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Moral injury and its toll on clinicians and patients: A conversation with Wendy Dean, M.D.

November 30, 2023

Dr. Wendy Dean began the conversation about moral injury in health care when she coauthored a 2018 STAT article that went viral. Recognizing that they had tapped into a conceptualization of distress that had been missing from physicians’ experiences, Drs. Dean and Simon Talbot coauthored If I Betray These Words: Moral Injury in Medicine and Why it’s So Hard for Clinicians to Put Patients First. We sat down with Dr. Dean to discuss her book and ask her how physicians can alleviate workplace distress and recognize its dangerous potential to negatively impact patient care.

In your book, you explain that burnout, a phenomenon that many physicians experience, is fundamentally different from moral injury, which represents a deeper level of distress. Can you explain more about how moral injury differs from burnout?

There has been so much good work done in the field of burnout, and we shouldn’t throw that away. We do need to address the administrative burden of health care and the unreasonable productivity expectations that increase with every year. Those are important topics, but those are what I think of as the operational challenges of health care. What we haven’t been addressing are the relational challenges. Moral injury is, at its root, a betrayal and, whether it’s intentional or not, it’s a betrayal that’s not been acknowledged or repaired. Ultimately, we need to pay attention to both moral injury and burnout because if we fix one and not the other, we are not going to completely repair the distress in health care.

What are the symptoms of moral injury, and how do they differ from symptoms of burnout?

Burnout is that classic trilogy we talk about. There’s a sense of ineffectiveness, emotional exhaustion, and depersonalization. It’s basically saying, ‘I’m overwhelmed. I don’t have the resources to do what I’m being asked to do.’

With moral injury, there’s a betrayal that evokes frustration, anger, and shame. It causes people to say, hold on, this is not about my ability to be resilient or efficient. This is about who I am, who I promised to be, and who I promised to serve in this profession. This is not the career nor the profession that I expected, and if I continue in this, I may have to think of myself as complicit in these broken promises. As a result, many physicians leave the profession entirely or drastically cut back on their hours because of that value misalignment.

Do you believe moral injury has the potential to impact patient care?

Absolutely. I watched what happened to my husband when he needed critical care, and that was the impetus for me to delve deeper into this. I watched his doctors, who seemed paralyzed by something other than my husband’s condition. There was something else going on in the background and I didn’t know what it was. I was thinking, they are willing to put his life on the line, but for what? And that’s when I started thinking about this distress. And I learned that the cardiology practice had just been purchased by a large hospital system and the physicians had new metrics to meet. Doctors were being scheduled 95% of their contracted hours, which meant that they had no time to talk to their patients. That’s when I started making the connection.

Have you experienced moral injury?

Oh, for sure, but at the time, I didn’t have the language for it. When I was practicing psychiatry, I had to make a decision: switch to a model based solely on medication management or continue to practice psychotherapy, an approach that I felt was better for my patients. The latter was poorly reimbursed by insurance plans, so I would end up being significantly underpaid, which made it hard to keep my private practice going. Ultimately, I chose not to make that shift, and decided to leave clinical care. It was a very hard decision to make.

When you’re faced with a betrayal, you either fix it or you acquiesce and transgress your deeply held moral beliefs and expectations. In recognizing that I was facing that dilemma, I also realized I had a choice to make. I chose to resist and say I’m going to stay aligned with my values. Other people may have come to a different resolution, but for me, that was the right choice.

Would you say the antidote to moral injury is recognizing your freedom to make a choice?

The solution to moral injury is to be able to stand up and speak out. It’s important, though, to recognize that this is not a luxury that everyone has, at least in today’s health care system. That’s why it’s important to reshape organizations so health care workers are more empowered to call out the challenges they are experiencing.

What needs to happen to get to that point?

We need to educate those entering the profession, and it needs to happen early in the process. Think of it like a professional sports team. They recognize that the risk of injury is there every single day. How do they deal with that? How do they manage that risk? They acknowledge the risk, then educate and train to minimize it. They make injury-reduction a priority. Let’s help health care workers get more facile at managing the obstacles they face. That doesn’t mean making them more resilient. It means giving them language for what they’re experiencing and giving them options for how to engage with their organization and say, ‘this does not accord with my education and training.’ But then the organization needs to be prepared to get that feedback and adjust accordingly to make repairs.

I worry that we as the “old guard” aren’t sufficiently preparing the next generation for what they are coming into and that makes them feel blindsided. We’ve seen the problems, and we need to be giving them every bit of information that we have about what the current environment of health care is like so that when they come out, they know where the levers are that they need to pull or the places where they can affect change. Those of us who have less to lose need to get loud.

What’s the incentive for organizations to take this on?

It’s tremendously expensive to be at the levels of turnover that we’re at right now. If organizations did the calculation of what it would cost to reduce turnover by just a few percentage points, it would pay for anything we could bring in to help them solve this problem.

What gives you hope that doctors like yourself can help to reform our current system?

The biggest hope I have is that we are the ones who built this system. We made these decisions. That means we can make different decisions for the future. We can renovate it. That’s a big part of why I wrote this book. Because to renovate it successfully, we need to understand why it was built this way. We also know that administrators and executives are experiencing moral injury, too. So, if we’re all experiencing this same thing, we have a common language. Now we need to come together and talk about that.

More from Wendy Dean:

You can find Dr. Dean’s book at https://www.penguinrandomhouse.com/books/718606/if-i-betray-these-words-by-wendy-dean-and-simon-talbot/.

You can also find out more about Dr. Dean’s nonprofit organization at https://www.fixmoralinjury.org.