson has prompted me to reflect deeply on the role of capitalism in medicine. Physicians begin their careers under a mountain of debt—mine exceeded $400,000. The financial pressures only mount, with recurring fees for licenses, board exams, and professional societies. These costs push many of us to prioritize high-paying jobs over those that align with our values. And yet, despite these sacrifices, we’re still beholden to a system that treats us as expendable.
So, what can we do? Here are a few potential solutions:
- Return to Direct Care: By removing insurers from the equation, physicians can rebuild the trust and autonomy essential to patient care. Specialties like psychiatry and primary care are leading the charge, but other fields are catching on. This movement feels like reclaiming our power.
- Reduce or Eliminate Medical Education Costs: Saddling young doctors with six-figure debt limits their career choices. A more affordable path to medicine would allow new physicians to prioritize passion over paychecks.
- Adopt Universal Healthcare. A system that guarantees access for all would reduce the administrative burden on physicians and improve outcomes nationwide. Lower morbidity and mortality rates would strengthen our country economically and socially.
- Address Bias in Medical Exams and Certification: The disparities in board exam outcomes demand scrutiny. Standardized testing should reflect competence, not reinforce systemic inequities.
The time for change is now. Physicians cannot continue to shoulder these burdens in silence. The health of our patients—and our profession—depends on it.
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