I once asked my physician mentor Rachel Naomi Remen, author of Kitchen Table Wisdom and the founder of The Healer’s Art (the only education about actual healing taught in medical schools around the world) what it would take to heal our broken health care system.
Rachel said that doctors must refuse to cooperate with a corrupt health care system that gives lip service to patient well being while ultimately selling out to the financial bottom line.
To heal the system, she insisted, doctors must strike.
But of course, most doctors have bleeding hearts and can’t bear to let anyone be harmed, even if it’s to take a firm stand for a better system. We vow to “First, do no harm.” So we can’t imagine someone actually dying because we’re picketing outside the hospital, demanding that patient care be put ahead of the financial bottom line and the corruption of the middlemen who rob both patients and doctors.
And so…we doctors continue to be accomplices to the ruthless middlemen in corporate health care who cause doctors to sell their souls in service to fulfilling what often feels like a spiritual calling.
What Is Moral Injury?
The problem is that selling out leads to moral injury, moral injury leads to the symptoms of what we call “burnout,” a state of mental, physical, emotional, and spiritual exhaustion. What is “moral injury?” First described in relationship to war veterans, moral injury is described by researchers as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Soldiers and doctors may be following orders and doing what we’re expected to do- with seemingly noble intentions- to save our countries from tyranny, to save lives, to fight back death.
And yet, deep down, we know what we’re doing is wrong, that innocent people are getting harmed, that we’re forcing ourselves to override our own moral compasses, that we could do better, if only we bucked the systems of oppression that have us in their claws as accomplices to causing harm, when we signed up to do what we thought was good, noble work.
Journalist Diane Silver describes moral injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” Harvard physicians Simon Talbot and Wendy Dean explain that “failing to consistently meet patients’ needs has a profound impact on physician well-being—this is the crux of consequent moral injury.”
In Reframing Physician Distress: Moral Injury Not Burnout, Talbot and Dean write:
“Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.
Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay—wounded, disengaged, and increasingly hopeless.”
And that was before the pandemic made everything worse. Since the pandemic, physicians are reeling from the symptoms of moral injury and burnout.
Symptoms of moral injury and burnout include:
- Helplessness, hopelessness, and feeling trapped
- Loss of meaning and purpose in work and life
- Growing cynicism and disillusionment
- An abiding sense of failure or self-doubt
- Troubled relationships
- Decreased work satisfaction
- Feeling detached, isolated, and lonely
- Depression
- Lethargy
- Headaches
- abdominal pain
- Muscle pain
- Chronic fatigue
- Frequent viral illnesses
- Changes in appetite, sleep, and body weight
- Loss of motivation
- Reduced job performance
- Reduced functioning in everyday tasks
- Social withdrawal and alienation
- Procrastination
- Frequent emotional outbursts
- Substance abuse
- Poor self care
- Suicidal ideation
- Soul sickness
Preventable Medical Error Is The #3 Cause Of Death
In 2017, I co-wrote an article Preventable Medical Error Is The #3 Cause Of Death In The U.S.. Are We OK With This? with medical school professor, Kitchen Table Wisdom author and physician Rachel Naomi Remen, MD. Shocked by the British Medical Journal article announcing that preventable medical error ranks only behind heart disease and cancer as the leading cause of death in the U.S., we touched upon this kind of moral injury in doctors, challenging the morality of a system that puts the bottom line ahead of patient safety.
Rachel and I wrote:
What goes unmentioned in most conversations about safety in medicine is that these safety protocols do not touch the root cause of this public health crisis, which lies in the priorities of the present system and the destructive effect of the economic bottom line on the health care provider-patient relationship. The problem is not a dearth of safety protocols. The problem is that the safety inherent in a genuine relationship between the patient and those who serve the patient has been sacrificed to the economic bottom line. The errors that lead to patient fatalities are rarely the result of lack of skill or training on the part of those who deliver health care. These errors are the outcome of a systemwide practice of prioritizing economic goals above safety goals.
The uncomfortable truth is that safety costs money. In the not so distant past, health care professionals knew their patients intimately. They not only knew their names, what they looked like, and the health issues that plagued them; they also knew what they did for a living, understood their family systems, were familiar with their financial challenges, and were privy to their secrets. Knowing the patient intimately helps the health professional serve the patient and protect him or her from harm. Even a decade ago, all surgeons still routinely visited patients prior to surgery to clarify what was planned, discuss the surgery, answer questions, and lay eyes and hands on the patient. They also visited their patients post-operatively to answer questions, discuss the outcome of the surgery, ensure adequate pain control, ensure that no obvious error had been made, and comfort family members. However, now it is possible for a patient to be operated on by a surgeon who only meets the patient in the operating room, often when the patient is already premedicated with sedatives or already asleep. Postoperative visits are rare and seen as unnecessary.
The problem does not just lie with surgery. Unlike doctors of the past who had genuine relationships with patients and their families, many practicing physicians now work in health care systems which require them to see 40 patients a day, many with complex problems requiring the management of multiple medications, whose side effects often interfere with each other. It is not uncommon for patients to be double booked in 15 minute slots, leaving only seven and a half minutes of time for each patient. All the fail safes in the world cannot make such a system safe. Imagine if your car mechanic had seven and a half minutes to assess and repair a significant problem with your car. Would you be surprised if your car failed on the freeway?”
250,000 preventable deaths per year. It is absurd to lay the cause of such an alarming statistic at the door of the health care professional. Few health care professionals would actually choose to practice in the health care provider-patient relationship the system imposes upon them. Such relationships are inherently dangerous.
Protecting patients against danger is built into the training of all health professionals. Within moments of receiving a medical degree, every new doctor speaks aloud a vow to do no harm, often using an oath that goes back thousands of years. People enter the field of health care with the intention to serve and make a positive difference in the lives of others. “Do no harm” is the foundational goal of such people. Yet the system itself does not support or respect this intention. The system does intend to do no harm, but only if it doesn’t cost too much. But doing no harm takes time. Doing no harm costs money. By placing a greater priority on the economic bottom line than on the value of doing no harm, the intention to do no harm is violated and invalidated, often on a daily basis, by the demands of the system. Doing no harm may actually be an impossible goal within the system as it exists today.
The data presented in the British Medical Journal suggests that the present health care system has become inherently untrustworthy. This violates the intention of the dedicated people who work within the system, the ones who enter into the practice of medicine, nursing, and other health care fields in order to be someone patients can trust when they are at their most vulnerable. If you were to ask doctors, nurses, and other health care practitioners to create the health care system, we would have a very different system.
The fact that preventable medical error is the third leading cause of death in America is simply unacceptable. The system is not working, not only for patients in clinics and hospitals, but for all those who serve within these systems and experience daily the conflict between the demands of the system, the regulation of individual practice, and the wish to do no harm. The road ahead is not clear. It is tempting to wonder what would happen if doctors, nurses, and other health care professionals entrusted with the lives of Americans were to just stop. What if we were to say, “Sorry, but I am not willing to put the lives of my patients in jeopardy any longer.” What would happen if we stood up for our deep commitment to do no harm and refused to participate in a system that puts people in jeopardy on a daily basis? What might be possible then?
Learned Helplessness In Doctors
Many patients are frustrated or angry at doctors, and it’s understandable why they should feel that way- when they’re at their most vulnerable and not getting their core needs met. But as doctors who were doing the best we could to meet the needs of our patients, usually at the exclusion of getting our own needs met, we know that it hurts to feel like patients don’t appreciate all of the sacrifices doctors make in our attempts to help our patients. To do your best to meet the needs of your patients and then to feel attacked by the very people you’re killing yourself to serve can leave you feeling desperate and in despair, resulting in what Dr. Martin Seligman calls “learned helplessness.” This learned helplessness can lead to depression, anxiety, addictions, and suicide.
What I know for sure is that doctors do not go through 12 years of grueling medical training because they are greedy, insensitive, or numb to the pain of their patients. On the contrary, most doctors care about serving the life force in others from the time they are young. In my situation, I was the “squirrel girl” of my neighborhood. From the time I was seven until I went to medical school at 22, I raised over 20 injured or abandoned squirrels and freed them into animal sanctuaries.
Most doctors have similar stories from early childhood days. We were born to help others heal. We were called to medicine the way priests are called to the priesthood—as a spiritual mission. We did not endure brutal medical training because we felt called to participate in a system that causes us to neglect or harm our patients. We certainly didn’t go through all that self-sacrifice because we want to prescribe expensive drugs instead of spending time getting to know our patients, holding their hands, meeting their families, listening to them tell us about what might have predisposed them to getting sick, holding space as they trust us with their stories of trauma, appreciating the intimacy of having a front row seat on their most tender moments of birth and death, and offering our generous hearts as they find their way back to their innate wholeness through the loving space we offer.
The Soul-Crushing Wound Of Practicing Inside A Corrupt System
Physicians know what we need to do in order to help others heal themselves. We are not so ignorant that we don’t realize that a patient with an autoimmune disease or chronic pain may need to muster up the courage to leave an abusive marriage or stand up for her needs to her boss more than she needs a pharmaceutical. But to open up that can of worms, to ask her about the health of her marriage or challenge her relationship to authority or ask about her childhood sexual abuse feels like an impossible task when you’re expected to see 40 patients per day. Yet to neglect such disease-inducing traumas that our patients face is medical malpractice, and as doctors, we know it. Thus the moral injury. Just as war veterans knew it was a moral violation to kill innocent women and children, writing them off as unavoidable enemy “casualties,” we doctors know we are selling out when we refuse to take a strong, unassailable stand for what is right for our patients.
When we are at the mercy of learned helplessness, we know something is desperately wrong, but we wind up paralyzed, feeling victimized by a system we participate with. It’s easier to feel powerless and blame “the system” than to come face to face with our own traumas, the ones that made us willing to neglect our own needs and leave us impotent when our patients need us to demand health care reform. Struck by our own stress responses, we flee or freeze—or we deny and defend—rather than own up to what’s really happening and fight for what is right for our patients and ourselves.
We’re eating our young in the medical profession. The best among us wind up quitting because the moral injury can make some of us, myself included, suicidal. Caught in incessant double binds, stuck between doing what we know helps patients heal and doing what is possible within a corrupt system, eats away at us, eroding our mental, physical, emotional and spiritual health.
Stanford physician and chaplain Bruce Feldstein warns that the soul can become sore when we experience too much heartbreak, especially spiritual heartbreak. The shamans call it “soul sickness,” which Dr. Feldstein calls “soul soreness.” The soul can feel bruised by the demands of a system that doesn’t provide care and tending to the soul of medicine and the people who practice it. Medicine is deep soul work. When we are practicing in alignment with our values, our souls soar. When we know what it takes to facilitate healing in our patients- and we are thwarted from doing what we know is right because of systemic impediments that feel beyond our control, the soul gets sore. As my mentor Rachel Naomi Remen once said to me, when our souls get too sore, the soul does its best to get you back on track, to realign you with the values of the soul, which are often very different than the values of our more egoic parts.
“The soul grabs you by whatever handle is sticking out,” Rachel said.
That handle might be ambition, a desire to make money in a different way, the yearning to create a lasting legacy, the muse’s impulse towards creativity, a childlike desire to play more, or even the erotic pull towards romantic love.
Sometimes that handle is a desire to make a transition in one’s medical career. Sometimes it’s to pursue a creative dream, like writing a book or starting an entrepreneurial business. Sometimes it’s just an impulse towards healing the healer, prioritizing our own health and wellbeing for a chance.
Whatever that handle might be, I empathize with doctors who are looking to pivot towards a life that doesn’t require selling out. That’s why I created the Whole Health Medicine Institute in 2013, to offer health care providers and therapists in transition a safe, brave container for transformation, education about what we should have learned in graduate school, but didn’t, and alternative business visioning, and activism.
We’ve just begun enrolling for the Whole Health Medicine Institute Class of 2025. We start in January.
To learn more, watch this free video series.
If you feel you’re suffering from moral injury, whether in health care jobs or other jobs that require you to sell out for a paycheck, my heart goes out to you. Maybe it’s unrealistically idealistic to think we can have meaningful careers that don’t require some degree of moral compromise, but I won’t give up trying to support those of us who are at least trying to live lives more aligned with the values of the soul.
If you’ve been thinking about joining us for the Whole Health Medicine Institute but you’ve been on the fence, this year’s program, the first hybrid in person/ Zoom training since before the pandemic, will be offering options to help us make sense of the changing state of health care, while also training health care providers and therapists to practice the most cutting edge, trauma-informed medicine and healing we know how to practice. We’ll also be helping you vision your own meaningful, soul-aligned career, as well as engaging in Heal The Healer practices intended to facilitate personal transformation and healing. We welcome you to join us!
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