If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First

It has been almost 2 yr since I encountered a senior anesthesiologist with an international reputation at a small anesthesia conference. This friend of more than two decades had recently changed his affiliation from one prestigious academic institution to another equally prestigious academic institution. When I asked how he was adjusting to his new professional environment, I was sad (but not surprised) to hear his dispirited response. He had been recently “counseled” (read reprimanded) for postponing an elective surgical procedure on a child who was not optimized before the scheduled operation. His “reward” for acting in the patient’s best interest was to be condescendingly lectured about the financial consequences of his “inefficient” decision. This was not the first such disillusioning episode he had experienced. We then had a lively discussion about the challenges of working in a broken, toxic, and corrosive healthcare system that prioritizes profits over patient safety and physician well-being.For decades we have known that burnout—a syndrome resulting from work-related stress characterized by emotional exhaustion, feelings of cynicism and detachment from patients (depersonalization), and a low sense of personal accomplishment—is prevalent among physicians. Distress experienced by many physicians traditionally had been attributed to a lack of resilience. Corrective measures focused on enhancing the victims’ resilience through a variety of unproven interventions that included stress management, yoga, and mindful meditation. In recent years, however, a more enlightened approach has seen the pendulum swing from blaming the victim to recognizing the true root cause(s) of the catastrophic situation that has resulted in the mass exodus of highly skilled, compassionate, and dedicated physicians from the medical profession. Rather than viewing their distress as being the result of individual frailty, clinicians increasingly are reframing their distress as a consequence of moral injury.If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians To Put Patients First by Wendy Dean, M.D., with Simon Talbot, M.D., is a comprehensively researched and worthy outgrowth of an article the authors wrote in 2018 wherein they declared that physicians are not burning out; rather, they are suffering from moral injury.1 Further, Drs. Dean and Talbot attached the blame for this sorry situation on corporate greed that places the best interest of the business entity, be it insurer, hospital, or healthcare system, above the best interest of the patient. Dr. Dean, formerly an emergency medicine physician who became a psychiatrist, and Dr. Talbot, a reconstructive plastic surgeon at Brigham and Women’s Hospital (Boston, Massachusetts) and associate professor of surgery at Harvard Medical School (Boston, Massachusetts) inform us that moral injury “occurs when a person perpetuates, bears witness to, or fails to prevent an act that transgresses their deeply held moral beliefs.” Notably, Dr. Dean is no longer clinically active, having devoted her full attention to addressing moral injury since 2019.The book’s title is derived from a 2010 translation of the Hippocratic Oath that ends with the pledge, “May I be destroyed if I betray these words.” Adhering to timeless principles of altruism, excellence, and compassion in changing times marked by a dissimilar hierarchy of values has become increasingly problematic. Since the 1980s, hospitals, corporations, healthcare systems, and certain governmental policies have been exerting ever more control over how doctors practice. First health maintenance organizations, then large healthcare systems, and later private equity brokered the physician–patient relationship to maximize their profits. It is daunting, after all, for recently trained physicians encumbered with $250,000 in student loans to be threatened with job loss if they fail to adhere to the party line. By 2021, 70% of physicians in the United States were employed by hospitals or corporations.2The book’s introduction narrates the saga of Health Management Associates (Naples, Florida), owner of the Carlisle Regional Medical Center in central Pennsylvania and numerous other facilities. Between 2009 and 2011, whistleblowers filed eight lawsuits against Health Management Associates, alleging fraud. The for-profit enterprise was accused of coercing physicians to abandon their medical judgment and ethics—to hospitalize patients who did not meet insurance criteria, to order more tests than their conditions warranted, and to hospitalize patients longer than necessary—to increase profits. Agents from the Federal Bureau of Investigation and Department of Justice spent 2 yr interviewing hundreds of Health Management Associates employees across at least eight states. The denouement involved Health Management Associates agreeing to pay a $260 million settlement for coercing physicians, under threat of losing their jobs, to provide unnecessary “care” against their best judgment and professional training. Although Health Management Associates strong-armed all its physicians to enhance revenue, the problem was particularly acute in emergency rooms.The first 13 chapters provide fascinating vignettes of how physicians attempted to deal with the deep distress that results when doctors are pressured to practice in ways that contravene their conscience and training. The ensuing moral injury was debilitating for some, and they left the profession of medicine. One talented, highly respected, and triple-boarded specialist in pediatric rehabilitation, Dr. Jacob Neufeld, was destroyed by the labyrinthine politics of the system and committed suicide after he was forced to enter a treatment facility for psychiatric evaluation when he complained about a patient safety issue. For several months, he had been the only physician in the state of Idaho who could manage baclofen pumps and was on call 24/7. The unrelenting on-call schedule took its toll, and when Dr. Neufeld repeatedly implored the hospital administration to hire an additional qualified specialist, they responded by suggesting he was an “impaired physician.”Emergency medicine and other primary care physicians are disproportionately represented in the chapters. However, the travails of orthopedic surgeons, an otorhinolaryngologic surgeon, and a radiologist are also documented. (No anesthesiologists appear in the book, although anesthesia services are frequently mentioned by the other specialists.) Readers will be especially encouraged by the story of Dr. Ray Brovont, an emergency medicine physician at Overland Park Regional Medical Center in Overland Park, Kansas, who was fired after he repeatedly complained about egregiously dangerous emergency room staffing in his facility, whose Code Blue policy required emergency room doctors to be in potentially three places simultaneously. In 2017, he sued EmCare (Dallas, Texas) and Hospital Corporation of America (Nashville, Tennessee) for wrongful termination, and in 2021, a Missouri court of appeals upheld a $26 million award in his favor. Dr. Brovont now owns and operates an infusion clinic for the treatment of depression and is practicing medicine as he believes it should be done, with hour-long appointments and holistic conversations.The physicians featured in If I Betray These Words are generally cast in an exculpatory light, caught between a rock and a hard place. (One chapter is appropriately titled “Dr. Sisyphus.”) Two physicians, however, behaved unconscionably. The action of one physician-administrator was instrumental in the downward spiral of Dr. Jacob Neufeld, and a physician-executive refused to hire more emergency medicine doctors despite repeated exhortations from Dr. Ray Brovont and after a patient death resulted from inadequate staffing.The authors underscore that American corporations were not always as ruthless as some have become. However, in 1970, the eminent economist Milton Friedman (1912 to 2006), who became a 1976 Nobel laureate, wrote an essay that appeared in the New York Times arguing that a company is responsible only to its shareholders.3 Indeed, until the latter part of the 20th century, General Electric was known as “Generous Electric,” acting as a steward of its employees, its customers, and the communities where it operated, not just its shareholders. That changed dramatically when Jack Welch (1935 to 2020) became chief executive officer in 1981. During his 20-year tenure, General Electric became the world’s most valuable company as Welch redefined how corporations measure success.Resistance to the edict of shareholder primacy, and the devastation it wreaks, may be emerging. In 2019, the Business Roundtable, a group of chief executive officers from some of the nation’s largest corporations, explicitly disavowed shareholder primacy, declaring the necessity for corporations to have a commitment to a broader group of stakeholders including employees, communities, and society. Strikingly, the Roundtable cited healthcare as one of the industries needing new principles of corporate governance.Absent a transformative revision of the goals and tactics of the $4.5 trillion healthcare industry, it seems unrealistic to expect a remedy for the moral injury physicians sustain when they are not provided with the requisite resources to deliver excellent patient care. The concluding chapter proffers several creative and multifaceted recommendations to ameliorate the current debacle, including improvement of the justly vilified electronic medical record. No doubt readers will want to peruse for themselves the other thoughtful proposals.If I Betray These Words is a consequential book that deserves a wide audience. Medical students, residents, attending physicians, and, crucially, patients from nonmedical backgrounds will benefit from the information contained in its pages. At times, physicians may become impatient with the granular descriptions of medical training and clinical situations that are all too familiar to seasoned practitioners. Nonetheless, this degree of detail is probably required to provide lay readers with an understanding of how physically taxing and mentally draining the practice of medicine can be, as well as educating them about the breadth and depth of the current crisis. And it is a crisis. Without immediate and effective corrective action, a national deficit of 122,000 physicians by 2032 is likely,4 with a domino effect reverberating throughout society.