Why It's Hard to Put Patients First

"The Doctor's Art" is a weekly podcast that explores what makes medicine meaningful, featuring profiles and stories from clinicians, patients, educators, leaders, and others working in healthcare. Listen and subscribe/follow on Appleopens in a new tab or window, Spotifyopens in a new tab or window, Amazonopens in a new tab or window, Googleopens in a new tab or window, Stitcheropens in a new tab or window, and Podchaseropens in a new tab or window.

First used in the context of Vietnam War veterans, the term "moral injury" refers to the psychosocial, behavioral, and spiritual distress that comes from perpetuating or witnessing events that contradict one's deeply held moral beliefs. In recent years, moral injury has increasingly been used to describe one of the main challenges clinicians face in modern medicine -- the challenge of knowing what care patients need but being unable to provide it due to constraints beyond the clinician's control, such as limited time or misaligned financial structures. Even more than emotional exhaustion and detachment, moral injury leads to profound shame and guilt.

One of the leading voices addressing moral injury among healthcare workers is Wendy Dean, MDopens in a new tab or window, a psychiatrist who has written widely on the issue, most recently in her bookopens in a new tab or window, If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First.

In this episode, Dean tells Henry Bair and Tyler Johnson, MD, about her own winding journey from orthopedic surgery to general surgery and finally to psychiatry, discusses where moral injury comes from and what it looks like, and explores what clinicians can do to address it.

2:35 Dean's early interest and winding path in medicine 5:12 How Dean's desire to become a surgeon was deterred by gender discrimination 13:22 What led Dean to psychiatry, and then eventually out of clinical medicine entirely 18:03 A discussion of what moral injury is and why Dean began to study it 24:19 Examples of how moral injuries occur in the day-to-day of medical practice 38:57 How physicians and hospital administrators can address moral injury, citing, as an example, the case of Raymond Brovont, MD 42:22 Dean's advice on how to navigate and push back against seemingly insurmountable bureaucracy 47:39 Moral Injury in Healthcare, the nonprofit Dean founded 53:04 What setting personal and professional boundaries looks like in medicine 57:37 Dean's advice to students and clinicians about fighting burnout

Johnson: Well, we're so glad to welcome you, Dr. Dean, to the program this morning. And we really appreciate the insights that you're going to offer and the kind of moral mission that you're on, which we'll talk a little bit more about. So thank you for being here with us.

Johnson: Okay. We'll go with Wendy from here on out. So, Wendy, could you first start off by telling us, how did you end up in medicine? What's your origin story or superhero story?

Dean: Okay. It's not a superhero story for sure. I never had ambitions other than medicine. Which is really odd because I come from a family that doesn't have any medical background. My family is littered with plumbers and salesmen and no one in medicine. And apparently I told my parents when I was in, I was about 8 years old, that I wanted to be a doctor and my dad nearly drove off the road.

Dean: You know, that's a great question. I never asked him. I think it was just so outside of his interest or experience. And for a kid of 8 years old to to say so plainly, this is where I'm going, I think was just, was a surprise to him. I was also really into horses, so I think he expected me to say, I want to go to the Olympics or I want to be a vet or whatever. But no.

Johnson: So, okay, so you have the ambition from the time that you're really small. Tell us, though, then, the story of how did that ambition get translated into reality? So where, you know, how when you were in college, did you just, was it really just a straight shot? You came in as a freshman in college and knew you wanted to be a doctor and then that's what you do when you were graduating and you just went all the way on through?

Dean: That is exactly what happened. From the time I was in high school, that was my goal. And so my nose was to the grindstone. I was pushing it the whole time. I was the kid who was doing internships when I was in college with pediatricians and orthopedists. I was volunteering in hospitals. I was working in pathology labs during the summer of college. All the things. I did all the things. I was, I worked for the athletic trainer in college. I worked for an ob/gyn in town, like, I did all the things.

Bair: Yeah, you were like creating your own clerkships. It's like all those specialties. It's pretty impressive. Like, medical students don't even get to do pathology. So you found your way there, too?

Dean: It was great. I mean, it was a histopathology lab, so I got to learn how to cut slides and how to stain them. And so I came in like knowing those special stainings and what it entailed. And how come it took 2 weeks?

Johnson: Well, okay, so, as those who are, you know, at least partway through their medical training know, you can kind of, if you decide I want to be a doctor, you can kind of ride the train up through medical school, right? Then you get to your third year or whatever, you know, depending on where you are, but your year of core clerkships, you try a little bit of everything. In your case, I guess you started that during college, but whatever. Now it comes time to do residency and/or fellowship, whatever your advanced training. Tell us a little bit about how you thought about -- so you're in medical school, how did you think about what you wanted to specialize in and then what did your post-graduate training look like?

Dean: Yeah. So I went into medical school intent on being an orthopedist, and I was in medical school in the late 80s, early 90s. That was a rough choice for a woman then, right? It's still not an easy path for a woman now, but it's way easier than it was. I ended up realizing that that was probably not going to be the fight I wanted to fight for my entire life. So I ended up in general surgery with the intent to go into plastic surgery.

And the more I looked at an 8-year training path -- because there were very few 3+3 programs at the time, so I would have to be a general surgeon and then go into plastics -- and then what my life would look like once I got out, I realized all these other things that I'd like to do in my life would fall by the wayside. But I tried it anyway.

And 3 years into my general surgery residency, I realized I can't tolerate having so little control over my life. Because if someone doesn't turn your OR room on time, you're stuck there until 9:00 at night and you don't have control over that. So I ended up leaving surgery, as much as I loved it, as much as I still do to this day, decades later, miss it. I left and I went and worked in emergency rooms for a couple of years, thinking that I was going to leave medicine entirely and eventually decided that that probably wasn't the best path. So I went back and did a psychiatry residency because the patients who came into the ER who were psychiatry patients were sort of, I didn't think I'd ever get bored. And that's kind of my kryptonite.

I am not insensible to how difficult the job of a physician is in general, and a surgeon’s job in particular, but guess what?

People have jobs that impinge on their personal lives, are difficult to deliver with encompassing perfection, and the outcomes of their professional efforts can have an impact on people, especially if they don’t do their job to perfection.

An airline pilot? A ship’s captain? A bridge or building architect?

The list could go on.

But if you decide to take a job as a surgeon, you better get it through your head that when you are being depended on to do you job which you get well compensated for, your time is not your own when your profession calls. Expecially if you took that job to fulfill a surgical task that people’s lives may well depend on.

If she isn’t tough enough or dedicated enough to accept that, she needs to find another job. I don’t want her to be my surgeon if I am in a car wreck. They pay surgeons a lot of money, and there is a reason for that. Because when the pager goes off at 3 AM, you are not only available sound asleep in your bed, you jump out of bed and get to the hospital because PEOPLE’S LIVES DEPEND ON YOU.

You don’t want that responsibility, GET THE HELL OUT OF THE PROFESSION.

Sorry. The tone of this article just pissed me off. She wanted the money, prestige, and respect, but didn’t want the work.

Wendy is my cousin.

I helped her do some of the preliminary research for her book. I have some decent experience in senior level management and behavior of people in stressful management situations.

What I told her when I looked at her research is that I had seen this type of stuff during many years of mergers and acquisitions. It is pretty common from people who were senior managers in an acquired company. All of a sudden, they were not the hot shit masters of the universe they used to be. Now…they were just a dog in the much larger machine.

The problem in the medical field is that these people have been told they were “the best” since middle school. All through college and medical school their training and abilities were driven in one direction: To be almost God Like. They work their asses off to get through med school, residency, getting certified and licensed..and then….they are tossed on the midnight shift in the ED and they are managed like “a cog in the machine.”

Now, my politics have never been in line with Wendy’s. But, she is the smartest and hardest working person I have ever known in my life. During my wife’s complicated medical issues, she was always there to help interpret results and give sound advice. He takes her moral obligation as a physician seriously.

Her book was written for the medical field. I worked in a short time in that field. My interactions with the clinical staff was interesting. The hospital had gone through a recent “merger.” The atmosphere was very familiar to me.

I saw up close how the clinical staff reacted to having their world turned upside down. Their reactions and complaints were literally the same as a call center supervisor in an acquired bank. These folks were smart about a lot of clinical things. But they were horribly naive about how businesses worked. Not all of them “survived” and they went off to find new homes.

The answer to this issue is educating these new docs in Medical school. They need to be made aware of the Medical Business. They need to have their expectations “adjusted.”

So, Wendy is a good, smart, and dedicated woman. In her context, she addresses what is new to her peers. From the outside looking in we look at this and say, “Duh…welcome to the corporate game.”

Thank you for that background, Vermont LT. I should be clear, my irritation was with the subject being interviewed, not the author. I pinged you to this reply because I saw in your post your history in working with the analysis and management of stress in professional settings.

When there are a lot of people anywhere, doctors will always be in short supply.

Unless they find a machine with software that can do all the diagnosis and treatment that is produced from an assembly line and not from a lengthy medical training regimen, doctors (and not just good doctors...ANY doctors) will always be needed far more than they are gotten.

With that in mind, you need to find out how someone is going to perform under stress, and in that terrible process of putting someone in a more-or-less controlled environment of working under some level of direct supervision, you can reduce the risk later of having someone crack under real pressure when they aren’t in that loosely protective cocoon.

It is much like the training US Marines had gone through in the past at places like Parris Island. They deliberately tried to put recruits under severe and unremitting stress in a semi-protected environment, so if a recruit graduated and went out into the fleet, they had a better chance of performing their mission without becoming functionally debilitated by the stress.

Still. I don’t enjoy seeing people in those stressful situations, even if you know the how and why. Especially if you keep in mind that it may indeed be part of the process to separate the wheat from the chaff, even if people don’t like to admit it.

So, I deal with them a bit, and sometimes I really like it, when you see a resident over time and you think “Yeah. That one will be a fine doctor.” I used to be a jet mechanic back in my time in the Navy, and you would see all the Ensigns and newly minted LTJGs come into the squadron. Being a plane captain, I would watch them carefully as they did their own pre-flight inspection (independent of the one I was tasked with doing) and you could often tell a great deal about that young pilot just by watching them perform this task.

What did they pay attention to? Were they actually DOING the inspection or just going through the motions? I had one pilot who would walk like a zombie, literally kicking the tires, walking around and looking at things with his eyes vacant and his mouth partially open. It was 100% clear to me he wasn’t thinking about the puddle of hydraulic fluid under the wheel well, as much as he was his own affairs.

But I had another pilot who came to us as a LTJG, and watching him come into the squadron, looking no different from any of the others that came before them, all struggling to come to grips with how to fit in personally and professionally in this new environment. Some would show it outwardly on their faces, and some would hide it, but you knew they all grappled with it in some way. And as I watched this new young officer, a LTJG Leenhouts, a tow-headed guy with a very young looking, midwestern boyish face, he was one that I heard the inward voice say “Yeah. That will be one fine pilot.” When he did his preflight, you could tell 100% that this man was 180 degrees the opposite of the young pilot of vacant eye and open mouth.

When he was looking up the tailpipe for stress cracks in the jet exhaust pipe, his eyes and face would assume an extremely focused look, and if you could see a thought bubble over his head, you might actually see “...The Detroit Diesel-Allison TF-41 turbofan engine that powers the A-7 Corsair has a flaw in the design of the tailpipe, where the combination of heat and vibration can cause cracks to occur. The tailpipe must be carefully examined before each flight...”

Of course, it was MY job and the job of the more advanced mechanics in the jet shop to look for those cracks in the metal, but...it was in the pilot’s preflight instructions to perform that examination as well. So when LTJG Leenhouts did this inspection, he was doing as if his life depended on it, which...it did. In contrast, the aforementioned officer would walk up to the tailpipe and turn mechanically to face it to appear to anyone watching he was actually looking, but...he wasn’t.

Just a few years ago, I stumbled across an article with a picture of then CDR. Leenhouts, standing next to the nose of a haze gray A-7 Corsair with dozens of mission stencils painted on it. He stood, hands on hips, his still light blond, still young-looking midwestern boy’s face looking back at the camera. The article said he had led the 1993 initial strike mission against Iraq launched from the USS John F. Kennedy. It also said that he was, at the time, the all-time carrier trap leader for the US Navy. More carrier landings than anyone else. That has probably been broken several times since.

But the point of all this is, there is a commonality to a new pilot entering a squadron and a new physician entering a residency program, and I found the parallel to be very strong, accurate, and quite interesting.

Sometimes, after their residency, One of them may get hired to stay on staff, and when I hear the news, I do a silent fist pump and hear the word “Yessss!” in my brain.

Very rarely, in all my years, have I heard the groan of disappointment in my mind upon hearing the name of a resident in our program who was going to join us, and that is a nice statement of respect for that process. It feels like a quality metric. So, we didn’t have many of them. I had one Resident who had acquired the “God Complex” early on as a young resident, and was quite rude to an older woman who worked for me, a woman who was as smart and dedicated to quality in her work as anyone I have ever known. In the workforce, EVERYONE revered and liked her because she was that good. She was offended by that young resident, and rightly so. So I got the resident alone and said in a not unkindly (yet firm) tone: “Look. You don’t want to be rude to her. She is someone who may save your career someday when she spots your mistake and gets it fixed for you before it can harm anyone. She is someone you want to drop all she is doing to help you.” That resident apologized to her, and in the end, he turned into a pretty good resident.

Anyway, this is all part of the weeding process, and if not weeding, training for handling the stress. That it is often overdone (or at least, has been in the past) is painful to watch, but...once in a while, you see one who figures it out, absorbs things, learns things, and shows real talent that in the end, is real. They stand out, and likely will continue, as that young LTJG Leenhouts apparently did.

Odd. In my career, I have gone through two different phases and types of ducklings turning into flying ducks. Or ducklings into Docs.

And that has been a rewarding part of my career. Just reminiscing...getting close to retirement...I think...:)

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