EP. 64: WHY IT’S HARD TO PUT PATIENTS FIRST

WITH WENDY DEAN, MD

A psychiatrist and author shares her journey in and out of medicine and what physicians can do to address moral injury in health care.

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Episode Summary

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 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 clinicians 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 health care workers is Dr. Wendy Dean, a psychiatrist who has written widely on the issue, most recently in her book, If I Betray These Words: Moral Injury in Medicine and Why it's so Hard for Clinicians to Put Patients First. In this episode, Dr. Dean shares 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.

• GUEST BIO

  Wendy Dean, MD was the first physician to use the term moral injury to describe the deep soul wound that affects a person’s identity, sense of morality, and relationship to society. Physicians who experience moral injury are unable to provide high-quality care.  

  Dr. Dean has worked in research funding oversight for the Department of Defense and as a non-profit leader supporting military medical research at Henry M. Jackson Foundation for the Advancement of Military Medicine. She has participated in efforts sponsored by the White House Office of Science and Technology Policy, the Biomedical Advanced Research Development Agency, DARPA, NASA, the Uniformed Services University of the Health Sciences and others. As Medical Advisor at Tissue Injury and Regenerative Medicine Program Management Office for the US Army Medical Research and Materiel Command, Dr. Dean’s expertise influenced FDA licensing for a $300 million portfolio of Department of Defense (DoD)-funded regenerative medicine research programs.  

  Dr. Dean graduated from Smith College and the University of Massachusetts Medical School. She did her residency training at Dartmouth Hitchcock Medical Center in Hanover, New Hampshire. A psychiatrist by training, she left clinical medicine when generating revenue crowded out the patient-centered priorities in her practice. Her focus since has been on finding innovative ways to make medicine better for patients and health care professionals technologically, ethically and systemically.  

• HIGHLIGHTS/RECAP

  In this episode, you will hear about:

  • Dr. Dean’s early explorations in medicine - 2:35

  • How Dr. Dean’s desire to become a surgeon was deterred by gender discrimination - 5:12

  • What led Dr. Dean to psychiatry, and then eventually out of clinical medicine entirely - 13:22

  • A discussion of what moral injury is and why Dr. Dean began to study it - 18:03

  • Examples of how moral injuries occur in the day-to-day of medical practice - 24:19

  • How physicians and hospital administrators can address moral injury, citing as an example the court case of Raymond Brovont M.D. vs EmCare Holdings Inc - 38:57

  • Dr. Dean’s advice for how navigate and push back against seemingly insurmountable bureaucracy - 42:22

  • Moral Injury in Healthcare, the non-profit Dr. Dean founded - 47:39

  • What setting personal and professional boundaries looks like in medicine - 53:04

  • Dr. Dean’s advice to students and clinicians about fighting burnout - 57:37

• EPISODE TRANSCRIPTION

  Henry Bair: [00:00:01] Hi, I'm Henry Bair.

  Tyler Johnson: [00:00:02] And I'm Tyler Johnson.

  Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

  Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

  Henry Bair: [00:01:03] 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 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 clinicians 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 health care workers is Dr. Wendy Dean, a psychiatrist who has written widely on the issue, most recently in her book, If I Betray These Words: Moral Injury in Medicine and Why it's so Hard for Clinicians to Put Patients First. In this episode, Dr. Dean shares 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. Tyler, take it away.

  Tyler Johnson: [00:02:20] 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.

  Wendy Dean: [00:02:33] Well, thank you so much. And Wendy is fine.

  Tyler Johnson: [00:02:35] Okay. We'll 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 the what's your origin story or superhero story?

  Wendy Dean: [00:02:47] 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 eight years old that I wanted to be a doctor and my dad nearly drove off the road.

  Tyler Johnson: [00:03:17] And here you are.

  Wendy Dean: [00:03:19] And here I am. Yeah.

  Henry Bair: [00:03:21] Yeah. May I ask why it was that your father reacted the way he did?

  Wendy Dean: [00:03:27] 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 eight 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.

  Tyler Johnson: [00:03:54] 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 when you were graduating and you just went all the way on through?

  Wendy Dean: [00:04:18] 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.

  Henry Bair: [00:04:51] Yeah, you were like creating your own 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?

  Wendy Dean: [00:05:00] It was great. I mean, I. 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 two weeks?

  Tyler Johnson: [00:05:12] 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?

  Wendy Dean: [00:05:52] Okay, so, so, so this is where people may not want to follow my path.

  Tyler Johnson: [00:05:59] So that's okay.

  Wendy Dean: [00:06:00] 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 eight year training path -because there were very few, three and three 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 like to do in my life would fall by the wayside. But I tried it anyway. And three years into my general surgery residency, I realized I can't tolerate having so little control over my life. Because if 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 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 E.R. who were psychiatry patients were sort of I didn't think I'd ever get bored. And that's kind of my Kryptonite.

  Tyler Johnson: [00:07:40] I actually want to pause for one moment. At Stanford, they have something called the E4C program, which is this group of about 20 faculty members who are kind of the primary designated mentors for medical students. So I have a group of five medical students in each class that are sort of I'm their point person along their their training journey. And I would say that one of the conversations that I have most frequently with those medical students is trying to process and make the exact decisions that you were just talking about where they're trying to balance. So actually, two things that you brought up. One is I've actually had multiple women who are considering going into orthopedic surgery who have to grapple with this idea of, well, gosh, on the one hand, wouldn't it be awesome if I could go into this field precisely to be a change agent, right, so that I can show that women can also be awesome orthopedic surgeons, Not that that needs to be shown, but to make it a safer space to have everybody know. That is what I should say. And then the other thing is people who are grappling with, wow, I feel called to do A, B, C, X, Y, Z thing in medicine.

  Tyler Johnson: [00:08:55] But I have this sense that if I do that, like if I look at the people who are 20 years down the road who are doing that, they are married to the hospital, right? Especially if they're on their whatever it is, transplant surgery, McHugh, CCU, whatever it is, if they're attending in the hospital, that's just where their life is. And they have this sense that especially for the training period, but maybe even after the training period, that their identity and their time will be almost entirely consumed by medicine. And so as much as they feel this almost a metaphysical calling to do something, they wonder if that's really if they really want to turn their life over entirely or almost entirely. At least that's what it feels like to to their job. So can you talk a little bit about both of those decision points, both the decision not to go into orthopedic surgery and then the decision to go into general surgery, but then later to leave it behind. Sort of walk us through what was going on in your mind as you made those decisions.

  Wendy Dean: [00:09:58] I'll say neither of them was easy. And to this day, I still wonder whether I made the right choice to turn away from orthopedics. It's how I think. It's. It's what I enjoy. As you know, when I was when I was in college and I would choose to read journals, I would read JBJS. Right.

  Tyler Johnson: [00:10:19] What is JBJS?

  Wendy Dean: [00:10:20] The Journal of Bone and Joint Surgery. Sorry. It was the.

  Tyler Johnson: [00:10:23] Fact that you knew that existed in college. Never mind. Read it regularly is more than many of our

  Wendy Dean: [00:10:27] Every week I read it every week. I mean,

  Tyler Johnson: [00:10:29] Guests did.

  Wendy Dean: [00:10:31] Yeah.

  Tyler Johnson: [00:10:33] That's impressive.

  Wendy Dean: [00:10:34] It was. I mean, it was fascinating for me. So giving that up was a real grieving process. And it felt like the reason I gave it up was because I saw the people and I and I think other people of my era, not necessarily women, but other students in my area, my era had a very different experience. The orthopedists that I saw where I did my rotations were. Very old school. There were a few who were amazing and were mentors, but. I did not see myself in that specialty. I could see me doing the work. I couldn't see me fitting in. And that felt like a really hard way to make a living or, you know, to make a career. And what I did have were. Real champions who were general surgeons who said, you're good at this, you have talent. We see it and we want to encourage it. And so that moved me away from orthopedics into general surgery.

  Tyler Johnson: [00:11:46] I hear sort of echoes in that decision making process of Francis Connelly, the Stanford neurosurgeon who wrote Walking out on the Boys, Right. Who actually was a neurosurgeon and then on the faculty and effectively walked away because, as you put it, it's not that she wasn't good at neurosurgery, it's just that after years of trying to survive in what was essentially then an old boys club, effectively, she just couldn't I mean, it just was not a hospitable place. There just it was as if the forces that were were trying to make it so there was not really a space for her.

  Wendy Dean: [00:12:22] Being a surgeon, no matter what kind of- being a physician is hard enough, right? Let's not fight our colleagues. In a way, it was I'm kind of surprised that I was smart enough to recognize that early on. But then when I got to general surgery, I realized I also realized that in order to carry on with that life, even for the five years of training. You have to be passionate about what you're doing every day and what you're doing in the OR. And I couldn't muster it for general surgery procedures. They were interesting. The work, you know, the trained dexterity of the work was really fascinating. But the clinical problems just didn't hold me to the degree they needed to to sustain that five years of training. And that and that's literally how I made the decision to leave general surgery.

  Henry Bair: [00:13:22] I think I'm particularly curious about the decision to go into psychiatry. I understand that you probably saw a lot of psychiatric patients coming into the ER. It's frequently where are they first come in, especially depending on where you practice. Um, but psychiatry and surgery are, I think if you poll most people, it's like the most polar opposites of any two surgical specialties.

  Tyler Johnson: [00:13:47] I'm thinking of those algorithms that you can find online how to choose your specialty with an algorithm tree. And they're like way in opposite corners.

  Henry Bair: [00:13:55] Yeah. So was that a difficult decision?

  Wendy Dean: [00:14:00] What was difficult was was facing other physicians responses to to my decision. I had more than one of them tell me that's a waste of an MD.

  Henry Bair: [00:14:14] So so these were non psychiatrists, I presume?

  Wendy Dean: [00:14:16] These were surgeons. I mean, they were surgeons and. I think there were other you know, there were other motivations behind it. So, you know, in part, it was I had always been fascinated with human behavior. My undergrad degree was in psychology, but my college allowed us to create our own majors. And so it was it was technically under the Department of Psychiatry, but it was neurophysiology primarily, and biology and chemistry and physics. So it had always fascinated me, that connection between biology and psychology. It was a way to study in depth what drove us. So I think my approach to psychiatry is a little bit different than a lot of peoples. It wasn't a pure interest in mental health per se, but it was also it was that and. How do we help people become agents of their own stories? When I was treating patients in my private practice, my goal was to become obsolete. To teach them how to manage their conditions by understanding human behavior and the neurobiological basis of psychiatric disorders and put those two together so that they could then figure out, here's how I need to live my life and manage my illness successfully.

  Tyler Johnson: [00:15:45] So now just just again to give us the appropriate backdrop. So you graduate now with training in psychiatry, and then what happens next? Where do you go from there?

  Wendy Dean: [00:15:58] So I went to the 10th busiest E.R. in the US, in Rhode Island, and I was the director of psychiatry there. Emergency psychiatry. And I did that for about a year and realized that the politics and the challenges in that system were, For me, Insurmountable. And it was. It was. It was just a bad it was a it was a bad match for me. And that system, I ended up leaving and and going back to the area where I trained and opened a private practice there, which was great. It gave me complete control over how I practiced. On the other hand, it was 24-7-365 on call because I was a solo private practice. But, you know, it allowed me to care for my patients the way I thought they deserved. And that was really important. My husband also left his surgery training, his neurosurgery training, and did sort of a wandering path and came back and trained in radiology. And once he finished his training, we moved from New England to Pennsylvania and I ended up opening another private practice, but in a very different sort of health care economics climate. In order to practice in Pennsylvania, the way I had in New Hampshire, I was going to have to switch to doing primarily med management rather than psychotherapy and med management together because the economics of the latter just didn't work and I didn't feel like I could do that and feel like I'd done well by my patients. So at the point, I realized that I actually left clinical medicine.

  Tyler Johnson: [00:18:03] Let's turn our attention. I think that you are a sort of a polymath in the sense that you have both surgery and psychiatry training. And then on top of that, you are now in addition to, I guess, no longer a clinically practicing doctor, but anyway, a doctor and also an author and a speaker and a from what I can gather, sort of aiming to be a change agent. And it seems like one of the themes that really brings a lot of those roles together is your focus on moral injury. And we have specifically in health care and you know, we have talked a little bit about moral injury and some of the the episodes that we have done as part of talking to other guests about other broader themes. And that has come up as a thread there. But I'm hoping that you can just walk us through because I think this is one of those phrases that I think was very little in use until relatively recently and even now is sort of, you know, a lot of people have probably kind of heard of it and they might even refer to it every once in a while. But if you try to pin them down and say, Well, yeah, but what does it actually mean? My guess is that even the people who think they know what it means, probably a lot of them have pretty different ideas of what it means, which just makes it difficult to even communicate about it. So just to start off, can you just tell us what is moral injury and how did you get interested in really focusing on that?

  Wendy Dean: [00:19:33] Yes, I'll say up front. I did not volunteer for this. I was conscripted in a sense by my own experience, both as a clinician, as a family member and as a patient myself trying to get care. So that's just the the foundation of this. I will say that in this emerging conversation, there is debate about what the true definition is in health care. But the definition that Simon Talbot and I work from, we're co co-founders in our organization and we we wrote the stat news piece in 2018 that kind of went viral and started a lot of this conversation. We tend to use a combination of two definitions. One is by Jonathan Shay in his book Achilles in Vietnam in 1994, which is that moral injury requires three things: betrayal, by a legitimate authority, in a high stakes situation. Now, he he developed that in the context of the military. Recognizing that folks who are coming back from combat looked like they were suffering PTSD, but it wasn't getting better with standard treatments. And so he said, let me think about this. This might be something different. And he started talking about a soul wound. In 2008, Brett Litz and William Nash sort of expanded on that concept and shifted it a little bit and said "it's perpetrating, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations." And again, they were working in a military population. But when you look at health care, those deeply held moral beliefs and expectations are the oath that we take to put our patients first. So it's when someone asks us to put something ahead of our patients, which all of our education and training has inculcated in us, are first. That's when we're at risk for moral injury.

  Tyler Johnson: [00:21:37] Now, let me just stop you there for a second, because I think that if I had heard that idea as a medical student. Right, I would have immediately. And I mean, Henry, you should comment on this, because as it turns out, you are only barely a medical student. You soon will no longer be one. But for now, you still are. So here our authority on medical students for now. But but I think if I had heard that definition when I was a medical student, I would have imagined some great dramatic something. Right? Like the denouement of some, you know, Shakespearean tragedy where you're forced to choose between this thing and this thing. And both of them have moral problems. And no matter which one you choose, then you know that then you're left, as you put it, with a soul wound. But I think that much of the point that you and and subsequently others have made is that while, yes, there may be some of those kinds of dramatic coming to a fine point scenarios in medicine, that's actually mostly not what we're talking about. Right. We're not talking about some thing that really calls your attention and you grapple with it for days or weeks. We're talking about just sort of the everyday currency of practicing medicine. So can you talk us through, though, because I think part of the issue here is to help people see the way that this is playing out in what they're doing or asked to do, you know, all day, every day. Henry does that does that feel sort of right to how we might initially think about that problem as opposed to what the reality is?

  Henry Bair: [00:23:13] Yes, I think so. And it's also probably more true for pre-clinical students because they haven't seen or done the day to day of clinical work. They've heard of burnout and maybe even the idea of moral injury, but it's all very abstract. And when they talk to residents and attendings dealing with moral injury and burnout, anecdotes are frequently mentioned, which I think contributes to the sense that a moral injury pops up in major moments of one's career, that you are fine until one day when something terrible happens and then you aren't. It's not until students start clerkships when they are in the hospital for 12 or 14 or more hours, working side by side with residents who are in the fire when they begin having to deal with the EMR or hear about how a patient's discharge plan is not feasible because of insurance reasons that they slowly realize moral injury is just a fixture of daily life. So yes, the evolution of our understanding of burnout and moral injury do change.

  Tyler Johnson: [00:24:19] So can you. Wendy, to that point, can you just walk us through first if let's say that I'm an intern on a whatever, whether it's a surgery service, internal medicine service, but I'm a I'm a very busy intern in a hospital. Illustrate for us some examples of what moral injury looks like in places where I wouldn't even know that something is happening, but that are happening over and over as I go through my day as an intern.

  Wendy Dean: [00:24:45] Yeah. So I think the challenge, the challenge for learners is that they don't really have they don't have the autonomy yet. They're following what their attendings require them to do or how their attendings tend to practice, right? So it may not become as apparent to them that they will not have the freedom to act as they would like. They may be following their attendings style of practice and say, when I get out, I'm going to be I'm going to do different than this. Not realizing that their attending is constrained in how they practice. So it may be things like over ordering tests or the simple what everybody says is not being able to look your patients in the eye because you have to attend to the EMR. Right. I've heard that over and over again. How can I build trust with my patients? How can I engage with them if I can't look them in the eye? That is at its most basic, that tension between who do I take care of? Do I take care of my patient or do I take care of my organization by taking care of the EMR? And it goes along in all kinds of small decisions from there. Do I order that x ray that I know isn't really necessary? Do I order the MRI? That is really, again, not necessary. Or conversely. I know my patient needs this particular chemotherapy, but I have to I have to assuage the insurance company first by trying these others. Right, or going through the hoops of getting the prior authorization. So those are the everyday tiny cuts that add up eventually to. The wound of moral injury. Each individual one doesn't seem like a big deal, but when you put them all together, they accumulate into a bigger problem.

  Tyler Johnson: [00:26:48] Yeah, you know, that leads me to think of two things. And I'd also love Henry, if this resonates with examples from your medical student training. I'd love to hear those too. But this is only sort of obliquely moral injury, but I think it really matters. So I helped to direct some of the inpatient oncology services at Stanford, and a number of years ago it became apparent. So there's this very big, important, quote unquote quality metric that is measured by a whole bunch of outside hospital assessment organizations, which is called the O2E mortality ratio, which means the observed to expected mortality ratio. In other words, if you look at all the hospitals in the world who admit patients who are similarly sick to the patients that you're admitting, what is the percentage of those patients who die while they're in the hospital? Right. And so what you're trying to do is you're trying to look at the average number to figure out what the expected number is. And then you look at the number that your hospital that die in your hospital to have the observed number, Right. And then that O2E ratio is, you know, intuitively really important, right? Because if I'm going to go check my loved one into a hospital, certainly I want to check them into a hospital where fewer people die than the average. Right. That makes that makes sense.

  Tyler Johnson: [00:28:11] But what was happening was that the the ratio on some of the services, it was worse than we wanted it to be. And what became apparent over time is that the reason for that was not because of substandard care. It was because the level of complexity of illness of the patients who were coming into the hospital was not being appropriately reflected in the measurement of the metric. And the reason that it wasn't being appropriately reflected was because it wasn't being comprehensively captured in the electronic medical record. And so, in effect, what we did over the course of a year and a half was we had endless meetings with this sort of sprawling bureaucracy that had its tentacles all throughout all parts of the hospital. Basically what we did over these 18 months was that we instituted a way that in the electronic medical record so that every patient who is admitted to the hospital, the doctor who is admitting them and writing a note about them, had to fill out this form where they basically went through and checked boxes for every single preexisting condition that the patient had while coming into the hospital. Right. So that if they were malnourished or if they had a pleural effusion or if they were septic or if they had an infection or if they, you know, had metastatic cancer or whatever, you had to go through and check all these boxes.

  Tyler Johnson: [00:29:33] So as soon as those boxes started getting checked so that the medical record appropriately reflected the medical complexity of the patients who was coming in, who were coming into the hospital. Then, you know, over the course of a few months without really doing anything to change the quality of the care per se, the observed to expected ratio improved enormously. We became one of the best in the country because we were more accurately reflecting the medical complexity of the patients who were coming into the hospital. Now, I want to be clear. Nothing about this was was dishonest or double dealing or underhanded. All we were doing, on the one hand, is figuring out a way to accurately reflect what was really going on in the hospital. Right. Which is I mean, what, you know, I guess ideally what you would want to have happen, but. At the same time. The way that we were doing that was by asking physicians or nurse practitioners or physicians assistants to fill out yet another very complex, nuanced form. At the end of a note, an admission note that in most cases was already many pages long, so that after spending pages articulating their medical reasoning and going through a complex problem list and all of the rest of it, now they get to the end of that.

  Tyler Johnson: [00:30:57] And here's this check box thing, this very long, complex form where you have to go through and check all of these boxes, even though everything that's there, you had really already just written in the note anyway, but it couldn't be abstracted in an efficient way. So then you had to go through and do it again. Right. And this was for every single patient who was admitted to the hospital. And so now you take some poor intern or nurse practitioner or physician's assistant or whatever who is already up to their eyeballs in work and often barely just staying above water. And now they have to do this additional thing on top of everything else. And then that leads me to the second thing, which is that just as an intern, you know, I think it's difficult for people who are not in medicine to understand the the steepness of the slope of the learning curve of being an intern in the hospital. Right. I mean, it is just everything all at once. And it is literally people's lives are hanging in the balance based on the decisions that you are making and the things that you're having to learn in real time. Right. And I think what is so enormously difficult about all of this is that in addition to having that enormous burden of people's lives depending on you while you're on this incredibly steep part of the learning curve, it is literally physically, humanly impossible to do all of the things that you are being asked to do.

  Tyler Johnson: [00:32:21] But all of the things that you don't get to or all of the corners that you have to cut or all of the times that you say you did a comprehensive physical exam, but you know that you really didn't. Or all the times when you say that you asked about this, you know, whatever, whether they took care of parakeets when they were 14 years old and you really didn't or whatever the thing is, Right. All of these things feel like giving in a little bit morally, like you're not quite measuring up. And yet if you if you just added together all of the things that you are supposed to have done at the end of a day, including filling out that checkbox form that I helped require everybody in the hospital to fill out, you would be required to do 37 hours worth of things in a 12 hour shift. And so you're left feeling as if you have been deficient and even morally wanting in not having done 25 hours worth of stuff when you were only given 12 hours to do 37 hours worth of things. Right. It just becomes this absolute impossible position.

  Wendy Dean: [00:33:20] And when you look at that, when you when you boil that all down, you're doing that extra checkbox exercise in order to measure up to what? Did that drive CMS reimbursement? Did it drive better marketing? Did it like, what did it do? How much value did it add to your patient care? And I think that's that's the challenge. And and that's where we're seeing the moral injury is that checkbox did not add value to patient care. It added to caring for the hospital. That's the crux of moral injury. Right. I'm being asked to do something that on its face, may not be. In the moment that one thing isn't a big ask. But when you add them all together and you take a look at why they're implemented. It's not in the best interest of the patient necessarily. It may be that, okay, family can go and see that really Stanford is better than these numbers suggest. But. Are those numbers we should be chasing? Is there some better way to do that?

  Tyler Johnson: [00:34:34] Henry, I'm curious about your experience in these things as a medical student who's finishing up your degree.

  Henry Bair: [00:34:41] I would say mostly sheltered. As a medical student, you are in the hospital. You are expected to show up at 5 or 6 a.m. or seven, depending on the specialty. And you stay as long as you know the team wants you to stay, which can be between 12 and 16 hours. But you're not responsible for making sure that all the boxes are checked. Now, the really nice interns are nice, depending on how you see it might give you the opportunity to start filling out those forms, to start admitting patients. But it's not real in the sense that you can't like, you know, the attending can't just sign off on it. Like the residents will have to review everything to make sure you actually did check all the boxes. So in some ways it actually adds more time overall, more man hours to the entire process. All that is just to say that, you know, as a medical student, you're not really on the hook for those things. So if you miss something, you can just say that, you know, and there's not there's not that pressure. There's not there isn't as much of a tension to feel like you have to say or document something that you didn't actually do.

  Henry Bair: [00:35:42] And of course, I can't downplay the fact that as a medical student, you just have more time. I have hours in the afternoon because I only have three instead of ten patients. And I think part of what helps maintain that balance when you realize that you're you haven't seen sunlight the entire day, like what kind of helps ameliorate some of the negative feelings that that come from? That is being able to spend that much time with the patient. And when you actually do click well with the work involved in caring for a patient, you're following along the treatment plan, You are taking into account what you know from the patient. That is very rewarding and I think I don't really know how feasible that is. You know, when I leave medical school and I'm an intern and I do have the 12 patients, you know, to take care of. So, yeah, I think to to a much, much lesser degree medical students don't experience that, but obviously have a lot of apprehension about what comes next.

  Wendy Dean: [00:36:41] And I think you shouldn't have, you know, I think as a medical student, your task is to learn the basics of being a doctor, right? To learn the clinical side of taking care of patients. And then somewhere in training, hopefully somebody is helping you to understand that there's more to taking care of patients than just the clinical side of care, that there are all these overlays of the business of health care and the leadership of health care that we really should be introducing along along the way in training. But as a medical student, I absolutely think that you should be sheltered and have the have the opportunity to think creatively, which doesn't happen when you're so pressed for time that you can look at the big picture and you can be curious and go explore the other avenues of of illness that maybe that patient doesn't necessarily display, but what about it?

  Tyler Johnson: [00:37:43] So I'm a mentor for medical students, and then I also help to lead our oncology fellowship program. And in both of those in both of those capacities, I talk with trainees who are going through very much right in the thick of a lot of the things that we're talking about. But I have to say that oftentimes, you know, part of it, I think there is value, I think there is meaning to waking up to the existence of moral injury. Right. Because in effect, what it does is it at least it allows you to see that it's not that you are a bad person.

  Wendy Dean: [00:38:17] Oh, for sure, Yeah, for sure. And I don't mean to say that we should be sheltering medical students and saying it's all hunky dory. I mean, I think we should be saying medicine is a difficult place to be. It's a complex place to be. And the better you'll be, better off, the more you understand about all of that. So if you go out into practice thinking, as long as I'm a good clinician, everything is going to be fine. That's going to be a rougher road than if you go out into clinical medicine. If you go out into practice thinking, I need to be a good clinician, but I also need to understand these other parts of medicine in order to be able to manage the environment that I'm going to be thrust into.

  Tyler Johnson: [00:38:57] But I think that the at least implicit and sometimes explicit that many question that many trainees have. You know, I can imagine, right, somebody is on their day off. They're going for a run in the middle of a very busy intern year, and they listen to this podcast and then they start to they start to look around and they start to say, Oh my gosh, now that I have thought about what moral injury means, I can see it all over the place. But then there is this, I think, an almost pervasive sense of, okay, but so then what? Like, I see it now, but especially as a trainee where I have virtually no, I don't even have a say in when I leave the hospital or when I get weeks off, let alone what the sort of bigger infrastructure within which I'm operating looks like. So then how do you address it?

  Wendy Dean: [00:39:45] So the first thing that I tell people is. The less you understand, the more out of control it feels. So. When clinicians come to me and say, Oh my gosh, this I feel overwhelmed by this. I say, The place to start is understanding what governs where you work. So first, read the policies of your hospital. Read the bylaws. Read the regulations that pertain to your specialty. Read legislation. Know that cold. So there's a case in Missouri, Ray Brovont versus Envision or Emcare. If you if you just Google Ray Brovont lawsuit Missouri, you'll come up with it and it basically goes runs through a playbook of how people of of how a very savvy clinician emergency room physician built a case against his employer. Who who was inflicting these challenges. What stuck out to me as I read that case was that he could quote line and verse. All of the regulations and legislations and policy that govern where he worked. And when he knew that, he knew what was out of bounds and what was in bounds. So that's the first place to start. The other thing I think is important is learning how within a large organization, how to stand up and speak out, which is the other thing that Ray Brandt is an example of, because his first career was in the military. And so he learned how to stand up and speak out in a massive concretized bureaucracy and. I think as as physicians, we're used to very immediate gratification. Because we have to be right. We can't be happy with things that take a long time to change. Our patients don't have the time for that. And what ends up happening is we ask for change and it doesn't happen and we get frustrated and walk away. And part of what we need to learn is how bureaucracies work, because 70% of us are employed now and how to get our voices heard, how to collaborate together and find ways to have collective voices. That doesn't necessarily mean unionizing. It can, but it doesn't have to in order to be heard.

  Tyler Johnson: [00:42:22] So I've been out of residency for about ten years and I was a chief resident right at the end of my residency, which I mention only because being chief resident, at least at Stanford, is very interesting because it gives you kind of a window into both worlds. Like you're still you still feel like a resident and you still mostly sort of live in the bunker with the residents. But at the same time, you also go to these hospital board meetings and you go to these things as if you were, you know, almost as if you were a chief of a division or something. It's very unusual in that sense because you really do get a seat at tables that you probably won't see again, if ever, for, you know, decades after that. But one of the things that has struck me is that traditionally, I think in the US there has been this sense that during the time of your training to become a doctor, it is as if you sign a form the day you start intern year that abdicates all right to any sort of a reasonable life or even reasonable treatment for the duration of the next decade or whatever. It's going to be right. Like you have no expectations of being able to set your own schedule, get your own health care, take off for sick days, go to family commitments, you know, let alone have healthy meals or see the sun or go home at a normal time or, Right? I mean, those things just all completely go out the window. Now, I will say that over the over the past decade, I have seen that conversation begin to shift.

  Tyler Johnson: [00:43:55] Right. I have seen that there has begun to be some discussion of things like maternity or paternity leave or lactation rooms at the hospital or, you know, discussions about how much time off is appropriate or discussions about how our residents and fellows going to get their own health care, including mental health care and all of those kinds of things. But I think those conversations are still very much the leading edge of the national conversation that are probably happening at some places. But there are undoubtedly many, many, many places where those conversations aren't even haven't even started yet. Right. And so I guess that, again, I just want to be sort of concrete for people like if you because if you belong to a place where those conversations are starting to happen or you know, there's a unionization drive or something like that where it's kind of in the water, then it may be intuitive enough in some ways to just say, okay, well, I'm going to join the union drive or I'm going to, you know, start advocating for lactation rooms or whatever the thing is. But if those conversations are not happening, if you feel like you're in a training program or for that matter, you feel like you're in attending, where the bureaucracy, these questions are completely invisible to them and you feel like you're just not even on the radar. Like, how do you start that change of learning to exercise your voice within a bureaucracy? Like what are some of the first steps that a person in that place could take?

  Wendy Dean: [00:45:28] I worked for almost ten years for the Army doing research, funding, oversight. I didn't wear a uniform. I was I was a civilian employee. And the most valuable lesson I learned there because, you know, talk about a bureaucracy is relentless curiosity. It is really hard for people to fault you for being curious. So my my MO was typically ask questions. And ask another question and another and another to try to help the organization. Get a window into a bigger into a bigger perspective. Right, because the bigger the perspective you can make, you can make it, the more you can include other people in the conversation and find solutions. You know, and it seems very simplistic, but getting getting yourself into the spaces where those conversations are are happening. So it may it may require volunteering for committees or offering to give feedback. And then once you get there, be curious. On more than one occasion, I would stop a meeting and just say, I'm sorry, but can you help me understand the goal of the meeting again? Like where what are we trying to do here? And it's amazing how when you can voice those things, other people around the table will say, Oh, that's a great question. Yeah, let's stop for a minute and re and rethink and then. It. You know, also the other important thing is to use those policies, bylaws, mission, vision and values, statements as anchors. How is what we're talking about now speaking to our mission or to our values as an organization and not doing it in a snarky way, but doing it in a truly, deeply curious way of wanting the organization to be better, not just for patients, but for clinicians as well.

  Henry Bair: [00:47:39] So I'm curious because you you founded and you now lead Moral Injury in Healthcare. Right. What is the work that you do there?

  Wendy Dean: [00:47:48] We founded it on the heels of that article that came out in 2018 and was received in a very different way than we expected. So there was a lot more interest in it than we thought. And since then, we've realized how hard it is for most clinicians to speak up. They don't feel safe. They fear retaliation. Our goal is to be able to have those conversations that others feel afraid to have. So to give clinicians voices without them having to put a face to it, to raise awareness of this separate thing that's causing distress. So there's burnout on the one hand, but then there's this relational disruption. That I think is is sort of like, you know, if we're treating shortness of breath and we've given the antibiotics, but somebody's still struggling, maybe it's maybe we need to add a bronchodilator. Right? So maybe maybe we need to talk about burnout and moral injury, the transactional operational things we need to do to reduce workload and the relational repair that needs to happen in organizations so workers truly feel supported and like their organization is trustworthy. And so we're we're trying to raise awareness there. We're doing consulting. We're doing assessments. We just wrote a book that outlines a lot of what we've talked about today in a very narrative nonfiction way that's accessible to a broad audience. And we have a podcast.

  Tyler Johnson: [00:49:21] One place where and this goes back to something you were talking about a moment ago that I think is really important is that I agree with you that, you know, we. I think there is power in forcing people, including the people who lead bureaucracies, to argue their stances and their actions from first principles, meaning getting them to say, so in the example of when we were implementing this process about the thing that I was mentioning earlier with the the box checking exercise, saying, well, okay, why are we doing this? Not how can we do this better, but why are we even having this meeting in the first place? Like, why Who cares about the ODE ratio, Right. And at some level, the almost always those conversations, as you pointed out earlier, are going to come back to one of two things. Either they're going to come back to patient care, which is and it's important to recognize that for physicians, that does not necessarily end the discussion. Right. For a reason. I'll get back to in a second. But it either comes to patient care or it comes to hospital care, right. The bottom line or the reputation, which is really ensuring the bottom line or whatever it is. Right. But the you know, we have talked before on the podcast and it still for me feels like one of the foundational things I have read in the past decade was this New York Times article called something like "The Business ofHealth Care is Built on the Exploitation of Health Care Workers."

  Wendy Dean: [00:50:54] Danielle Ofri I quoted all the time.

  Henry Bair: [00:50:57] We've actually spoken with her on the podcast.

  Wendy Dean: [00:50:59] So yeah, she's, she's fantastic.

  Tyler Johnson: [00:51:02] Yeah. So and the idea there is that you have these morally invested workers, physicians and nurses, nurse practitioners, physicians assistants, who within reason and often without reason, are willing to go to the very limit to provide good patient care because they feel that they are morally required to do that. And then on the other hand, you have hospitals and health care systems who at the end of the day are looking to make money. And so they will squeeze efficiencies and squeeze and squeeze and squeeze. And meanwhile, the people who are working on the health care frontlines will give more and more and more and are squeezed and squeezed and squeezed until finally they break. So the reason that I put that out there is because as a physician, you have to be really careful that even if the first principle from which you're arguing to do a thing is patient care, that doesn't necessarily mean that that's the end of the discussion. And you just say, Well, this is patient care, so I just have to do it because you are still human and you still can only do 12 hours of work in 12 hours.

  Wendy Dean: [00:52:06] Right. I absolutely agree with that. I think that's the basis for why a lot of people object to unions. Because there's this sense that's inculcating inculcated through our education and training that we should be willing to do anything and everything for the patients, that they always come first. But. There are limits. And so that's the other place where I think I would that I would recommend clinicians start is to learn boundaries. We're not well trained in that during residency or during medical school. And in fact, we're encouraged not to have them. But knowing where we can set reasonable boundaries to say, this is my limit, with all due respect, if I if I go past this, I'm not going to be providing the care that you want me to provide. I think is I think that's reasonable.

  Henry Bair: [00:53:04] There's also a very strange tension where, as you mentioned, there is an expectation for clinicians to always put the patients first and, you know, at all costs. But the system doesn't quite let us do that right. For for all these all these bureaucratic reasons and the red tape. So you talked about setting boundaries. What are some of those boundaries?

  Wendy Dean: [00:53:26] So some of the boundaries is no, I won't see eight patients in an hour. That's not good for the patients. It's not good for me. And ultimately, it's not good for the hospital because I'm going to be at risk for making mistakes. So, no, I'm going to see I'm going to limit my visits to 4 or 6 an hour or whatever.

  Henry Bair: [00:53:47] This might be like the medical student in me asking, But can doctors working for hospitals do that?

  Wendy Dean: [00:53:55] Well, I mean, that's debatable, right? And and then the question for you is, if you can't set those boundaries where you know your care is going to be compromised, can you continue to work in that system? And the answer for me when I was in systems that were doing things that that I thought weren't good care. Was I left. And, you know, in in the book, I have a I have an example of someone who left two positions within. Two years? Yeah, two positions in two years. When she was asked to do things that she thought went against best care for her patients. Everybody has a different answer to that question. And some people who are primary earners who have a ton of education, debt, you know, on and on and on, their answer is sometimes a forced choice. But knowing that you're doing it rather than just reacting to it, I think is important for understanding. Your choices in the future. Mhm.

  Henry Bair: [00:55:05] Yeah. I always, to be completely frank I think when because we don't often have guests who are clinicians who've talked about walking away from medicine. We have had a few, but not often. I think it's important to hear those voices, such as your own, because they could be extremely helpful and relevant to current trainees and current clinicians. At the same time, I. Let me just illustrate this. My concern with one of the comments we got actually from a recent podcast episode with a surgeon who left clinical practice or who left being a surgeon, she's still in medicine. She's just not a surgeon anymore. A comment was, Well, you should be careful about broadcasting these stories because if you're too honest about how hard it is in medicine, we won't get as many future doctors. And we already have a health care workforce shortage. So, I mean, we can't exacerbate that, can we? You know, so what is that balance there? Maybe this is just yet another reason that we need to fix the system, Right? But I don't know what response you might have for that.

  Wendy Dean: [00:56:11] So I worry about that all the time. In doing research for the book, I a, I was noticing how often physicians these days are sort of doing what I call melting. So they're they're not leaving medicine, but they're reducing their clinical time to what they think is tolerable. So some are down to four days a week, some are down to two days a week, and the rest is administrative or research time. And I understand absolutely why they're doing that. But I also worry. When I can't find health care in my local community, whether it's a viable option. So what I think we need to do is to say if clinicians are doing this, if they're melting away, we need to be asking why. And addressing the system challenges that caused them to to do that. So that because honestly, almost every one of them that I talked to said I still love the work I do and I love the patience that I take care of, but it's everything else that's around that that's causing me to need to to dial back. So if we can make the workplace an easier place to be and and make clinical workflow more seamless and less abrasive. I think we'll have less problem with access.

  Henry Bair: [00:57:37] So, Wendy, you have been so generous with your time and you've already offered a lot of practical advice from setting boundaries to being vocal about raising issues with the administration and with the workplace. To close us out, do you have any other final practical advice for students and trainees to apply into their day to day work?

  Wendy Dean: [00:58:00] I think one of the most important things is to find like minds where you are. So not necessarily to find people who are equally disgruntled with the system, but to find people who share your values and who are willing to collaborate on getting to better. I think that's really essential. And we forget we get so isolated in in the work that we're doing and the pace that we set that we don't make time for that. And I think that's critical. And if they're not local to you find them somewhere, anywhere. I also I also want to say that in spite of the challenges that we've brought up in the past hour, I couldn't keep doing this work if I weren't optimistic that we can change. And I really think that especially now, we're at a critical point. We're sort of at an inflection point for medicine. And given the exodus of both nurses and doctors in the past two years, three years, I think the attention is focused on what needs to change in health care. For that exodus, for that outflow to stop. And that to me is is paradoxically a hopeful situation.

  Tyler Johnson: [00:59:17] Yeah, I echo that in the sense that I think there really is a feeling that the tide is starting to turn right. And one way in which I can in good conscience tell even trainees that I think this is a good time to start leaning into these ideas is because they're like the national conversation is starting and that doesn't mean that it's finished. It doesn't mean that the changes are coming tomorrow, but even changes that you may advocate for that you don't see. I think you can feel fulfilled in knowing that some of those changes are going to accrue to the people who come five or 10 or 15 years after you. And and that is still a meaningful work, even if you're the person who's planting the seed, not the person who's harvesting the fruit.

  Wendy Dean: [01:00:05] Yeah, I mean, that's that's the other piece of this is we're not sprinting. This is an ultramarathon. And pacing yourself is critical.

  Henry Bair: [01:00:14] Yeah. Well, with that, we want to thank you again, Wendy, for taking the time to join us in conversation.

  Tyler Johnson: [01:00:20] Thank you so much, Wendy.

  Wendy Dean: [01:00:21] It's a pleasure. Thank you so much for inviting me.

  Henry Bair: [01:00:26] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctor's Art.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

  Tyler Johnson: [01:00:45] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments. I'm Henry Bair. And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.

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LINKS

In this episode, we discuss Achilles in Vietnam: Combat Trauma and the Undoing of Character by Jonathan Shay, MD, PhD, and The Business of Health Care is Built on the Exploitation of Doctors and Nurses by Danielle Ofri, MD, PhD.

Dr. Wendy Dean is the cohost of the Moral Matters podcast.

You can follow Dr. Dean on Twitter @WDeanMD.