The Moral Crisis of America’s Doctors

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Dean’s essay caught my attention because I had been immersed in reporting on moral injury for several years. During that time, I had the opportunity to interview individuals working in low-status jobs that often presented ethical dilemmas. I spoke with prison guards tasked with overseeing violent inmates, undocumented immigrants laboring on the inhumane “kill floors” of industrial slaughterhouses, and roughnecks toiling on offshore rigs in the fossil fuel industry. Many of these workers were hesitant to share their experiences, fully aware of how easily they could be replaced. In comparison, physicians seemed privileged, earning substantial salaries and holding esteemed positions that shielded them from the drudgery endured by countless others in the workforce, including nurses and custodial workers within the healthcare sector. However, in recent years, despite their esteemed status, many physicians have found themselves subjected to working conditions more commonly associated with manual laborers in factories or warehouses. They face constant scrutiny of their productivity on an hourly basis and endure pressure from management to work faster.

Initially, I assumed that doctors, being highly skilled professionals, would be more willing to discuss the distressing conditions they faced compared to the low-wage workers I had interviewed. However, the physicians I reached out to were fearful of speaking openly. One doctor wrote to me, “I have since reconsidered this and do not feel this is something I can do right now.” Another sent a text saying, “Will need to be anonymous.” Some of my sources had even signed nondisclosure agreements that prohibited them from speaking to the media without permission. Many worried about potential disciplinary action or termination if they upset their employers—an especially valid concern in the expanding realm of healthcare controlled by private-equity firms. In March 2020, an emergency room doctor named Ming Lin faced repercussions when he expressed concerns about the Covid-19 safety protocols at St. Joseph Medical Center in Bellingham, Wash. Despite working at the hospital, Lin’s actual employer was TeamHealth, a company owned by the Blackstone Group. This incident exemplifies the challenges physicians encounter when attempting to voice their grievances within a complex healthcare system.

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.

There are, of course, plenty of doctors who like what they do and feel no need to speak out. Clinicians in high-paying specialties like orthopedics and plastic surgery “are doing just fine, thank you,” one physician I know joked. But more and more doctors are coming to believe that the pandemic merely worsened the strain on a health care system that was already failing because it prioritizes profits over patient care. They are noticing how the emphasis on the bottom line routinely puts them in moral binds, and young doctors in particular are contemplating how to resist. Some are mulling whether the sacrifices — and compromises — are even worth it. “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 instruments of betrayal.”

Not long ago, I spoke to an emergency physician, whom I’ll call A., about her experience. (She did not want her name used, explaining that she knew several doctors who had been fired for voicing concerns about unsatisfactory working conditions or patient-safety issues.) A soft-spoken woman with a gentle manner, A. referred to the emergency room as a “sacred space,” a place she loved working because of the profound impact she could have on patients’ lives, even those who weren’t going to pull through. During her training, a patient with a terminal condition somberly informed her that his daughter couldn’t make it to the hospital to be with him in his final hours. A. promised the patient that he wouldn’t die alone and then held his hand until he passed away. Interactions like that one would not be possible today, she told me, because of the new emphasis on speed, efficiency and relative value units (R.V.U.), a metric used to measure physician reimbursement that some feel rewards doctors for doing tests and procedures and discourages them from spending too much time on less remunerative functions, like listening and talking to patients. “It’s all about R.V.U.s and going faster,” she said of the ethos that permeated the practice where she’d been working. “Your door-to-doctor time, your room-to-doctor time, your time from initial evaluation to discharge.”

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