Physicians suffer from "moral injury"

"If I Betray These Words

By Wendy Dean, with Simon Talbot

(Steerforth, 291 pages, $29)

'Thou must be like a promontory of the sea," the Roman emperor Marcus Aurelius wrote in "Meditations," "against which, though the waves beat continually, yet it both itself stands and about it are those swelling waves stilled and quieted."

Though he intended these words to describe the practitioner of Stoicism, they also define the ideal disposition of a doctor. As the chaos of the hospital reigns, the physician tunes it out and focuses on helping the patient.

Alas, this paradigm seems more at home in a bygone era than in our current medical system. Burnout now consumes American physicians, who are overworked, nonautonomous and adrift without help.

Such is the crisis facing physicians, according to the psychiatrist Wendy Dean and the hand surgeon Simon Talbot, co-founders of Moral Injury of Healthcare, a nonprofit focusing on distress in the healthcare workforce. In their new book, "If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First," they state that today's physicians are "seeing more patients, in less time, with fewer support staff," and are "required to use technology that interfere[s] with rather than facilitate[s] care." As a result, our healers feel exhausted, cynical, alienated and ineffective. However, the authors argue, "burnout" is a misnomer -- it suggests that physicians lack resiliency. They claim physicians suffer from "moral injury" instead. This places the blame on the system, not the physicians.

Drs. Dean and Talbot appropriately fret about the scope of moral injury. Ten percent of doctors have thought about or attempted suicide. One in five U.S. healthcare workers have left the profession since 2020 and close to half of healthcare workers plan to leave their current jobs by 2025. Almost 50% of U.S. physicians experience burnout and there was a dramatic increase in burnout among U.S. physicians between 2020 and 2021. As a result of moral injury, physicians experience poorer physical and mental health, patients suffer from poorer health outcomes, and the medical system loses around $4.6 billion yearly.

The authors illustrate the ill effects of moral injury on individual physicans through a series of riveting and poignant vignettes. One particularly troubling chapter tells the story of Jay Neufeld, a pediatric rehabilitation specialist taking care of disabled children. Neufeld worked for St. Luke's Hospital and Children's Specialty Center in Boise, Idaho. To help keep the institution solvent, hospital administrators shortened his appointments and increased patient volume. As the authors describe, "when he overstayed his scheduled time with a patient, assistants would interrupt him and say, 'Dr. Neufeld, your twenty minutes are up.' " Then one of his colleagues quit and Neufeld was the only physician left in his group. His request for more support went unanswered. When his contract came up for renewal, he faced a 30% salary cut. Subsequently, when the hospital's lack of physician coverage nearly led to the death of a patient, Neufeld further pressed his supervisors. But it was in vain. Trapped, he eventually took his own life.

How did this happen? Each chapter and story emphasizes a similar conclusion: "No matter how [physicians] respond, they are all victims of a profit-generating machine that has taken over healthcare." Profit and nonprofit hospitals, "motivated largely by revenue," cut staff, increase physician work hours, hijack physician autonomy and silence any dissent with threats of termination. Caught between the oaths they took as medical students and the crushing pressures of corporate healthcare, doctors suffer moral injury.

While the authors identify an important concern -- that current profit-seeking behavior stymies physicians and patients -- such au courant criticisms of capitalism are incomplete in explaining moral injury. Profit motives in medicine have existed for decades and will likely always exist to a certain degree. In 1894 an editorial in the journal Medical Record argued that doctors saw hospital growth "critically, not to say coldly," and resented the motive of hospitals to "get as much out of them with as little return as possible."

Today, surveys of physicians provide a more comprehensive story. They identify other factors, some of which are mentioned by Drs. Dean and Talbot, as sources of moral injury: increased bureaucracy, lack of respect from staff, lack of respect from patients, and burgeoning government regulations.

Not all of this relates to corporate greed; for instance, bureaucracy is always a side effect of government regulation. Indeed, our modern medical system now paradoxically combines the worst excesses of socialism (bureaucracy) and capitalism (greed). This contradictory yet sinewy co-existence is ultimately responsible for physician burnout. And it can only exist in a cultural environment confused about medicine's purpose.

If a physician labors only to see and please as many patients as possible, then patients, hospital staff and hospital CEOs will treat physicians as service personnel, profit-generators and "providers." If we think of doctors as algorithm-checking assembly workers, then providers belong in a bureaucracy befitting such a role. However, medicine aims to heal the individual patient, an endeavor that requires negotiation, discussion, time and care within a hospital or clinic room. Our laws and our culture ought to drive medicine toward that goal, not distract from it. If we recognize the health of the patient as medicine's purpose we necessarily treat the doctor-patient relationship as an end that every aspect of the system serves. Only this will attenuate bureaucracy, greed and moral injury.

"If I Betray These Words" ably humanizes modern, troubled physicians and rightly recognizes an important cause of their suffering. But if we want to make our doctors promontories of the ocean, stilling and quieting the swelling waves as we heal, then we must look much deeper than the corporate enterprise taking advantage of a profession lost at sea.

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Dr. Rothstein, a neurologist and fellow in bioethics and American democracy at the Ethics and Public Policy Center in Washington, D.C., hosts the podcast "Searching for Medicine's Soul."" [1]

1. First, Do No Harm
Rothstein, Aaron.  Wall Street Journal, Eastern edition; New York, N.Y. [New York, N.Y]. 04 Apr 2023: A.17.