The Scripted Physician
The Prequel to AI
For most of the twentieth century, the doctor-patient relationship stood at the center of American medicine. Physicians often owned their practices, made their own clinical decisions, and bore direct responsibility for the people in their care. The relationship was personal. Patients knew their doctors by name, and doctors in turn felt a profound sense of duty to those who entrusted them with their health. Over the past four decades, however, that dynamic has eroded.
In place of professional autonomy, physicians today increasingly find themselves employed by large hospital systems, corporate medical groups, and managed care organizations. In the early 1980s, approximately 76% of physicians were owners of their practices. By 2012, this figure had declined to 53.2%, and by 2022, only 44% of physicians identified as practice owners. This downward trend continued into 2023, with just 22.4% of physicians remaining in independent practice. Conversely, the proportion of physicians employed by hospitals or corporate entities has risen sharply, reaching 77.6% by January 2024.1
This shift from ownership to employment has not only changed where doctors work, but also how they work, and for whom. Consequently, physician authority is now circumscribed not only by legal risk and billing codes, but by a growing layer of non-clinical oversight: hospital administrators, insurance middlemen, and government payers. Decisions that once belonged to the bedside are now filtered through quality metrics, preauthorization portals, and algorithmic guidelines designed by people far removed from the point of care. Physicians are no longer at the helm of medical practice. They have been displaced and subordinated to an expanding managerial class composed of MBAs, health system executives, nurse administrators, venture capitalists, and private equity stakeholders. In this restructured order, the doctor is no longer a leader or owner but a line-item employee tasked with executing someone else’s business plan.
This is not just a structural change, it is a paradigm shift with sweeping consequences for the quality, character, and purpose of the care the system delivers. The patient is no longer the doctor’s patient in any meaningful sense; they are the client of a health system. The doctor is no longer an independent advocate, but a managed employee. Most crucially, the patient is no longer the customer. In a system dominated by third-party payers, the true customer is the insurer, or Medicare, or Medicaid—the entity that pays the bill and dictates the terms. Increasingly, the patient is more accurately described as the product, moved through a process designed for billing optimization and throughput. The “care” part of healthcare has become subordinated to performance indicators, and clinical judgment must increasingly answer to operational efficiency.
Health executives have embraced this transformation. From their perspective, the variability of individual physicians is a liability. Personalized medicine, when truly practiced, is inefficient. It defies standardization, it resists automation, and it introduces unpredictable costs. The ideal system, from an administrative standpoint, is one in which physicians are interchangeable parts. The health executive views physicians as technicians executing protocols. The fewer decisions made at the bedside, the better.
In this light, the rise of AI in clinical medicine is not a revolution—it is a predictable and logical endpoint. For forty years, physicians have been incrementally pushed toward script-following and metric compliance. But we have also played a role in our own undoing. Many of us accepted the steady march toward employment, sold our practices to corporate buyers, and adapted to the protocols that slowly replaced our judgment. We traded autonomy for stability, and in doing so, helped pave the road toward a system that no longer needs us.
In retrospect, it is difficult not to see this as a slow, collective march toward our own obsolescence. The physician who adheres strictly to the algorithm, who becomes fluent in the script, is ultimately making himself replaceable. Artificial intelligence merely completes the arc. A machine never questions the metric. It never refuses an order set. It does not weigh the ethical tension between what is billable and what is right. For patients who have already grown used to disinterested, overburdened physician-employees rushing through checklists, the transition to algorithmic care may feel like no great change at all.
Yet there remains, for now, a crucial difference. Physicians can still say no. They can still advocate. They can still quietly disobey the pressures exerted by administrators in the service of a patient whose needs do not conform to the prescribed model. It is an imperfect resistance, but it matters. The doctor who still cares remains the final safeguard against the full mechanization of medicine.
AI offers administrators the chance to eliminate even that. It promises a future where no human objection impedes throughput. However, when we lose the doctor’s defiance, we do not merely increase efficiency. We lose the final human barrier between the patient and the system that sees them as a cost center.
I hope that the future of healthcare doesn’t hinge entirely on smarter code. Technology, including AI, has the potential to support us—to sharpen our diagnoses, reduce error, and extend our reach. Used well, it can empower physicians to spend more time connecting with patients, not less. The goal is not to reject these tools, but to ensure they serve the clinician rather than replace the clinician.
What stands between harm and healing is not the technology, it is the person who chooses to use it wisely, or not at all. It isn’t the algorithm that protects the patient, it’s the human who chooses when to follow it, and more importantly, when to deviate. That judgment, that human element, is what makes medicine a moral act rather than merely a mechanical one. What may yet redeem this system is not the precision of its code, but the presence of a human heart and soul behind the decisions that matter most.
Muoio D. More and more physicians are working under hospitals, corporate entities, report finds. Fierce Healthcare. January 24, 2024. Accessed May 30, 2025. https://www.fiercehealthcare.com/providers/more-and-more-physicians-are-working-under-hospitals-corporate-entities-report-finds
Physicians Advocacy Institute. Physician Employment Trends: 2019–2023. PAI-Avalere; April 2024. Accessed May 30, 2025. https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/PAI-Avalere%20Physician%20Employment%20Trends%20Study%202019-2023%20Final.pdf