By Eddie Saliba, APRN, FNP-C

When the pattern became impossible to ignore

A patient came into the office after two or three days of cough, congestion, body aches, and fatigue. Fairly typical upper respiratory symptoms. I offered to test him for COVID. He scoffed and dismissively declined any viral testing.

Apparently he already “knew” what this was. According to him, it was “turning into bronchitis,” and what he “needed” was a Z-pack. I explained that after only a few days of symptoms, there was no evidence suggesting bacterial infection. I explained that most upper respiratory infections are viral. I explained that antibiotics are not harmless medications and inappropriate use contributes to resistance and unnecessary (even detrimental) adverse effects.

None of it mattered. He continued demanding antibiotics. Then came the obligatory justification: “But I have asthma.”

Except his asthma was well-controlled with only a rescue inhaler. He had never smoked. No recurrent pneumonia history, or pneumonia as an adult. No severe pulmonary disease. Just another patient who had spent years being conditioned to believe that every respiratory illness requires antibiotics because somewhere along the line someone got tired, gave in, and prescribed them.

Not long after that encounter, another patient called the office late on a Friday afternoon demanding a refill of a chronic medication. A statin. Not insulin. Not antiseizure medication. Not an anticoagulant. A statin. He had allowed himself to run out and became verbally abusive toward staff because the office was closing for the weekend. Apparently his failure to plan was now our office’s emergency.

Over time, I began realizing these were not isolated frustrations. They were symptoms of a health care culture increasingly unable, or unwilling, to distinguish compassion from codependence. This distinction matters. This distinction needs to matter. Because compassion is not equivalent to endless accommodation. At some point, American health care blurred the lines between caring for people and enabling destructive behavior.

America built a chronic disease economy

We love to say that the U.S. has the “best health care system in the world.” In some ways, we absolutely do. If you are critically ill, severely injured, septic, actively dying, or in need of advanced surgical intervention, American medicine can be extraordinary.

But prevention? Serious question. I’m still waiting for the answer. Prevention is not what the system was structured around.

The uncomfortable reality is that the U.S. does not primarily operate a health care system focused on fostering health. We run an extraordinarily advanced chronic disease management economy.

Obesity rates continue to climb. Type 2 diabetes rates continue to climb. Metabolic syndrome rates continue to climb. Fatty liver disease rates continue to climb. Hypertension, sleep apnea, sedentary lifestyles, processed food consumption, chronic stress: preventable chronic illnesses now dominate. Sickness has become normalized to such a degree that many people no longer recognize how unhealthy the baseline American lifestyle has become.

Meanwhile, the system itself remains largely reactive. We intervene after disease develops. We manage complications after years of physiologic decline. We prescribe medications after prevention has failed, and often continue intervening long after meaningful recovery is no longer realistic. And while prevention is frequently discussed, rhetorically, it receives nowhere near the same cultural, financial, or institutional emphasis as downstream disease management.

Whether intentional or emergent, the incentives became catastrophically misaligned with long-term public health. We subsidize highly processed foods. We normalize sedentary lifestyles. We underemphasize nutrition literacy. We underfund meaningful preventive education. Then we act surprised as the population becomes progressively sicker.

And the most disturbing part? Entire industries profit from the consequences. Hospitals profit. Pharmaceutical companies profit. Insurance companies profit. Consulting firms profit. Device manufacturers profit.

Everyone talks about “fixing health care,” yet the system remains economically dependent on chronic disease existing on a massive scale. That is not conspiracy thinking. That is structural reality.

Bandaids, not reform

Politicians repeatedly promise to “fix health care.” What we usually get are bandaids: administrative restructuring, insurance reshuffling, new layers of bureaucracy, more paperwork, more billing complexity, more metrics, more performative initiatives. But very little that fundamentally changes the upstream drivers of chronic disease.

The Affordable Care Act expanded access for many people. That matters. But access alone is not equivalent to meaningful health care reform. Many Americans remain buried under high deductibles, large copays, expensive medications, insurance restrictions, prior authorizations, and fragmented care.

We continue treating the consequences of poor public health while investing comparatively very little into creating an actually healthy population. And frankly, there is something profoundly absurd about a nation endlessly debating health care affordability while simultaneously normalizing ultra-processed diets, chronic sleep deprivation, sedentary lifestyles, escalating obesity, and widespread metabolic dysfunction.

We are trying to mop the floor while leaving the faucet running into an overflowing sink.

Prevention was never truly prioritized

One of the most astounding realizations I had during my own health care education was how little practical nutrition knowledge many people, including health care professionals before formal training, actually possess. Most Americans graduate high school without understanding basic nutrition labels, caloric density, macronutrients, fiber intake, food marketing, or how chronic lifestyle patterns gradually contribute to disease.

Health literacy is treated like an elective hobby instead of a societal necessity. Math and English frequently require four years of high school coursework. Health education is often treated like filler. This makes no sense.

If we truly cared about prevention, practical health literacy would begin early and continue throughout primary and secondary education. Children should learn nutrition literacy, exercise fundamentals, sleep hygiene, medication literacy, stress management, preventive health, and how to critically evaluate health information.

Instead, many people enter adulthood completely unequipped to navigate the modern health environment surrounding them. Then we shame them after decades of inadequate preparation. That is not prevention. That is societal negligence.

The collapse of health literacy and respect for expertise

The internet democratized access to information. Unfortunately, many people mistake that for democratization of expertise. Access to information is not the same as the ability to interpret information.

Reading three articles online does not replicate years spent studying physiology, pharmacology, pathology, evidence-based medicine, diagnostic reasoning, and risk-benefit analysis. Nor does it replicate years of real-world clinical experience.

Yet modern health care culture increasingly treats medical expertise as interchangeable with algorithm-amplified opinion. A functioning society can absolutely support free speech while still recognizing that not all opinions carry equal evidentiary or professional weight. We do not allow individuals without training to pose as engineers, pilots, or licensed clinicians in professional settings. Yet somehow, social media increasingly blurs the distinction between expertise and confidence.

People now receive health information from influencers, podcasts, TikTok clips, Facebook groups, supplement marketers, wellness gurus, and monetized outrage algorithms. And many lack the training necessary to distinguish randomized controlled trials, observational data, anecdotal reports, expert consensus, pseudoscience, and outright misinformation.

The democratization of information unintentionally created the illusion that expertise itself had become democratized. That illusion has consequences. Patients increasingly arrive convinced they already know the diagnosis, treatment plan, and medication they require. Not because they possess deep understanding. But because they consumed content engineered to make them feel informed.

The customer-service model of medicine

Modern health care increasingly operates like consumer retail. And this should terrify us. Patients now “shop” for medications. Direct-to-consumer pharmaceutical advertising fuels this mentality even further.

The U.S. remains one of the only countries on Earth allowing prescription medications to be advertised directly to consumers. That means people are now exposed to commercials for highly specialized medications requiring extensive diagnostic evaluation and specialist interpretation: DMARDs, biologics, complex autoimmune therapies, advanced psychiatric medications. Meanwhile, many viewers lack the clinical framework necessary to determine whether those medications are even remotely appropriate for them. Yet we have normalized a culture where prescription drugs are marketed during football games.

Insane.

Health care increasingly rewards accommodation over evidence-based boundaries. Patients demand antibiotics, steroids, unnecessary imaging, controlled substances, work excuses, urgent refills for nonurgent issues, and immediate reassurance for ordinary discomfort. Administrators fear complaints. Clinicians fear poor reviews. Staff absorb abuse. And many providers, under immense time, pressure, and emotional exhaustion, eventually start throwing antibiotics at patients who woke up with the sniffles because arguing for fifteen minutes is emotionally harder than writing a prescription.

That is not good medicine. That is burnout culture.

And the irony is that this appeasement often worsens the underlying problem. When we prescribe unnecessary antibiotics for viral illnesses, we frequently miss the actual issue: health anxiety, uncertainty intolerance, the inability to tolerate ordinary human discomfort.

Patients feel sick. They become anxious. They seek intervention. Clinicians provide unnecessary treatment. Symptoms improve naturally over time. The patient attributes recovery to the intervention. The cycle reinforces itself. Then the next cold becomes another demand for antibiotics.

One of the foundational principles of science is tolerating uncertainty. Medicine, despite all its technological advances, still operates largely in probabilities rather than absolutes. Yet modern health care culture increasingly treats uncertainty itself as pathology.

Patients demand certainty. Clinicians feel pressured to provide it. Administrators fear dissatisfaction when it cannot be provided. As a result, we increasingly medicate, test, scan, prescribe, and intervene, not always because science demands it, but because discomfort with uncertainty does.

I also suspect we still underestimate the physiologic consequences of repeated unnecessary antibiotic exposure: microbiome disruption, antimicrobial resistance, potential long-term effects on immune regulation and metabolic health. We may eventually discover that our obsession with immediate reassurance created consequences we barely understood at the time.

Compassion is not codependence

This is where the lines became dangerously blurred. Compassion matters deeply. But compassion is not the abandonment of standards, boundaries, accountability, or reality. Modern American health care increasingly resembles a codependent system: repeatedly rescuing, repeatedly accommodating, repeatedly buffering consequences, while avoiding honest conversations about responsibility.

Patients leave against medical advice. Then return. Patients repeatedly ignore medical recommendations. Then expect clinicians to absorb the consequences, indefinitely. Patients wait until the last possible moment to address preventable issues. Then create manufactured urgency for everyone around them. And health care workers are increasingly expected to tolerate hostility, manipulation, entitlement, and abuse under the banner of “patient-centered care.”

No.

Compassion without boundaries eventually stops being compassion. It becomes enabling.

Autonomy absolutely matters. Patients have every right to make decisions regarding their own health care. But autonomy does not merely include the right to make decisions. It also includes the responsibility to endure the consequences of those decisions. Shared decision-making loses meaning when responsibility becomes entirely one-directional.

When intervention stops being healing

Modern medicine became extraordinarily good at prolonging biologic survival. That does not necessarily mean we became equally good at discussing suffering, dignity, quality of life, or the limits of intervention.

Sometimes medicine heals. Sometimes medicine prolongs suffering because no one is emotionally comfortable acknowledging decline. We increasingly struggle to distinguish preserving life from prolonging dying.

I have seen patients kept alive through extraordinary medical and technological effort despite profound neurologic decline, inability to communicate, complete dependence, severe chronic illness, and minimal meaningful quality of life. I have seen elderly patients with multiple chronic conditions undergo aggressive interventions that technically succeeded procedurally while accelerating overall decline.

A 99-year-old with progressive frailty falls, fractures a hip, undergoes major surgery, then declines and dies shortly afterward. Technically, the surgery “worked.” But did we truly help?

These are uncomfortable conversations. But avoiding uncomfortable conversations has become one of modern health care’s defining features.

Moral injury and frontline burnout

Many clinicians are not burned out because they stopped caring. They are burned out because they cared too long without sustainable boundaries.

There is a difference.

I went into health care because I genuinely care about people. All people. My colleagues and I value our staff deeply. Our medical assistants are not “beneath” us. We function as a team. We protect each other. We communicate constantly. We pitch in where needed. We built an environment based on mutual respect. And frankly, that is exactly why abusive behavior toward staff becomes intolerable. Health care workers are increasingly expected to absorb emotional dumping, administrative overload, impossible expectations, chronic understaffing, verbal abuse, and endless accommodation while still maintaining perfect empathy at all times.

That is not sustainable.

And perhaps most frustrating of all, low-value consumeristic care increasingly steals time, energy, and attention away from patients who are genuinely trying. The patients who actually want education, actually want prevention, actually attempt lifestyle changes, actually engage meaningfully in their health.

Those patients deserve better too.

Administrative detachment and the corporate layer

One of the most demoralizing aspects of modern health care is how frequently operational decisions are made by individuals furthest removed from patient care: consultants, executives, administrators, committees, corporate initiatives, cost-cutting exercises, workflow redesigns, productivity metrics. Meanwhile, frontline clinicians and staff, the people actually doing the work, frequently find their firsthand operational insight overlooked. Hospitals spend enormous sums hiring outside corporations to “optimize” health care systems while simultaneously underpaying and overburdening the clinicians carrying the system operationally.

Knee-jerk reaction after knee-jerk reaction. More restructuring. More metrics. More performative initiatives. Meanwhile, morale deteriorates. Burnout worsens. And the people closest to patient care increasingly feel unheard.

The people furthest removed from patient care increasingly determine the conditions under which patient care occurs. That is absurd.

The desperate need to unblur the lines

Modern health care blurred critical distinctions: compassion vs. enablement, autonomy without accountability, information vs. expertise, service vs. servitude, preserving life vs. prolonging suffering, and health care vs. customer appeasement. We cannot indefinitely compensate for chronic disease normalization, weak prevention, administrative detachment, consumer medicine, misinformation, uncertainty intolerance, and personal irresponsibility while pretending those forces are unrelated.

Health care professionals are not infinite emotional resources. Clinicians are not responsible for overriding every consequence of human behavior. And no health care system can sustainably function when accountability itself becomes taboo.

Compassion matters deeply. But compassion without boundaries is not sustainable health care.

It is codependence.

Eddie Saliba is a nurse practitioner.