“In honor of the knowledge I’ve received from my teachers, I swear to care for anyone who suffers, prince or slave. If I ever break this oath, let my gods take away my knowledge of this art and my own health. Here speaks a citizen, a servant of people. May I be destroyed if I betray these words.” —Hippocrates1
Long before the pandemic, physicians were suffering from “moral injury” — a violation of one’s values, ethical code, or sworn duty — because too often they had to choose between their patients and the profits and performance measures of corporate medicine, claims the author of a new book.
Wendy Dean, MD, president and co-founder of Moral Injury of Healthcare, and her colleague, Simon Talbot, MD, wrote a comprehensive and surprisingly personal book about physicians at the end of their tether: If I Betray These Words.2
Previously, Hospital Employee Health interviewed Dean about moral injury during the pandemic. Causes include the patient deaths nurses witness, those trying to treat patients knowing others are left unattended too long, and the death of their colleagues early on for the want of PPE.
Dean wanted to look at physicians and corporate medicine, which in her opinion set the stage for the devastation that occurred when SARS-CoV-2 appeared.
“I intentionally did not write a book about COVID because I wanted to be crystal-clear about this: Moral injury was a problem before the pandemic, and if we don’t change things, it will continue to be a problem afterward,” Dean says. “Regardless of COVID, the issues addressed in the book need to be solved.”
That said, COVID-19 could scarcely have arrived at a more opportunistic moment to wreak havoc on the U.S. healthcare system.
“Many of the ways that healthcare had been managed prior to the pandemic were in part responsible for why we were so crippled responding to it,” Dean says. “Cutting [resources], lean staffing, reducing space to the absolute minimum to maximize the return on investment for each square foot. Just-in-time supply chains so that we didn’t have stockpiles of anything. All of that meant that we were flat-footed in our response to COVID.”
Of course, the pandemic had a compounding effect, but the medical economics changes that have occurred over decades have affected physician mental health.
“The sheer volume of demand is wearing them down, but their bigger concern is that they are breaking a promise they made years ago, when they entered the profession of medicine — that they would do no harm and always put patients first,” Dean wrote. “Physicians have one of the highest rates of deaths by suicide of any profession. Most doctors don’t get to that point, of course. No matter how they respond, they are all victims of a profit-generating machine that has taken over healthcare.”
Corporate Mentality
In broad strokes, Dean traces this corporate mentality to economist Milton Friedman’s 1970s theories that that rewarding shareholders is paramount. In the book, Dean described how “hard-nosed” CEOs with “creative accounting tactics” and not necessarily any medical background consolidated “an industry that was once made up mostly of small community hospitals — extracting enormous profits for themselves and their shareholders. … I couldn’t figure out why our society so readily accepted health systems more focused on profits than patient care.”
Step back and take a broader view of that last point and you may find yourself standing on the fringes of nationalized healthcare — something Dean did not address in depth in the book but tells HEH it is “one of the conversations we need to be having in healthcare and as a society. Is it OK to make a profit off people’s vulnerability like this? The most absolutely egregious example of it, but it really is just kind of the logical extension of it everything else, is in hospice care. Private equity firms have gone into hospice care.”
Citing concerns that equity firms may maximize short-term profit and then resell, one medical commentator noted the utter lack of transparency in these transactions — which are not legally bound to be revealed in any detail.
“Approximately 16% of hospice patients are cared for by hospices that are owned by either private equity or publicly traded corporations, yet we know virtually nothing about the quality of care provided when these entities take over a hospice program,” wrote Joan Teno, MD, MS.3
The Doctor Is Sick
Physicians are bound by their ethical standards to put these patients first, but policies designed to increase profits may undermine hospice care — a heretofore sacrosanct area of healthcare.
“It’s really eroding what should be a sacred space,” Dean says. “No matter what your religion or spirituality is, the process of dying should be a sacred space, and it’s now being intruded on by private equity and profit-making.”
As described in case studies, this creep of profiteering has caused physicians to sustain moral injuries. Some of the physicians interviewed for Dean’s book ended up leaving the field altogether, or reluctantly continuing — with some level of anger — because their income was critical to their family. Others found a path to practice medicine that put patients first or fought the perceived injustice of the system with decidedly mixed results.
Hannah: “Sometimes, it felt hypocritical to stay in a system that allowed what she perceived to be substandard care, and most weeks, it took everything she had not to quit in a rage. But Hannah was torn — who would protect her patients if she left? … Hannah was the last specialist caring for patients who were hospitalized, and she spent nearly every shift addressing diagnoses and treatments that well-meaning non-specialists had missed. She couldn’t imagine leadership would cut deeper, but less than a year later they came for her.”
Matt: “As productivity targets increased, his already-packed clinic schedule was even more crowded, leading to long [disrespectful] waits for his patients. … And there were other problems interfering with patient care, from understaffing, which delayed his surgeries, to misaligned performance incentives, which led to infighting between team members rather than cooperation, to waiting weeks for insurance approvals for surgery or imaging. He felt stymied at every turn.”
Jay: “With a complex specialty like pediatric rehabilitation, Jay was already chafing at a pay change to productivity-based bonuses that essentially rewarded those who saw more patients. His key co-worker left and, to Jay’s surprise, the hospital left the position unfilled — month after month. This meant that Jay was essentially always on call. He protested to management that the situation was untenable and got the impression it would be resolved in his upcoming contract meeting.”
It was not, but he was advised to sign the contract or face an evaluation for “impairment” at an inpatient facility, Dean reported. Convinced he was in no way impaired and thinking to resolve the issue quickly, he agreed and went to the facility. Once admitted, things took a turn for the worse as an initial diagnosis of burnout became overlapped with “disruptive behavior.” He was released with an arrangement to attend mandated counseling.
Jay killed himself two weeks later. His wife wonders if he lost his life by standing up to the system.
“As more clinicians understand their distress as moral injury rather than individual frailty, they are increasingly willing to stand up to corporate recklessness,” Dean wrote. “In general, we see less moral injury in organizations where doctors and other clinicians are full partners in organizational decision-making and leadership is open and responsive to clinician feedback.”
In these types of environments, the electronic medical record (EMR) is tracked in part because it is a known driver of moral injury. “Demands for documentation have gotten so unwieldly that meeting them can lead to inefficient and even inattentive care, and the consequent moral injury is driving people away.” Dean wrote.
“I often say that the EMR separates clinicians from their patients during the day and from their families at night,” she says.
In addition, tying executive compensation to measures of clinician well-being can be an effective way to make sure administration is invested in the problem.
The intent of the book is preventing moral injury and improving care by closing the gap between physicians and patients. The latter group Dean sees as the ultimate power broker in healthcare — if patients can be convinced their caregivers need allies.
“I wrote this book to help them understand what their clinicians are going through,” Dean says. “They may say I knew healthcare was hard, but it shouldn’t be this hard. How do I support the clinicians who really care for me and who I care about as a result?”
This is a long-standing and ongoing problem about the clinicians currently entangled in this python’s embrace of money and medicine — those who cannot forget they vowed to treat the suffering.
“I think the first thing is to let them know they’re not alone,” Dean says. “That really goes a long way. I can’t tell you the relief I’ve seen on people’s faces. Then find others who are of like mind. Work as a group to give feedback to leadership about what needs to change. How can we all work together to change this? [It will take more than] clinicians who are already beleaguered by the expectations of the system.”
REFERENCES
- Arenas A. Hippocrates’ oath. Arion: A Journal of the Humanities and the Classics 2010;17:73-74. doi:10.1353/arn.2010.0051.
- Dean W, Talbot S. If I Betray These Words: Moral Injury In Medicine and Why It Is So Hard for Clinicians to Put Patients First. 2023. Steerforth Press, Lebanon, NH.
- Teno JM. Hospice acquisitions by profit-driven private equity firms. JAMA Health Forum 2021;2:e213745.
Long before the pandemic, physicians were suffering from “moral injury” — a violation of one’s values, ethical code, or sworn duty — because too often they had to choose between their patients and the profits and performance measures of corporate medicine, claims the author of a new book.
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