Burnout is a big and burgeoning problem in the United States. According to a recent Mayo Clinic report, it affects 28% of the general working population. Among physicians, however, the rate is markedly higher, ranging from 44% to 54% in most studies.

More concerning are the consequences: Doctors who report burnout symptoms are twice as likely to commit a medical error. They’re also twice as likely as their patients to commit suicide.

Though the physician “burnout crisis” has left many in the profession battered, bruised, and pleading for help, there has been little noticeable improvement in recent years. To understand this strange division—between the urgency of the problem and the lack of effective solutions—I’ve surveyed patients and fellow physicians, scoured the latest research, news coverage, and social media commentary.

Most often, doctors look at burnout as a problem with a single etiology (cause). Instead, burnout has three distinct causes:

1. The health care system
2. Moral injury
3. Medical culture

The majority of physicians who believe burnout is tied to just one cause (particularly to a broken health care system) also believe that the solutions are beyond their control. In reality, each of these causes requires attention and action from doctors. Until that happens, the troublesome symptoms of physician burnout will only intensify.

Cause No. 1: the health care system 

In surveys, physicians almost unanimously blame America’s health care system for their burnout, pointing to a number of systemic obstacles standing in their way: cumbersome computers, vexing regulations, endless paperwork and long hours at the office.

Indeed, the health care system is poorly designed for care delivery. Physicians spend nearly twice as much time completing administrative and insurance forms as they do treating patients. The computers stationed in their exam rooms and offices are programmed to aid with billing and claims, much more so than to aid with clinical practice. Amid these barriers to better care, doctors feel both overwhelmed and abandoned.

As a surgeon and former medical group CEO, I’m intimately familiar with the challenges of practicing medicine in the 21st century. Across my career, I’ve been highly critical of the system’s antiquated structure, reimbursement model, and information technologies. Like my colleagues, I favor administrative simplicity, relaxed insurance regulations, better tech, and more time with patients.

However, there are two contrasting lenses through which to view these systemic failings. The doctors’ lens sees insurance executives and hospital administrators as preventing high-quality care delivery with endless restrictions and paperwork. Through the opposite lens, execs and administrators see themselves as health care’s financial stewards, concerned about the affordability of health care for American families and businesses.

Doctors are certain everything they do contributes to better patient care. But insurers and hospital administrators see things differently. The latter group knows 30% to 34% of all health care dollars are wasted on ineffective and unnecessary services (tests, treatments, and interventions).

Herein lies the struggle. Doctors see the problem as a failure of the “health care system” whereas others see the problem as a failure of the “delivery system.” And because the two sides perceive two different problems, their solutions conflict. Doctors want more support staff, less paperwork, and fewer restrictions—solutions that would require added resources. Insurers, on the other hand, want to curb health care cost inflation. In today’s economic climate, any burnout solution that costs more money (without driving efficiencies within the delivery system) won’t happen.

Cause No. 2: moral Injury 

Doctors are sworn to “first, do no harm.” This sacred vow supersedes all other workplace priorities. When the demands and requirements of today’s health care system conflict with the doctor’s duty to heal—that is, when the system inflicts harm on patients—doctors experience what’s called “moral injury,” a term first used to describe the psychological distress of combat soldiers.

According to the authors of a widely cited op-ed, “Failing to consistently meet patients’ needs has a profound impact on physician well-being—this is the crux of … moral injury.”

I’ll give you a recent example. While hiking in the mountains two weeks ago, my friend experienced a dizzy spell. His doctor diagnosed him with vertigo and ordered a CT scan to make sure it wasn’t a more serious (and potentially deadly) brain problem. When the results came back as inconclusive, the doctor appropriately ordered an MRI. Two weeks later, the insurance company still hasn’t approved this necessary test. As my friend waits in prior-authorization limbo, he remains highly anxious and unable to concentrate. The doctor, in turn, feels deeply frustrated and helpless because he can’t provide high-quality medical care for his patient.

To some doctors, this is the health care system’s greatest failure. And the resulting symptoms are what you’d expect: hopelessness, disengagement, and depression.

But to hold the moral high ground, doctors must also acknowledge and address the occasions when they, themselves, cause harm to patients.

I’ll give you a few examples. According to the U.S. Centers for Disease Control and Prevention (CDC), clinicians in hospitals clean their hands less than half of the time they should, which contributes to the dangerous (and deadly) spread of infection. Similarly one-third of antibiotics are unnecessarily and inappropriately prescribed by physicians, which can leave patients susceptible to dangerous, drug-resistant “superbugs.” Finally, recent studies suggest that doctors now perform hundreds of procedures that are found to be medically ineffective. These interventions can produce dangerous side-effects, increase the risk of medical error and, amid ever-rising health care prices, potentially bankrupt patients.

There’s no denying that doctors are often put in a position to fail—situations they can’t control. But there’s no denying that doctors also contribute to our nation’s poor-quality outcomes on their own. Until physicians acknowledge and address the full breadth of harm being done to patients, their laments over moral injury—like their demands for systemic change—will continue to fall on deaf ears.

Cause No. 3: medical Culture

In western civilizations, the culture of medicine began taking shape approximately 2,500 years ago with the oath of Hippocrates, a text that made sacred the physician’s vow to treat those in need and honor patient privacy. Medical culture, both then and now, is a combination of values, beliefs, and traditions that are passed down from one generation of doctors to the next. It profoundly influences what physicians think, say, and do.

For the overwhelming majority of medical history, this culture was constructive. The desire to heal, combined with a righteous sense of mission, guided every clinical decision, even when there was little doctors could do to help patients. For centuries, doctors relied on their experience, wisdom, and intuition as the best defenses against disease, injury, and illness. Their kindness, empathy, and compassion sustained the doctor-patient relationship through history’s most difficult moments. Even today, much of what calls doctors to the profession is rooted in these ancient cultural precepts.

As a physician, I’ve seen these positive traits on full display while participating in surgical missions around the world. As a health care CEO, I saw them when we deployed teams of doctors to help victims of natural disasters. In 2004, hundreds of Kaiser Permanente physicians volunteered to provide medical relief to tsunami victims in Sri Lanka. Six years later, my colleagues again raised their hands and flew to Haiti following a deadly earthquake. There, they worked 12- to 14-hour days in treacherous and taxing conditions. And despite the long hours, no pay, lack of technology and stressful circumstances, every doctor returned to work invigorated and refreshed.

When doctors are able to truly help people—when they’re reconnected with a higher purpose—the symptoms we associate with burnout tend to vanish into thin air.

But medical practice today feels far removed from these missions. Scientific and societal transformations are turning the doctor’s world upside-down, challenging the underpinnings of medical culture like never before. The doctor’s intuition, experience, and independent judgment no longer contribute to superior outcomes. Scientifically derived approaches to care—such as evidence-based medicine, clinical checklists, and algorithmic pathways for physicians to follow—have undermined the doctor’s autonomy and exceptionalism. As more patients turn to the internet for medical advice and as insurers increasingly challenge requests for tests and procedures, physicians are grieving their loss of status and respect.

Ultimately, doctors are struggling to cope in a world where everything is changing quickly except for the medical culture. This clash between the values physicians were taught, and their new reality is producing some of the telltale symptoms we associate with burnout, including disillusionment and despair.

Increasingly, doctors are rebelling against medical science and societal expectations. They reject monthly performance reports that evaluate patient “service” and “satisfaction.” They resist the notion that patients should be treated like “consumers” or that doctors should be labeled “providers.”

Medicine, once a respected profession, even a calling, has become just a job for many—one that 60% of doctors wouldn’t recommend as a career.

Physicians are suffering, and they need help. But they’ll get no relief by merely pointing out the shortcomings of the health care system or drawing attention to the moral injury it inflicts. Though these burnout causes have made victims of physicians, today’s doctors are neither helpless nor guiltless. Medical culture must evolve in order to address health care’s runaway spending and lagging quality. Until it does—until doctors eliminate wasteful services, embrace scientific advances, and take responsibility for rising costs—all the problems that plague American health care, including physician burnout, will only get worse.

Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.

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