Winter 2024 - Vol. 19, No. 4
In 2006, Shervin Dean, MD, shortly out of residency, joined the Tristan Radiology group. Six months later, the Deficit Reduction Act of 2005 reduced funding for radiological procedures and testing. Attempts to align Tristan with the very business-minded Pinnacle Health and then UPMC left the Tristan team feeling that they were compromising patient care and their own accountability.

As a result, the group eventually dissolved in favor of a joint venture in which the employees of Tristan would work with Penn State Health as Community Medical Group employees. In the words of Wendy Dean, MD, a psychiatrist and former emergency physician — and Shervin’s spouse — they finally felt they could “focus … on doing good.”¹

In 2018, Dr. Wendy Dean, along with Simon Talbot, MD, appropriated the term “moral injury.” The term had previously been used to describe the wounds warriors incur on the battlefield when they are unable to help their brothers- and sisters-in-arms.² The most ominous threat is when leaders force their teams to betray core beliefs.

Veterans of war describe this threat as a crisis-of-confidence in their own virtue as well as the good within all they encounter.³ Threats to their values may be as dire as any wartime threats to their lives, and, even when diagnosed as “post-traumatic stress disorder,” moral injury may jeopardize veterans’ ability to serve. This is a despair that who they are may be compromised in a Faustian and irreparable way. Among veterans, innovative approaches include encouraging work in charity, and in the end, some may need to redefine what it means to be a soldier.³

In the profession of medicine, Drs. Dean and Talbot believe, we are as much at risk in our hospitals and clinics. Moral injury, they argue, is a term just as appropriate to the loss of control many clinicians feel when our systems threaten our values. In 2023 they expanded their original postulate and closely examined the very compelling trials and tribulations of several individuals and health systems in their book, If I Betray These Words.

                                                       
The book contains a cast of characters that will be familiar to many of us who have lived and practiced in Pennsylvania over the past 10 years. In this page-turner, they hold up the solemn oath we each take, to stake our lives to “care for anyone who suffers, [be they] prince or slave.” As binding now as when Hippocrates first modeled this ethic, we are more conflicted than were the ancients. Our allegiances are multifaceted — to our families and communities as well as our systems, and to layers of government bureaucracy. Further, we may be beholden to what non-experts counsel regarding fluoride or vaccines and to insurance companies demanding prior authorization. In short, we are at risk for “cuts to the soul,” similar to our veterans.

Drs. Dean and Talbot suggest there is hope and lay out a prescription to help us renew and strengthen our covenant. To begin, each of us must revisit the core values that compelled us to study medicine, including the commitment to charity and the pursuit of scholarship that inspired us. There also tends to be less moral injury when clinicians have a seat at the leadership table and when clinician well-being is tracked as a metric for which leadership is held accountable. Thus, the authors implore that physicians must be involved in decision-making at every level and that leaders must remain committed to the physical, mental, and spiritual health of all stakeholders — to the patients, as well as the staff and clinicians who work for them.

At the same time, it remains reassuring to see our leaders in the trenches. “Go to the Gemba” is a Lean principle that many of us practice, and Drs. Dean and Talbot aim to motivate leaders to continue to spend time on the wards and in the clinics, to see things at the field level.

Policy wise, we should be encouraging Congress to put limits on consolidation, to protect rural communities — a concern that seems urgent and close to home, with recent financial turmoil that has led to loss of access at nearby Crozer Health.⁴ Further, insurance and billing reform could go a long way toward relieving practitioner distress, especially if it includes ending the ridiculous practice of prior authorization.

Health care professionals are trained to put the needs of our patients first, to practice virtuously and in an evidence-based fashion. Our systems should give us the wherewithal, time, and space to do just that.

REFERENCES
1. Dean W, Talbot S. If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First. Steerforth Press; 2023.
2. Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. July 26, 2018. Accessed November 20, 2024. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
3. Silver D. Beyond PTSD: soldiers have injured souls. September 1, 2011. Accessed November 20, 2024. https://psmag.com/news/beyond-ptsd-soldiers-have-injured-souls-34293/
4. Brubaker H, Gantz S. Crozer Health may be placed into state control, an unprecedented move after years of financial turmoil. Philadelphia Inquirer. October 29, 2024. Accessed November 20, 2024. https://www.inquirer.com/health/crozer-health-delaware-county-pennsylvania-20241029.html