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How difficult is it for doctors to keep their honest intentions towards patients from medical school going into their practice?
It seems that as doctors progress in their careers, they become indifferent or kind of careless in their approach to patients and this leads to unethical behavior or attitudes towards patients. Becoming like this is my biggest fear regarding my career...
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James’s Answer
I would say that in my 40 years of practice I worked with perhaps one or two of thousands of physicians who seemed indifferent or acted unethically. The vast majority of physicians work very hard to learn all the latest things, be available long hours, put patients ahead of themselves (and unfortunately, sometimes their own loved ones)... I am sorry you have experienced a very different reality.
I will echo others' comments: it is very hard to take care of patients when insurance companies and regulations demand unhelpful documentation that takes a lot of time away from seeing patients. It is profoundly aggravating to send in a "clean" bill, only to have the insurance company decline or downcode (pay less). It is awful to have patients questioning you often because "they read something..." or because they want a medication that is not appropriate for which they saw a television ad.
So, if we want physicians to remain the dedicated professionals we want them to be, we must improve the system that makes it hard to offer that excellent, compassionate care.
I will echo others' comments: it is very hard to take care of patients when insurance companies and regulations demand unhelpful documentation that takes a lot of time away from seeing patients. It is profoundly aggravating to send in a "clean" bill, only to have the insurance company decline or downcode (pay less). It is awful to have patients questioning you often because "they read something..." or because they want a medication that is not appropriate for which they saw a television ad.
So, if we want physicians to remain the dedicated professionals we want them to be, we must improve the system that makes it hard to offer that excellent, compassionate care.
Updated
Rita’s Answer
I think this depends on the physician. If you are working for another group, this will not be the problem. From what I see, most unethical behavior comes from doctors who own their own practice. Why? Because when you work for yourself, you realize how little pay you get from the insurance. It's sad to say but although doctors do make a good income, if you factor in the number of hours of education and training, I sometimes wonder if it's not worth it. I've seen some doctors order particular tests not necessarily because the patient needs the test but because they can bill more for the procedure.
I do believe doctors become indifferent and it's just because of the number of hours we work and burn out. I'll give you my personal experience. I had my own medical practice. For 8 years, I worked every day seeing patients (except holidays and weekends) without a vacation except for 1 day. When I say I did not work on the weekends, I mean, I was not seeing patients but I would open my computer to review patient notes, refill medications, and review labs. I started work at 6:30 AM reviewing all the labs and answering patient questions before work would start and often worked through lunch to have a 15 minute lunch. Patients often had an "emergency" and had to be squeezed in so my schedule was worse. After doing this for so many years, I burned out. I had no compassion left because I had no compassion for myself. So what is the answer? You need to take care of yourself. You need to take vacation and nurture yourself so you can help others. If it's your own practice, it's going to be difficult because daily, people need to talk with you and want to be squeezed in. They will give you the guilt treatment. I once squeezed in 20 patients. You cannot work this way. If you work for someone else, there are other headaches.
I'm working in clinical research. One clinic wanted to pay me $100/hour without benefits. Although that may seem a lot, when I called my AC person, they were charging $150 per job that would probably take 30 minutes. Don't do medicine for the money. It will give you a stable income but it won't make you rich. Do it because you love the job. You will be sacrificing a lot. Like any job, it's not how much money you make but how you spend your money. I was able to retire early because I used the money I made in medicine to invest. I could have done the same thing with another job.
Good luck!!
I do believe doctors become indifferent and it's just because of the number of hours we work and burn out. I'll give you my personal experience. I had my own medical practice. For 8 years, I worked every day seeing patients (except holidays and weekends) without a vacation except for 1 day. When I say I did not work on the weekends, I mean, I was not seeing patients but I would open my computer to review patient notes, refill medications, and review labs. I started work at 6:30 AM reviewing all the labs and answering patient questions before work would start and often worked through lunch to have a 15 minute lunch. Patients often had an "emergency" and had to be squeezed in so my schedule was worse. After doing this for so many years, I burned out. I had no compassion left because I had no compassion for myself. So what is the answer? You need to take care of yourself. You need to take vacation and nurture yourself so you can help others. If it's your own practice, it's going to be difficult because daily, people need to talk with you and want to be squeezed in. They will give you the guilt treatment. I once squeezed in 20 patients. You cannot work this way. If you work for someone else, there are other headaches.
I'm working in clinical research. One clinic wanted to pay me $100/hour without benefits. Although that may seem a lot, when I called my AC person, they were charging $150 per job that would probably take 30 minutes. Don't do medicine for the money. It will give you a stable income but it won't make you rich. Do it because you love the job. You will be sacrificing a lot. Like any job, it's not how much money you make but how you spend your money. I was able to retire early because I used the money I made in medicine to invest. I could have done the same thing with another job.
Good luck!!
Michael Cadra, MD, DMD, FACS
Oral and Maxillofacial Surgeon, physician and dentist
43
Answers
Updated
Michael’s Answer
I need to first agree with Rita, "it depends on the physician", and most of what she has to say. However, I my initial response based on 40 years experience in medical staff leadership, student and resident training is that there is little or no difference in the solo vs. group practice ethical behavior, unprofessional conduct or medical liability claims. Yes, unethical behavior occurs all along the academic path, including outright cheating, poor communication skills, and professional misconduct. Continue reading to see what I found with a quick question to OpenEvidence.com, a licensed health provider only AI tool.
My strong belief is that the tendency to indifference to professional relationships and carelessness can be traced to conduct well before acceptance to medical school. The AMA and other organizations have developed "professional readiness exams" or "situational judgment tests" such as the AMA PREtest (Professional Readiness Exam) or CASPER which is often paired with DUET.
The 10 competencies that are commonly assessed on Casper are:
Ethics
Self-awareness
Empathy
Collaboration
Professionalism
Equity
Motivation
Communication
Problem solving
Resilience
I believe that the schools are now weeding out those with traits that might lead to burn-out, unprofessional conduct, and other problems. Schools are now looking for GREAT communication skills, both verbal and written and ethics, as well as the aptitude to excel in basic science courses.
Now let's see what AI tells me:
"The evidence on this topic is mixed and does not consistently support the assumption that group practice is protective against burnout, ethical problems, or malpractice liability. In fact, several studies suggest the opposite for burnout, while the data on ethics and liability are more nuanced.
The relationship between practice size and burnout is surprisingly counterintuitive. A U.S. study of over 10,000 clinicians and staff in smaller primary care practices found that solo practitioners less commonly reported burnout compared to those in non-solo practices (2–5 clinicians vs. solo: adjusted OR 1.71; 95% CI 1.35–2.16), and that health system affiliation was independently associated with higher burnout (aOR 1.42; 95% CI 1.16–1.73). [1] The authors concluded that practice-level autonomy may be a critical determinant of burnout. [1] Similarly, a study of zero-burnout primary care practices found they were more commonly solo and clinician-owned.
The evidence does not directly compare rates of sexual misconduct or boundary violations between solo and group practice settings, but several converging lines of evidence suggest that professional isolation and nonacademic settings are associated with higher risk, while group and institutional settings may offer structural protections — though they are far from immune.
Physicians often overestimate their communication skills, and these skills have been shown to decline over the course of a career. [1] A study of 62 orthopaedic surgeons found that more years in practice was significantly associated with lower patient satisfaction scores for careful listening (P = 0.048) and lower total satisfaction scores (P = 0.029). [2] Similarly, in academic otolaryngology, a weak but statistically significant decrease in Press Ganey scores was associated with longer duration of practice (r = −0.11, P = 0.018). [3] A primary care study found that patients were significantly more satisfied with physicians aged 30–40 compared with those over 60, and satisfaction on the "Orderly/Time" domain was lower for physicians over 60. [4]
A study of communication competency across training levels found that students acquired a "satisfactory" level of communication skill early in the curriculum, but no further improvement was observed between third-year students, interns, residents, and consultants — suggesting that clinical experience alone does not enhance communication beyond a basic threshold.
Physician indifference toward patients — clinically termed depersonalization — arises from a convergence of systemic, psychological, developmental, and interpersonal factors rather than any single cause. The evidence identifies several interconnected pathways.
Burnout and Emotional Exhaustion
The most extensively studied driver of physician indifference is burnout, which Maslach described as the process by which "energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness." Depersonalization — characterized by a poor attitude, cynicism, and treating patients as objects — is one of the three core domains of burnout. [1-2] A Finnish study of 2,423 physicians found that patient-related stress was the single most important predictor of depersonalization (accounting for 52% of explained variance), while time pressure was the dominant predictor of emotional exhaustion (45% of variance). [3] Systemic factors driving this include excessive workloads, productivity-based pay structures, documentation burden, loss of autonomy, and lack of support staff. [4-5]
Moral Distress and Moral Injury
When physicians are repeatedly prevented from providing the care they know is right — due to institutional policies, resource constraints, or reimbursement structures — they experience moral distress, which can progress to moral injury characterized by feelings of betrayal, guilt, and anger. [6] A 2026 national survey found that approximately 2 in 5 US physicians reported high moral distress, and 3 in 4 of those with high moral distress also exhibited burnout symptoms. [6] Moral distress and burnout are correlated but distinct: moral distress accounted for ~30% of the variability in emotional exhaustion and ~25% in depersonalization. [6]
Qualitative study of medical students in early clerkship found that empathy loss was not driven by negative role models alone, but by the process of making patient care routine, which shifted patients from "individuals with suffering" to "objects of the work of being a physician." Online discussion forums revealed that cynicism develops progressively as a [9] coping mechanism in response to limited support, hierarchical demands, and long work hours, compounded by institutional tolerance of unprofessionalism."
Enough of OpenEvidence: In your case it is important to establish a work-life balance, establish good financial habits so that you are not stressed financially. Residents are now covered by a 80 hour/week work rule and rules covering sleep and dedicated time for study and relaxation. I see too many young doctors come out, enter into great practices earning a multiple of their resident salary but start spending way more than their salary. Nearly 50 years ago a mentor told me that physicians are "Masters of Delayed Gratification", until some money hits their wallet.
Sorry, I cannot provide the peer reviewed articles that the OE used to come to the above conclusions.
Good luck on your journey!
My strong belief is that the tendency to indifference to professional relationships and carelessness can be traced to conduct well before acceptance to medical school. The AMA and other organizations have developed "professional readiness exams" or "situational judgment tests" such as the AMA PREtest (Professional Readiness Exam) or CASPER which is often paired with DUET.
The 10 competencies that are commonly assessed on Casper are:
Ethics
Self-awareness
Empathy
Collaboration
Professionalism
Equity
Motivation
Communication
Problem solving
Resilience
I believe that the schools are now weeding out those with traits that might lead to burn-out, unprofessional conduct, and other problems. Schools are now looking for GREAT communication skills, both verbal and written and ethics, as well as the aptitude to excel in basic science courses.
Now let's see what AI tells me:
"The evidence on this topic is mixed and does not consistently support the assumption that group practice is protective against burnout, ethical problems, or malpractice liability. In fact, several studies suggest the opposite for burnout, while the data on ethics and liability are more nuanced.
The relationship between practice size and burnout is surprisingly counterintuitive. A U.S. study of over 10,000 clinicians and staff in smaller primary care practices found that solo practitioners less commonly reported burnout compared to those in non-solo practices (2–5 clinicians vs. solo: adjusted OR 1.71; 95% CI 1.35–2.16), and that health system affiliation was independently associated with higher burnout (aOR 1.42; 95% CI 1.16–1.73). [1] The authors concluded that practice-level autonomy may be a critical determinant of burnout. [1] Similarly, a study of zero-burnout primary care practices found they were more commonly solo and clinician-owned.
The evidence does not directly compare rates of sexual misconduct or boundary violations between solo and group practice settings, but several converging lines of evidence suggest that professional isolation and nonacademic settings are associated with higher risk, while group and institutional settings may offer structural protections — though they are far from immune.
Physicians often overestimate their communication skills, and these skills have been shown to decline over the course of a career. [1] A study of 62 orthopaedic surgeons found that more years in practice was significantly associated with lower patient satisfaction scores for careful listening (P = 0.048) and lower total satisfaction scores (P = 0.029). [2] Similarly, in academic otolaryngology, a weak but statistically significant decrease in Press Ganey scores was associated with longer duration of practice (r = −0.11, P = 0.018). [3] A primary care study found that patients were significantly more satisfied with physicians aged 30–40 compared with those over 60, and satisfaction on the "Orderly/Time" domain was lower for physicians over 60. [4]
A study of communication competency across training levels found that students acquired a "satisfactory" level of communication skill early in the curriculum, but no further improvement was observed between third-year students, interns, residents, and consultants — suggesting that clinical experience alone does not enhance communication beyond a basic threshold.
Physician indifference toward patients — clinically termed depersonalization — arises from a convergence of systemic, psychological, developmental, and interpersonal factors rather than any single cause. The evidence identifies several interconnected pathways.
Burnout and Emotional Exhaustion
The most extensively studied driver of physician indifference is burnout, which Maslach described as the process by which "energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness." Depersonalization — characterized by a poor attitude, cynicism, and treating patients as objects — is one of the three core domains of burnout. [1-2] A Finnish study of 2,423 physicians found that patient-related stress was the single most important predictor of depersonalization (accounting for 52% of explained variance), while time pressure was the dominant predictor of emotional exhaustion (45% of variance). [3] Systemic factors driving this include excessive workloads, productivity-based pay structures, documentation burden, loss of autonomy, and lack of support staff. [4-5]
Moral Distress and Moral Injury
When physicians are repeatedly prevented from providing the care they know is right — due to institutional policies, resource constraints, or reimbursement structures — they experience moral distress, which can progress to moral injury characterized by feelings of betrayal, guilt, and anger. [6] A 2026 national survey found that approximately 2 in 5 US physicians reported high moral distress, and 3 in 4 of those with high moral distress also exhibited burnout symptoms. [6] Moral distress and burnout are correlated but distinct: moral distress accounted for ~30% of the variability in emotional exhaustion and ~25% in depersonalization. [6]
Qualitative study of medical students in early clerkship found that empathy loss was not driven by negative role models alone, but by the process of making patient care routine, which shifted patients from "individuals with suffering" to "objects of the work of being a physician." Online discussion forums revealed that cynicism develops progressively as a [9] coping mechanism in response to limited support, hierarchical demands, and long work hours, compounded by institutional tolerance of unprofessionalism."
Enough of OpenEvidence: In your case it is important to establish a work-life balance, establish good financial habits so that you are not stressed financially. Residents are now covered by a 80 hour/week work rule and rules covering sleep and dedicated time for study and relaxation. I see too many young doctors come out, enter into great practices earning a multiple of their resident salary but start spending way more than their salary. Nearly 50 years ago a mentor told me that physicians are "Masters of Delayed Gratification", until some money hits their wallet.
Sorry, I cannot provide the peer reviewed articles that the OE used to come to the above conclusions.
Good luck on your journey!