Nov. 2, 2023, David Mitchell (Chicago) — Though it often takes more than a decade for new concepts to take root in health care, Wendy Dean, M.D., has already made a profound effect on physicians with her work on moral injury, a term that she and co-author Simon Talbot, M.D., introduced to health care in 2018.
Take, for example, Ashley Bieker, M.D., who quit her job as an employed family physician in a Tacoma, Wash., outpatient clinic to pursue better options two weeks after reading If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First, which Dean and Talbot published in April.
“I was like a frog in a boiling pot,” Bieker said Oct. 28 at the Family Medicine Experience, where Dean outlined steps to combat moral injury during a presentation in a full ballroom and followed up in a question-and-answer session in the Xchange expo hall. “I was extremely unhappy. I wasn’t planning on quitting, but the book was what I needed to hear. The problem wasn’t me. It was the result of economic and financial trends, the consolidation of health care and the role of insurance companies.”
Dean was not suggesting that doctors walk away from their jobs en masse but rather that they should find allies among patient groups, physician peers, other medical professionals (even administrators) and advocate for change when confronted with health systems that do not function in the best interests of physicians, patients or communities.
AAFP EVP and CEO Shawn Martin and author Wendy Dean, M.D., speak about solutions to moral injury at the 2023 Family Medicine Experience.
Her mainstage presentation, like Bieker’s former job, was a bit like a slow boiling pot — minus the frog. Dean started with a history lesson that examined the idea that a company’s primary responsibility is to satisfy shareholders by maximizing revenues. With that background information simmering, Dean proceeded to the boiling point: Applying the profits-over-people approach in health care has led to consolidation, a shifting trend from private practice toward physician employment, the scourge of metrics and the rise of physician burnout.
The U.S. health care system, she said, leaves patients unsatisfied, which makes them less likely to follow medical advice, leading to worse outcomes. That leads to the frustration and dissatisfaction of physicians.
“I have real hope that we can change,” Dean said.
Physicians who know how much sleep they need, how much time they should spend with their families and what to do to be healthy are like a sports car, Dean said. The problem, she said while pointing to a picture of a pothole-riddled road, is that physicians can’t always care for themselves due to a complex health care system.
“We need to worry about fixing the potholes in the road, not tuning the machine,” she said.
Dean clarified that burnout and moral injury are two different things.
Burnout is the exhaustion, cynicism and decreased productivity caused by a broken health care system.
Moral injury is the feeling of being betrayed by someone in a position of authority in a high-stakes situation. In health care, this results in physicians being unable to fulfill their mission of providing high-quality care.
Dean said health care needs morally centered organizations that are just, trustworthy and courageous.
“When things go wrong they look for ways to improve, not for who to blame, and they push back on burdens to their workforce,” she said.
Dean offered the late Leon Haley, M.D., M.H.S.A., C.P.E., who was the CEO of the University of Florida Health, Jacksonville, as an example of a health care executive who understood moral injury. Haley walked through the emergency department every day, regularly spent time on inpatient floors and talked to a wide range of employees. He used their feedback to advocate for change and followed up.
Because roughly 40% of administrators also suffer from moral injury, Dean said, physicians can find partners to address problems.
“We get better when we work together,” she said. “Build coalitions, find your group and help each other. Lock arms with your nurses. We’re not going to get through this without each other.”
New AAFP President Steven Furr, M.D., FAAFP, showed a slide of an empty AAFP Board room during his inaugural speech the previous day and urged members to get involved in leadership. Dean referenced that slide and echoed Furr’s call for family physicians to lead. Practices like yoga and mindfulness can help with well-being, she said, but they’re not enough without action.
“When you are invited, ditch your scrubs and show up,” Dean said. “Work together to find more acceptable solutions. Invite (administrators) to ditch their suits and ask them — beg them — to shadow you.”
AAFP EVP and CEO Shawn Martin pointed out during the main stage event that physicians may worry about reprisals for speaking out. Dean reiterated that it was important to work with allies and also emphasized the importance of tone and perspective.
“If we advocate for patients, that’s a strong position to come from,” she said. “Nobody can argue with better patient care.”
During a Q&A with members later, Dean called FMX “the feistiest meeting” she’s ever attended and called on family physicians to “own that at your day job.” If a subspecialist is being difficult, she said, family physicians should remind them, in a humorous way, how much more difficult their job would be without primary care.
Wendy Dean, M.D., covered a wide range of topics Oct. 28 at the Family Medicine Experience, including advocacy, career options and well-being. The AAFP has a plethora of resources to help family physicians on all fronts.
Stay informed on state and federal issues that affect family medicine, learn how the AAFP protects and promotes the specialty, and take advantage of tools and resources that help you make a difference. Learn more and lobby directly with members of Congress during the Family Medicine Advocacy Summit May 19-21, 2024, in Washington, D.C. You can also connect with health policy experts and learn advocacy strategies from chapters and Academy staff at the AAFP State Legislative Conference.
The Academy has hundreds of opportunities, including roles for students, residents and new physicians, to get involved in national leadership. The AAFP also offers leadership development events specifically for students and residents; chief residents; residency program directors; member constituency groups (women, minorities, new physicians, international medical graduates and LGBTQ+ physicians or physician allies); and chapter leaders and aspiring leaders.
The AAFP offers a 10-month program to help members become leaders in physician well-being; an annual Physician Health and Well-being Conference; free CME on topics related to burnout, depression, self-care, suicide prevention and more; and an FMIG Well-being Champion program that helps students help their peers.
“Say, ‘How many pre-op clearances have I done for you? How many times have I taken stitches out of your patients? Without me, your life is a lot worse,’” she said.
“I can’t tell you how important it is to educate people who create the legislation and regulations under which we have to work,” she said. “They never see it from the back side. They only see it as a patient. Educate legislators about our work and how challenging it is.”
Earlier this year, the Federal Trade Commission asked for public comments about non-compete clauses. That, she said, is a great example of how physicians could make a difference.
“When they ask for public comment, make a public comment,” she said. “When 10,000 physicians write in about non-compete clauses, it matters.”
Dean remains optimistic.
“The bad news is medicine is broken,” she said. “The great news is that medicine is pretty broken. Anywhere you start fixing it, it’s going to get better. When you feel hopeless, act.”
What about Bieker, who chose a break from employment over the boiling pot? She said she was considering options such as direct primary care and also planned to talk to recruiters at the FMX career fair who might offer a better working environment.
AAFP members spoke about well-being during a Q&A session at FMX.
Dozens of other attendees – employed and private practice physicians from a range of military, rural, hospice, inpatient and outpatient settings -- also had questions for Dean in an extended Q&A in the Xchange. Tomi Olaniyan, M.D., of Freehold, N.J., is in her second post-residency job in three years, having left an outpatient job with too much administrative burden for a hospitalist role in which she felt less burdened but also like “a little fish in a big pond.”
What did she learn from Dean?
“We have a voice,” she said, “and we should leverage what we offer to get what we want. We need to work together because there is power in numbers.”