Treating Systemic ‘Moral Injury’ in Medicine

Derick Alison
Derick Alison
15 Min Read

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    Emily Hutto is an Associate Video Producer & Editor for MedPage Today. She is based in Manhattan.

In this exclusive Instagram Live clip, Jeremy Faust, MD, editor-in-chief of MedPage Today sits down with Wendy Dean, MD, president and co-founder of Moral Injury of Healthcare, and Adam Brown, MD, MBA, founder of ABIG Health, to discuss moral injury and burnout in healthcare.

Watch the first part of this discussion here.

The following is a transcript of their remarks:

Faust: If you’re in the clinical environment and you’re me — you’re not like the CEO — what’s the move? What’s the hack to make this so that it doesn’t cause inexorable burnout, or worse, you have to leave and all that.

Dean: So number one, there’s no hack. Bottom line is, there’s no hack.

This comes about as an erosion of community, the fabric of community. Where it starts is rebuilding the community. So as clinicians, as physicians together, we need to start working together to push back, to speak out.

Because when you, Jeremy, as the lone voice speak out, then you’re the asshole. But when you and all of your colleagues speak out together — and not just you as emergency physicians, but with your orthopedists, with your pediatricians, with everybody else — when you speak together in a reasonable way, understanding what the administrators face as their own challenges, then you can start to find solutions together.

And by the way, administrators and managers also suffer moral injury, about 40% of them in a study that we did last year.

Faust: That doesn’t surprise me. A lot of people who go into administration weren’t on day one saying, “How can I become a corporate suit and become the man?” They really meant well and they do mean well. But then also their hands are tied by — it’s a stakeholder issue, who do I report to and what’s my job?

And so, Dr. Brown, from the MBA perspective as well, I’m curious how you’ve seen that play out.

Brown: It’s interesting. I was giving a talk at Chapel Hill on Friday about the complexities and challenges in the United States healthcare system. And one of the things I said, and I truly believe this, is I have yet to meet an individual that was, “I want to screw over doctors and I want to screw over patients.” I’ve yet to meet a person like that.

And for those who are not coming from a healthcare background, meaning healthcare training as a nurse or a physician, oftentimes they’re reliant upon a physician, a nurse, a clinical leader, to explain to them what is going on on the ground and what’s going on at the bedside. So if we are not as clinicians speaking in one voice or as a community to what some of the problems are, we’re not going to fix them.

I look at the EMR system — there’s the big three, you’ve got Cerner, Meditech, and Epic, which are the big EMR systems. I’ve also not met many physicians that have said, “Hey, these are really great systems. They make my life a lot better. These are amazing, and I love using them throughout my day.”

Just think if we, as clinicians and nurses, pulled together to really start advocating for better solutions to make it more efficient and not something that is creating more and more and more administrative burdens on the part of clinicians. Just think if we as clinicians pull together to start advocating for those real changes in credentialing and licensing that took away some of the stigma of getting mental healthcare when we need it. Think about if we started speaking in one voice as a community, the change that could be made.

Because I believe if we did that, many people on the business side would start to say, “Hey, a critical constituent and stakeholder within the walls of our hospital or our clinics need either help or they need to do things in a different way, because either we are going to lose them to another industry, or we’re going to lose them physically, which is a big problem.”

So I do think that it’s part of us coming together and speaking more in one voice with credibility and creating that alignment across the board.

Faust: One question I have been pondering is, how do we get our systems to align with our values? In other words, how does that work? Who’s responsible for making it that way?

The last thing I’ll say before I unleash you to the crowd here is that a lot of times people do things that they think are in their best interest, and then once you’ve shown them, actually no, what you’re doing is not in your best interest, then you come together. The system, so to speak, I feel maybe has a view that needs to be changed.

Brown: So Jeremy, I will tell you — this is not probably all that shocking coming from a business person who’s also a clinician — but how we finance this system, what we financially incentivize is what we get. The healthcare system that we currently have right now is exactly designed how we are financing this healthcare system. So that’s where my answer is going to come from.

If we want to align parties — whether it’s the hospital systems, the payers, the clinicians — altogether, we need to fundamentally change how we are paying for the healthcare system. Think about it, we have changed in some ways. CMS has been looking at patient experience and patient satisfaction and those sorts of things.

We haven’t necessarily done those sorts of things on the provider side. Are hospital systems trying to ensure that physicians or clinicians, nurses, et cetera, are satisfied in the work that they are working in?

We’ve been in such a fee-for-service type of world that every single bit of volume that comes in means a new revenue stream for the hospital or new revenue source. If we were to change that and change [so that] we can spend more time with our patients trying to identify solutions for them, and then get reimbursed for that and keeping them safe, that changes the way we practice and changes the way that we interact. So I believe that a lot of the alignment will come from how we are financing the system and the changes that we need to be making in how we finance the system.

I know that’s a really high 50,000-foot answer and it will take a long time to get there, but we need to start having that conversation to see the role that capitalism plays, and does it align fully with our compassion for our patients and our colleagues.

Faust: That’s 50,000 feet. That’s 100,000 feet, and it’s huge. I can almost see it’s a future that seems distant.

And it made me think, how long has this been going on? I mean, I know that in the past 20, 30 years that the field of medicine has changed. But, Dr. Dean, in your opinion, when did this really go off the cliff? What’s the lesion that caused this to become a crisis?

Dean: I think we started early with, at the very, very beginning, was when we started down the HMO route, then around 1990 when we started to see a lot of consolidation and vertical integration, it’s taken off. And really in the past decade, it has accelerated. Every single person I talked to marks it at about a decade ago that we really saw the onset of the distress.

Faust: I wonder if that’s something, to encapsulate what you just said, if it really has to do with a little bit of autonomy — everything to do with autonomy.

In the past if you were a physician who also owned your practice and you didn’t have higher-ups to answer to, you could say, “You know what? I’m going to make a little less money because I believe in doing it this way. I’m going to make that decision.” Well, now you don’t get that opportunity because someone’s going to write you an email saying that you didn’t bill properly.

The question I wonder is not necessarily is it a capitalist problem, although it might be partially, but really is it a matter of ownership in terms of who gets to make those calls? Who gets to make that nuanced call?

Dean: I think it is definitely that. I think people who are in private practice have more sense of their own autonomy. They can make those choices and they can find the balance that they need.

But the other thing that we have to keep in mind is the incredible acceleration of the cost of a medical education, which means people are less able to take the risk of being in private practice and need the stability of being employed.

Brown: Jeremy, this goes back to what I was saying about how the system is financed. If you look at the reimbursement rates for clinicians, they’ve actually continued to degrade. And some of the answers — at least to address reimbursement declines with payers — have been to consolidate, which means they’ve had to relinquish much of the autonomy that they were having.

This is why it goes back to the 150,000-foot conversation that I was having. It all links back to [that] some of the decisions that are being made today are trying to address the reimbursement challenges.

Now, to be clear, I am not saying that capitalism is bad. Capitalism really improves innovation, it improves productivity — there’s a whole host of things — but we’re not currently living in a capitalist society in our healthcare system. There are regulations that are granting winners and losers right now, and those regulations are really making patients and clinicians lose and other larger vertically-integrated entities winners — you just have to look at their profit margins to see that.

That’s where I think a solution … is in where clinicians and nurses can speak in one voice to change that and bring back some autonomy in the practice setting.

Dean: I would also add that the thing that we haven’t talked about is bringing patients into the conversation.

Brown: Oh, absolutely.

Dean: We’re all going to be patients one day. We need to think about that too.

Faust: Yeah. I was going to ask you each: what’s the one thing that you want listeners to take away? But I think that might be it. I mean, we have to have the patient as part of it.

I’ll just add one final thing before we sign off, which is that I think that the cause and the solution to this problem are pretty complicated, and it’s not going to be a snap of the finger to fix it. But I will say, as with almost any problem, just knowing about it and educating our clinician peers about it is a huge step in the right direction so that people don’t feel so alone, right?

Knowing my little bugaboo is the mask thing and feeling like that’s out of line with my values but it’s coming from a higher place, but everyone else has something else that’s probably bugging at them. And knowing that this is not normal, this is not the way it was supposed to be, I think is very important for our own sanity as clinicians and providers.

So I just thank you both for shining a huge light on this problem.

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