Caring for Patients in a Crowded Cockpit Leads to Moral Distress
Updated September 4, 2026
Imagine if a commercial pilot, after years of training and thousands of hours in the cockpit, had to call an airline operations manager with no flight credentials to ask permission to change course around a storm. Imagine if the operations manager could delay the decision, request more paperwork, and ultimately insist the pilot fly through the storm. The pilot’s only recourse would be to seek review from another pilot employed by the same airline, all while remaining responsible for everyone aboard the aircraft. As a pilot, would you feel satisfied flying for that airline?
The comparison sounds ridiculous, but it is not entirely foreign to medicine. Physicians are routinely asked to justify necessary care to people who do not share their training, do not know the patient in the same way, and do not bear the same responsibility for the outcome. For many clinicians, this interference is no longer an occasional frustration. It has become part of the structure of everyday practice.
The cockpit is already crowded
External interference is only part of the problem. Physicians are also working inside practices where the patient visit ends long before the work associated with it does. The electronic inbox continues to fill, documentation remains unfinished, prior authorizations hold up care, and denials generate another round of administrative work. Much of this work occurs outside the time traditionally understood as patient care.
A 2023 study of 307 primary care physicians found that clinicians spent a median of 36.2 minutes in the electronic health record for each patient visit. That included 7.8 minutes devoted to the electronic inbox and 6.2 minutes of what researchers call “pajama time,” meaning EHR work performed between 5:30 p.m. and 7:00 a.m. or on weekends. [1] Those numbers help explain why physician workload cannot be understood simply by counting appointments. The visible workday and the actual workday have become two different things.
While pajama time may sound cozy, after-hours administrative work is probably not what most physicians imagined when they chose a career in medicine. The deeper concern is not merely inconvenience or work-life balance. When clinicians repeatedly encounter barriers that prevent them from providing care in the way they believe is right, the result can become something more serious. It can become moral distress.
Burnout and moral distress are not the same thing
A national study published in 2026 found that 39.1 percent of physicians reported a high level of moral distress related to their work. Physicians were substantially more likely to experience moral distress than workers in other fields, even after researchers adjusted for personal and professional characteristics. [2] The study also found a strong relationship between moral distress and burnout, although the authors emphasized that the two conditions are distinct. Burnout generally reflects prolonged workplace stress, while moral distress arises when clinicians believe circumstances prevent them from doing what they consider ethically right for a patient.
The overlap between the two is difficult to ignore. Among physicians reporting high moral distress, 75.1 percent also met criteria for burnout, compared with 30.7 percent among physicians with lower moral distress. Physicians with high moral distress were also almost twice as likely to report an intention to leave their practice within two years, 34.5 percent compared with 18.2 percent. [2] If moral distress contributes to physicians reducing clinical hours or leaving practice altogether, its consequences extend beyond the individual clinician. It becomes a workforce and access problem for the healthcare system itself.
Prior authorization makes the problem concrete
Prior authorization offers one of the clearest examples of how administrative systems can create both workload and moral distress. The physician recommends a course of care based on training and knowledge of the patient, but treatment may still depend on approval from a payer process operating outside the clinical relationship. A utilization-management function can be legitimate in principle, particularly when the goal is to discourage unnecessary or unsafe care. The problem arises when the process becomes so burdensome or indiscriminate that it delays appropriate care while consuming enormous amounts of clinical capacity.
The AMA’s 2025 Prior Authorization Physician Survey illustrates the scale of the burden. Physicians reported completing an average of 40 prior authorizations each week, consuming approximately 13 hours of physician and staff time. Ninety-five percent said prior authorization delays access to necessary care, while 79 percent reported that patients sometimes abandon treatment because of authorization challenges. Ninety-four percent said the process contributes to burnout, and 26 percent reported that prior authorization had led to a serious adverse event for a patient in their care. [3]
Those findings help explain why administrative burden can become something more profound than irritation. A physician may believe a patient needs treatment, know a delay could cause harm, and still find the decision trapped inside a process the physician does not control. The clinician remains responsible for caring for the patient even while another organization controls whether the recommended care can proceed. Seen from the cockpit, the source of moral distress is not particularly mysterious.
System problems require system solutions
The encouraging part of the research is that some of the burden appears responsive to organizational change. In the 2023 EHR study, greater team participation in orders was associated with less total EHR time, less after-hours work, and less inbox time. Practices with pharmacy technicians also showed significant reductions across those same measures. [1] The researchers concluded that organizational factors matter and that EHR burden should be addressed at the system level.
That distinction matters because physician burnout is still too often framed principally as a wellness problem. Personal well-being matters, but meditation apps and resilience training cannot correct a poorly designed workflow, an understaffed practice, or a payer process consuming 13 hours of work every week. Leaders who want to address burnout have to examine the environment in which physicians are practicing. Staffing, delegation, technology, payer processes, scheduling, and administrative expectations all belong in the conversation. Clinicians need operational relief, not another lecture about resilience.
Clearing some room in the cockpit
No practice can eliminate every source of physician frustration. Payer requirements will continue to exist, electronic records are not going away, and modern medical practice will remain administratively complicated. The relevant question is whether physicians should personally absorb as much of that complexity as they currently do. In many practices, the answer should be no.
Practice leaders can examine where physician time is being consumed, which work genuinely requires a physician, and which responsibilities can be redesigned or shifted elsewhere. They can improve delegation, strengthen administrative support, challenge unnecessary payer friction, and build systems that protect clinicians from becoming the default destination for every unresolved problem. None of those changes solves physician burnout by itself, but together they can materially change what it feels like to practice medicine.
Physicians enter medicine to care for patients, not to spend their careers fighting the machinery surrounding patient care. A crowded cockpit will never be completely empty, but we can decide how much unnecessary equipment belongs there and who should be responsible for operating it. If we want physicians to remain in practice, experience professional fulfillment, and exercise sound clinical judgment, we should give them enough room to fly the airplane.
Sources
[1] Rotenstein LS, Holmgren AJ, Horn DM, et al. System-Level Factors and Time Spent on Electronic Health Records by Primary Care Physicians. JAMA Network Open. 2023.
[2] Tutty MA, West CP, Dyrbye LN, et al. Moral Distress and Occupational Burnout in US Physicians. JAMA Network Open. 2026.
[3] American Medical Association. 2025 AMA Prior Authorization Physician Survey.
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