Picture a patient with uncontrolled diabetes. The diagnosis is correct. The treatment plan is sound. And yet she is choosing between paying the utility bill and buying insulin this month, and no one in the clinic ever asked. Boyd Burns, an emergency medicine physician and Interim Dean at the University of Oklahoma, Tulsa, School of Community Medicine (OUSCM), has watched that scenario repeat itself throughout his career, and he believes it represents the central failure of American healthcare right now. "We will, at times, create a treatment plan and unintentionally assume everyone has the same ability to carry it out," Burns said. "But patients live in very different realities."
The tension Burns keeps returning to is one between medical capability and medical delivery. The science, he argues, is often excellent. What lags behind is a system designed around its own operational convenience rather than around the circumstances of the people it serves. He reaches for an analogy that cuts cleanly: "It would be like watching someone tee off on a long par five with a putter. Intuitively, we all recognize that would not be the most effective or efficient approach. The challenge is not that the golfer lacks effort, it is that the tool does not match the situation." In medicine, the standardized treatment plan is frequently that putter.
Prior authorization offers a concrete example of the delivery gap Burns describes. With 90 percent of physicians reporting delays, the distance between a correct diagnosis and actual treatment can stretch long enough to cause real harm. Burns points to treatment abandonment and worsening health conditions as direct consequences, framing them as predictable outcomes of a system that places bureaucratic process between patients and their care. His argument is that fixing the delivery problem requires redesigning systems around patient realities, not around institutional defaults.
Perhaps the sharpest reframe Burns offers concerns what the medical establishment often labels noncompliance. "What looks like patient noncompliance is often something else entirely: a person making difficult decisions under difficult circumstances," he said. "A single mother of three, living in a food desert without reliable transportation, choosing between heat and medication isn't being noncompliant. She's surviving." That distinction, between irrationality and triage, changes both the diagnosis of the problem and the appropriate response. It also changes the physician-patient dynamic in ways that, Burns contends, produce measurably better outcomes.
At OUSCM, the curriculum has been built to train physicians who can hold both pieces at once, the clinical and the contextual. Students tour food deserts, engage with poverty simulations, and learn food as medicine in working kitchens. The outcomes Burns cites are striking: OUSCM graduates remain in underserved communities at rates 20 percent higher than the national average, Tulsa's life expectancy gap across socioeconomic zip codes has narrowed by nearly four years, and ER utilization dropped by 75 percent between 2011 and 2023. Social determinants of health currently account for roughly $320 billion in annual U.S. healthcare spending, a figure Burns says is projected to reach $1 trillion within 15 years. "Removing the tension or conflict between doctor and patient by integrating the patient's lifestyle into the diagnostic plan is a fiscally sound choice," he said.
The throughline in Burns's argument is that this is a solvable problem, but only if medical education changes what it teaches. "Our responsibility is not simply to diagnose disease, but to understand what stands between the patient and success." The results in Tulsa suggest that when physicians are trained to ask what is actually going on in a patient's life, the care improves and the costs come down. Whether that model spreads depends less on scientific discovery than on whether the institutions training the next generation of physicians decide to take the question seriously.
