In Part I of this series, I discussed a new condition called moral injury, which occurs when physicians and nurses are compelled to make decisions they don’t believe are in the best interests of their patients. There has been a transformation of the healthcare system in the last 50 years that has caused this problem.
Fifty years ago, most physicians were employed in private practices where they had the freedom to make their own decisions without second-guessing. Today, most physicians are employed by hospitals or large corporations that dictate the practices of medicine for them. This can lead to mental anguish, called moral injury, when their decisions conflict with their own moral values. It is a condition not unlike Post Traumatic Stress Disorder (PTSD), which is commonly experienced by soldiers in war.
We know that PTSD is highly correlated with the alarming statistics of suicide in military veterans. It now appears the same phenomenon may be occurring in physicians who no longer work in private practices.
Eyal Press, writing in The New York Times, has called attention to this phenomenon, which was first reported by a psychiatrist, Dr. Wendy Dean, who worked for the U.S. Army. Dean has continued her study of the problem and finds it is increasing as more and more physicians leave private practice and join hospital or large corporate staffs.
Press had interviewed workers in menial occupations whose jobs were ethically compromising, such as prison guards who patrolled the wards of violent penitentiaries, undocumented immigrants who toiled on the “kill floors” of industrial slaughterhouses and roustabouts who worked on offshore rigs in the fossil-fuel industry. But physicians seemed exempt from these work conditions due to their higher wages and prestigious jobs – until now. In recent years, despite the esteem associated with their profession, many physicians have found themselves subjected to practices more commonly associated with manual laborers in auto plants and warehouses, like having their productivity tracked on an hourly basis and being pressured by management to work faster.
Emergency Room doctors seem to be especially vulnerable. E.R. doctors have found themselves at the forefront of these trends as more and more hospitals have outsourced the staffing in emergency departments in order to cut costs. A 2013 study by Robert McNamara, the chairman of the emergency-medicine department at Temple University in Philadelphia, found that 62 percent of emergency physicians in the United States could be fired without due process. Nearly 20 percent of the 389 E.R. doctors surveyed said they had been threatened for raising quality-of-care concerns, and pressured to make decisions based on financial considerations that could be detrimental to the people in their care, like being pushed to discharge Medicare and Medicaid patients or being encouraged to order more testing than necessary. In another study, more than 70 percent of emergency physicians agreed that the corporatization of their field has had a negative or strongly negative impact on the quality of care and on their own job satisfaction.
Of course, many physicians are quite happy with their work and their profession. But most of those in my unofficial surveys are still in private practice. More and more doctors are coming to believe that the pandemic merely worsened the strain on a healthcare system that was already failing because it prioritizes profits over patient care. They are seeing how the emphasis on the bottom line routinely puts them in moral binds, and young doctors in particular are contemplating how to resist.
“I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. She notes that the term moral injury was originally coined by the psychiatrist Jonathan Shay to describe the wound that forms when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instrument of betrayal.”
(Note: More on this subject in Part III of this series.)
