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Emily: This is The Nocturnists Conversations. I'm Emily Silverman. What happens when doing the right thing in medicine becomes impossible, when it's not the science but the system itself that stands between a doctor and her patient's well being? My guest today is Dr. Wendy Dean, a psychiatrist, writer and co-founder of the nonprofit Moral Injury of Health Care. The beginnings of her groundbreaking work came, not in the clinic or in the boardroom, but in her own garden, hands in the soil, when she first connected the struggles that she and her colleagues were facing to the concept of moral injury.

In her powerful book, If I Betray These Words, Wendy explores the dissonance that clinicians feel in a healthcare system increasingly driven by profit over people. We talk about the origins of the term moral injury, how it differs from burnout, and why the very oaths that draw physicians into medicine can, when betrayed, become a source of anguish.

In this episode, we'll hear about a doctor who was fired over dinner for refusing to put patient safety at risk, a beloved pediatrician who was sent away for a psychiatric evaluation and never returned, how corporate consolidation is quietly gutting primary care from the inside out, and the brave clinicians fighting back with lawsuits, new care models, and bold acts of defiance. This conversation is heartfelt and unflinching. It'll make you rethink what's broken in healthcare and what it will take to fix it. Before we dive in, take a listen to Wendy reading an excerpt from her book, If I Betray These Words. Here's Wendy.

Wendy Dean: The deadline for choosing a title for this book arrived unexpectedly as I was deep into writing Chapter 6, which is about a doctor who takes his own life. In a flurry of communications with a publisher and editor that grew more frantic by the hour, we tried to distill the essence of the work to a word or two. The collected stories deserved exactly the right title, but despair about a flurry of imperfect ideas melded with the grief I was feeling about the character in Chapter 6, and I was lost.

As I often do when stuck in a morass, I paused and returned to the source document, so to speak, to the oath we take as physicians in its many forms. This oath represents what each of us believes is our duty to society in joining this profession and embarking on a lifetime of tending to strangers in their moments of greatest vulnerability and need. It is the commitment that calls us to be our best selves. I read the Declaration of Geneva of the World Medical Association, the Oath of the Healer, the American Medical Association Code of Medical Ethics, the Osteopathic Oath, the Maimonides Prayer, and many versions of the Hippocratic Oath.

Similar themes ran through them all: gratitude toward teachers, a commitment to lifelong learning, an obligation to nurture the next generation, selflessness, one's duty to patients above all else, honesty, humility, confidentiality, love. When I discovered a 2010 translation of the Hippocratic Oath by Amelia Arenas, published in Boston University's journal Orion, I found the title. This version of the oath echoes the themes of all the rest, but the last lines took my breath away.

"I pray that the attention I give to those who put themselves in my hands be rewarded with happiness, and in honor of the knowledge I have received from my teachers, I swear to care for anyone who suffers, prince or slave. If I ever break this oath, let my gods take away my knowledge of this art and my own health. Here speaks a citizen, a servant of people, may I be destroyed if I betray these words."

The covenant we make is not simply about how we will do a job. It is also about who we will be when we don the mantle of physician. It prescribes our conduct, calibrates our moral compass, and entwines both with our identity. Betraying these words, then, forsakes our identity, which can unmoor us and threaten our dissolution. In standing up to moral injury and fighting for our oaths, we are fighting for our patients as if our lives depend on it, because figuratively and too often literally, they do.

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Emily: I am sitting here with Dr. Wendy Dean. Wendy, thank you so much for being here.

Wendy: Oh, thank you. It's my pleasure.

Emily: Wendy, you grew up in Massachusetts. You grew up riding horses.

Wendy: I did.

Emily: Your dad was a traveling salesman. Your mom was his secretary. You announced at a pretty young age that you wanted to be a doctor. You started in surgery, thought you might want to go into plastic surgery, and then eventually pivoted to psychiatry. Part of the reason you wanted to pivot to psychiatry is you were very interested in the patient's story. Even in your career as a psychiatrist, just starting out, the job wasn't quite what you imagined. Tell us about coming up in medicine, and when did you start noticing that something was wrong?

Wendy: Oh boy. [laughs] I think all along I was picking up these tremors of, "Hang on, wait. Maybe this isn't exactly what I signed up for," but I think it really intensified, probably when I got out into practice in my first job. I started realizing, okay, maybe I could have forgiven all of the rest of the issues that I was feeling, because that was training, and training just comes with an awful lot of baggage that most of us just want to leave behind when we walk out of those doors.

To the credit of my training program, they had taught us an awful lot about the business of medicine. I wasn't coming out into it naive and feeling blindsided and betrayed in that way, but what I realized when I got out into my first job was how precious little control I had over the care I could provide to my patients. It was a combination of payer issues, government agency, and regulation issues. It was an issue of the structure of the healthcare system I was working in. I realized that it was going to be much harder to get my patients the care they needed than I ever imagined it would be.

It was like I knew I signed up to work hard; we all did. I signed up to see some of the worst things that happened to human beings. What I did not sign up for was having my hands tied and being unable to care for my patients in the way they needed me to do. I thought at that moment that it was just my own personal failing. I thought this is really weird, because I am extremely resourceful in general, and yet I can't make this doctoring thing work. I tried for a decade to make it work, and I went into every single different business model and structure that I could think of. Eventually, I just thought there's something about this that I can't make work, and I left clinical practice.

Emily: We had on the show Dr. Dhruv Khullar, who writes for The New Yorker, and he recently wrote a piece called The Gilded Age of Medicine, in which he talks a lot about corporatization and consolidation and how things have changed over the last few decades in how the business of healthcare is structured. In your book, you write a lot about this, about how the businesses become these big, hulking, faceless institutions that prioritize shareholders over patients. I heard Dhruv talk about it, but I'd be curious to hear your take on it. How and why did that happen?

Wendy: How long do we have?

Emily: If you could boil it down? [laughter]

Wendy: I think the truth is, if you boil it down to two simple things, we decided that healthcare was costing too much. We had to control costs. The best way to control costs is to control the physicians' pen. The only way to control the physicians' pen is to control the employment of the physician. A lot of where medicine headed was to force employment of physicians, and it wasn't set out manifestly to force that, but it really accepted that, not realizing that there are secondary issues that come along with that.

The other was neoliberal capitalism, is the best way I can put it, which is Milton Friedman's doctrine that the only obligation of a corporation is to maximize shareholder value, which was then put into action by Jack Welch, and it's spread across business as a whole. It said that we don't have to take care of our communities, we don't have to take care of our workforce. All we have to do is take care of our shareholders.

In essence, what that did was created an entire generation of healthcare leaders, executives in large corporations who followed that tenet, because everybody wanted to be Jack Welch. He was a billionaire. Business school started teaching Welchian strategies, and that spread out beyond for-profit industrial corporations. It spread into nonprofits, it spread into healthcare. We have these profiteering mindsets in healthcare without having had the discussion of, "Is this the right place for that to be?"

Emily: There are some ways in which capitalism, as much as it's caused the problem, could help solve the problem, for example, competition. It seems like a lot of the problem is when there's a big corporation buying up a bunch of different hospitals and clinics in a small region, that once they buy it all up, it's all bought up, and there's no competition. It's almost anti-capitalist in a way. You could say it's a monopoly. Maybe you could speak a little bit to that, because we want competition. That's how we get health and the economy, but that competition is being really smothered and stifled by a lot of these enormous healthcare corporations.

Wendy: The reason why we have such massive consolidation and vertical integration is because we've also bought into the notion that there are economies of scale. If we have a bigger corporation, then our costs may be lower. Unfortunately, David Dranove and Lawton Burns wrote a great book called Big Med, where they proved over and over and over again that those promises are pretty empty. We don't get economies of scale, we don't get lower costs, we don't get better outcomes, we don't get better coordination, even, we get higher prices when healthcare organizations become a monopoly, just like in any other industry.

Emily: Here you are a psychiatrist working for a decade, trying to make it work in this environment where healthcare is consolidating, like you said. One day you're in your garden, and you're weeding the garden, and you're listening to the radio, and you hear something on the radio, and that changes your life. Tell us about that day in the garden.

Wendy: Yes. That day in the garden was about six years after I had left clinical practice and I was working for the US Army, doing research funding oversight for hand and face transplants and regenerative medicine. I had been hearing about the clinicians across the country who loved the work that they did, who loved their patients, who are at the tops of their games, and felt crushed. As I was in the garden, I had been thinking that there was something that was just not right.

I kept talking to these physicians and saying, "Are you burned out?" And almost every one of them would say, "Well, I don't have better language for it, but that doesn't hit right with me." I'd been looking for different language. As I was weeding, doing the therapeutic, ripping things out of the ground, I was listening to NPR, I think, and I heard a story about this thing called moral injury in drone pilots.

I knew from the work that I was doing that drone pilots don't actually fly into combat. They live in a suburban area, they drive onto base, they fly their drones, they drive back home, and yet they were experiencing moral injury. I thought, "Hang on, this sounds an awful lot like what the physicians I'm talking to are experiencing." That moral injury is defined as betrayal by a legitimate authority in a high-stakes situation that causes you to transgress your deeply-held moral beliefs, the oath that we took to put our patients first.

Emily: You reach out to your friend Simon. Simon is a physician colleague, and you write an article about this idea of moral injury, and maybe we could apply it to doctors. Maybe that's why doctors are so miserable, not that they're burned out, but maybe what they're having is moral injury. You submit this article to the New England Journal of Medicine, and it's rejected, and you submit this article to JAMA, and it's rejected, and then you finally publish the article in STAT News, and then tell us what happened. What was the response?

Wendy: Oh, boy. [laughter] The doors blew off. Let's just put it that way. STAT News, they publish a bit like a newspaper, because they're an affiliate of the Boston Globe, and I wasn't used to that. Typically, journals will give you warning when your articles could be published, and they didn't. I knew it had gotten published because at six o'clock in the morning when I went into work, I opened my inbox and I already had an email that said, "I have been looking for this language for the last three decades," and it went from there. Simon's inbox, my inbox was full. People were stopping us in the quarter.

I distinctly remember about a month into this journey, I was walking down the street, my phone number is not published, and I got a call. It was a physician from Arizona who said, "I thought it was me. This is language I've been looking for for decades, and now I know it's not about me." It went on and on and on and on, and so we published this in the middle of 2018. The article was the most-read article in STAT News in 2019. As of a couple of years ago, it was still one of the top five articles for STAT News ever. It's not because we're clever, it's because we struck a nerve.

Emily: How did you go from that article to this book? Whose idea was that?

Wendy: Oh, yes, it was not my idea. [laughter] If you read the dedication in the book-- Can I do that?

Emily: Sure.

Wendy: The dedication says, "To patients and clinicians who all deserve better. For Austin and Caleb, my two kids, who are why I love and fight so fiercely, and for Shervin, my husband, who has always said I should write a book. I used to think he loved me." Yes. I was really clear that writing a book was not something that was in my bailiwick. Simon and I had dinner with Sam Shem one night, who is the author of The House of God, which was sort of the pop culture book when I was in medical school, and even for physicians who are much older than me.

He was reviewing the galleys of his latest book, Man's Greatest Hospital. We were talking about the process, and he knew about moral injury, and he had invited us to talk specifically about that concept. He looked at me, and he said, "You should write a book." To my eternal embarrassment, I laughed out loud. I said to him, "No, I'm probably not the right person." Honestly, he just kept after me. Every month or so for about three months, he would drop me a line and say, "Hey, do you have an agent yet? Do you have a publisher yet? Have you started writing yet?" That's how it started.

Emily: One of the difficulties about writing about this topic is doctors don't want to talk, they don't want to go on the record, they don't want to give their name. There's a story in this book that illustrates why. It's the story of Ray Brovont, an emergency medicine doctor. I was wondering if you could tell us Ray's story as a way of explaining to the audience why physicians may be shy or nervous about talking about this topic.

Wendy: Ray's story is a great story. He is a US Army veteran. He's an emergency physician. When he separated from the army, he went out into practice outside of Kansas City, and he was the medical director of an emergency room in Overland Park, Kansas. He was getting a lot of pressure from his supervisors and from his bosses and from the corporation as a whole to reduce the staff in his emergency rooms from double coverage, meaning two physicians at all times, to double coverage for just six hours and single coverage for 18 hours.

Now, mind you, in this hospital, they were covering the adult ER, the pediatric ER, the ICU, and the hundreds of beds on the floor. If there was an emergency in any of those places, an emergency physician was expected to attend. Ray kept saying, "This is too much. My physicians can't be in two places at once. There is going to come a time when bad things happen and somebody is going to be harmed as a result." Sure enough, that time came, about 18 months, two years into his argument, and when that happened, he wasn't quiet.

He defended his physician; he defended his own position, as this is untenable, and he was fired. He was blackballed. They had promised him that he could go to another location and work there, but didn't fill him on the schedule. He fought back, and he actually ended up winning his suit. If anybody wants a playbook in how to fight back, Google Ray Brovont, B-R-O-V-O-N-T, lawsuit, and you will get a playbook. It was masterful, and that's the reason why he won. I really think that it's a lesson that we should all learn and at least be curious about, even if we don't have to deploy the same tactics ourselves.

Emily: Is this the story where he told his boss that the conditions in the hospital were unsafe, and then his boss invited him to dinner and fired him at dinner?

Wendy: Yes.

Emily: Then he sued them for wrongful termination, and the lawsuit dragged on for four years, and then he won $26 million.

Wendy: Correct.

Emily: That, I think, has kind of a happy ending in a way, but is also alarming, and I think explains why physicians don't want to speak up inside the hospital, but especially to the press or to you. What was your experience like going around, "Hi, I'm Dr. Wendy Dean. I'm writing this book about moral injury. Are you willing to go on the record?"

Wendy: Yes, it was hard. I have 13 chapters, and I think I spoke to at least four dozen physicians to get those chapters, and several of them said, "Okay, yes, you can tell my story, but you have to anonymize as much of it as you can," because it's not safe.

Emily: There was another harrowing story, and we have some good stories, so we're going to come to those in a bit. I just wanted to point out this one other story, because it was so striking about this pediatric PM&R doctor, Jacob Neufeld. Tell us what happened to Jacob.

Wendy: Jacob Neufeld was a PM&R doc. He was in his early 50s. He had moved to Boise, Idaho, to St. Luke's to set up a pediatric PM&R practice. They were the only tertiary care facility, the only tertiary pediatric PM&R practice in all of Idaho. When he got there, St. Luke's was in the midst of a lawsuit by the FTC about consolidation with a hospital system down the road. What he didn't know was that that was going to have significant financial implications. A couple of years in, St. Luke's lost their suit.

They owed $25 million. They were deep in the hole, and they started ratcheting up the pressure on all of their physicians, including Jay. Jay said, "These are the most vulnerable of the most vulnerable patients," and he was resistant to their pressure. Eventually, long story short, he was called out by the administration as being disruptive. They told him that in order to remain as a physician, he had to get an evaluation, an inpatient evaluation, a psychiatric evaluation?

He ended up there for 10 weeks, even though he didn't drink, he didn't do drugs, he didn't have any mental health challenges that were causing him to be unable to function. As part of this program, if he didn't adhere to their recommendations, he would be reported to the Board, and his license would be at risk. In the process of that 10-week experience, he became extraordinarily demoralized, and he eventually died by suicide.

Emily: Just for the audience, the event that caused his hospital to send him away to this psychiatric evaluation was that initially, it was him and another physician who would swap call days to receive urgent calls about kids who were having issues, and then the other physician, I guess, left or got a job somewhere else. Then he was the only doctor on call, and that went on for months and months, and he was just on call, 24/7, for months and months. Then there was one week where he had to be out of town. Sure enough, they didn't find anyone to cover him.

A kid came into the hospital with a baclofen pump, which is a pretty rare, specialized type of pain management system that he was one of the only people in the country who knew how to think about and manage these baclofen pump devices. This kid comes into the ER, and he's away, and there's no coverage. He actually flew back. He actually wanted to serve this kid who didn't have anyone there. That was kind of a last straw for him. That's when he approached the leadership and said, "This isn't sustainable." Then their response was to call him disruptive and send him on this 10-week psychiatric evaluation. Pretty disturbing. What was that like researching that story? It's just such a sad story.

Wendy: That was one of the toughest. I mean, there are a lot of tough stories in the book. It was one of the toughest in part because it was hard to get sufficient background data, because St. Luke's was in the midst of a lawsuit, and so they wouldn't talk, and previous executives wouldn't talk. I was trying to triangulate without having access to folks. It was also just hard to carry that story, knowing, from some of the people that I talked to who were close to him, describing him as a character. This work was his passion, his patients, and defending his patients he was passionate about. I think that was really, for him, that was the real risk in this, that he wouldn't be able to do that work anymore, and who would he be if he didn't have that work?

Emily: Yes. You talk in the book about all the years of course that we spend in training and building up our identity around our profession in many cases. Like you said for him, so much of his identity was bound up in that work. The threat of losing his license escalating to to a crisis. As I'm reflecting on this story, I'm thinking about something that comes up sometimes when we're talking about issues like physician burnout or moral injury among physicians. Sometimes it's difficult to muster sympathy from the general public.

The idea is that physicians are, of course, privileged and wealthy and in a position of power. In a lot of cases, those things are true, but it's more complicated than that. We hear a lot of these stories, and I think sometimes the public can struggle to view physicians as victims. I was wondering if you had any thoughts on that, or if you encountered any of those barriers in your reporting about these physicians really struggling to try to do the right thing in these unethically structured, corporate, unsafe environments.

Wendy: Physicians are looked at as a privileged class. Regardless of our current position, I think if you ask any physician, over the past 20 years, our voice has been quieted, our authority, our decision making capacity within our health systems, as we've become employees, has really diminished. When most people think about physicians, they think about that independent physician who's hung out their own shingle and is making their own way, which is how it used to be.

Referring back to your comment about competition, it would be great if we could get back there to a place where physicians truly were independent and had the ability to make decisions based on their patients' needs, but we're not there. That is one of the biggest challenges that we face. Part of the reason I wrote the book was to help folks, not just clinicians. This was targeted at a lay audience to help them get a window into what is life like for physicians.

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Emily: You in the book, we get a lot of portraits of physicians, but we also get a lot of portraits of executives, and there's some overlap. There's non-physician executives, and then there's physician executives or leaders. There's some stories in there about leaders or executives who are strictly profit-motivated, couldn't really care less about patient safety or patient outcomes, and then there's some exemplary stories of executives who are collaborative and thoughtful and thinking about patient safety.

Some of the names that come up for role models are Leon Haley Jr. and Ed Tafaro. Then, some of the names that come up for maybe not doing such a great job leading the system, people like William Schoen or Mike Young. I was wondering if you can maybe pick a few of these and paint a picture for the audience like, what does it look like to have this type of leader, and what could it look like to have that kind of leader?

Wendy: Yes. William Schoen, I love that story. I stumbled onto that story by accident. He was the CEO of Health Management Associates, which ended up buying the hospital in my backyard and behaving badly there, to the point where they were investigated by the FBI and the Department of Justice and ended up paying a huge fine. One of the things that he said was that he freely admitted, "I don't know anything about healthcare. All I know is that monopoly is good."

Emily: He had come, right?

Wendy: I know it's laughable. He had come from the glass making industry, then gone into beer making, and had taken a family brewery, Schaefer Brewery, that everybody you know who grew up in the '60s and '70s knew, and basically sold it off for parts, and then came for healthcare and did the same thing. He consolidated these small community hospitals that were in the middle of nowhere, and he basically knew that he had his thumb over the physicians who practice in those hospitals and the emergency physicians actually whistle blew.

There was a 60 Minutes episode about this hospital, and they said, "We're being asked to admit patients who don't need to be admitted. We're being asked to order tests that don't need to be ordered, and it's all to make quota." If there had been the language of moral injury at that period, they probably would have used it and said, "I'm struggling between my professional obligation and the business imperatives of my healthcare system," and, "Oh, by the way, I'm in a tiny town, and if I leave here, I'm going to have to uproot my entire family to move. My hands are tied no matter which way I turn."

That's life under someone like William Schoen, who is sort of what I would classify as a Jack Welchian acolyte. Then there's someone like Leon Haley Jr., who is the former CEO and Dean at University of Florida in Jacksonville, who tragically died about a month after I met him. He was remarkable. He was a former ER physician. Every day, he would park in the emergency room parking lot, would walk through the emergency room, talk to whoever was there. It didn't matter.

Physician, nurse, tech, environmental services. Got the pulse of his organization, and then would go to his office and decide, "Okay, who else do I need to visit? What do I think is happening here?" He walked the floors of the hospital on a regular basis. At one point, I went in and talked to the organization, to the leadership, and I asked them, "Do you want me to ask him to step out so that you can talk to me frankly?"

Unanimously, they said, "Absolutely not. We want him here. He's got our back." It's remarkable. It's just remarkable. In fact, in November, I gave a talk in New York, and I had a woman come up to me after my talk, and she was in tears, and she said, "I just want to thank you, because I work at University of Florida, and Leon Haley was one of the best leaders I've ever met, and we still miss him."

Emily: He wasn't just nice. He was financially successful as well.

Wendy: Right. It wasn't that he was nice, it was that they viewed him as a warrior for their needs. He would go to bat for them. He was strategic. He was not afraid of a little bit of conflict. He was not afraid of a little bit of politicking, if it served to improve the workforce.

Emily: I've heard a lot of physicians call for more physician executives, or if not a physician executive, have physicians in the room, have physicians at the table. I think that's very important. I've also heard a counterargument, of course, this comes from more of the business people who say that physicians may be wonderful people, and they may know a lot about medicine, and they may know a lot about patients, but they don't know anything about business.

Just because you're a physician doesn't mean you can run a business, it's a completely different skill set. There's a lot you need to know. I'm sure it's not a dichotomy, but I'm wondering what you think about this. Do we need to, at the very least, have physicians in the room more, or what do you think about this idea of the physician executive and the commingling of physicianhood and business leadership?

Wendy: I think there is no question that the business of healthcare is incredibly complex, so is the Krebs cycle, so is renal physiology, so is cardiac physiology. All of those things are complex. If we can manage biochemistry, physiology, anatomy, pathology, we can learn all of those other things, but we have to be willing to learn it. At the same time, one of the things that I am absolutely clear about is that physicians who move into the executive space still have to retain one foot in the patient advocacy side, that we bring our clinical acumen and expertise into the boardroom. We don't leave it at the door.

Emily: There's this conversation I've seen a lot online about the Affordable Care Act in 2009 and this rule that was included that placed a moratorium on new physician owned hospitals. The idea was that they could open the hospitals, but they couldn't accept Medicare or Medicaid, which was effectively a death knell. Then, five years later, this moratorium was loosened a little bit. They allowed physician-owned hospitals in rural areas or those serving Medicaid populations. I'm wondering about this idea of the physician-owned hospital. Why are there laws and rules blocking that? Is the idea that there's a conflict of interest, and so we're trying to protect the public by not commingling the doctor and the business person or? Can you explain that to me?

Wendy: Yes, sure. It is complex, but the bottom line is that when physician-owned hospitals exist, their competition for the rest of the hospitals in the area, there have been clear studies done that sit, that show they don't cherry-pick, and yet they have better outcomes at lower cost. Of course, that's a real risk. One of the arguments is that it's a conflict of interest, except when you look at these hugely consolidated health systems, they have Stark Law waivers, so physicians in those hospitals are expected to refer in-house. It makes no sense. It makes no sense. The physicians who own hospitals have a conflict of interest, yet the physicians who are employed by the hospitals don't have a conflict of interest because they're employed and they're serving their employer, not themselves. It makes no sense to me.

Emily: Is that a low-hanging fruit legislatively? Should we just lift all those laws and let physicians open their own hospitals and compete with the megalopolis and see what happens?

Wendy: It would be fascinating. I think when you look at the physician hospitals that are existing, they're proving the point that it matters.

Emily: I'd love for you to speak about primary care. That is a thread that runs through your book, and you talk about a primary care doctor named Stuart who gets his dream job at Brigham running this innovative primary care clinic, but several years in, even that starts to get soured and tarnished in a lot of ways.

You also tell the story of a physician named Rita who leaves and unplugs from the corporate rat race and opens her own direct primary care practice. I wrote a piece about direct primary care, so I had a little private entree into that topic and just learned a lot about that movement. Was wondering if you could speak a bit to how this corporate consolidation is affecting specifically primary care, which arguably sits at the heart of medicine.

Wendy: Primary care physicians are in such difficult places right now. I think part of the challenge is that they're expected to manage some of the most difficult care and to take on the preventative role that is highly regulated and incentivized in very bizarre ways. Yet, despite the fact that their downstream revenue is probably the highest of any specialty, their direct revenue is very low, so they end up having to get subsidized from some of the other specialties.

That process pits us against each other. At some point, we're going to have to realize we need to fight together to get fair reimbursement for all of us, because orthopedic surgeons may be doing really well now, but if they don't have any primary care physicians who are optimizing their patients for surgery, they're not going to be doing a lot of surgery.

Emily: Or if they don't have any primary care physicians who are referring their patients to orthopedic surgeons.

Wendy: Correct.

Emily: I also wanted to talk about this idea that becoming a physician leads to eternal job security. A lot of the physicians in the book, you talk about their backgrounds and their upbringing and how they grew up, and how a lot of them came from unstable family situations. The reason they chose medicine, one of the reasons was this idea that if you're a doctor, you can always get a job. Then you tell the story of Priya, who worked at a hospital, and then during COVID, elective procedures were canceled.

The hospital was hemorrhaging money. It was these waves of layoffs, and she got laid off, and so she took a job elsewhere, and then I think she got laid off again. She said, I think there was a quote in the book where she said, after losing two jobs in the middle of the biggest public health crisis in a century, she no longer trusts the long recited rhetoric about medicine as a stable career. I was wondering if you could talk a bit about that.

Wendy: Yes. I think Matt Ramsey in Chapter 1 was the first one who voiced that. He grew up in Schenectady, New York, in the era when Jack Welch had taken over GE. He watched his friends' families go through those periods of difficulty and instability. He said, "I don't want that. I want to go to this noble profession that's going to ask me to be a better man, and is relatively stable," which it was when physicians primarily were self-employed. Back in the 80s, 80% of us were self-employed. Once we became employees, especially in a corporatized environment, we became expendable, like other corporate employees are. Now it is necessary for us to think of ourselves as corporate employees as well as physicians.

It has happened relatively quickly, and so we haven't done a good job of preparing our young physicians for how to work in that environment, what they need to do to protect themselves, how they need to conduct themselves. Nor have we asked ourselves, is this what we want from healthcare? Do we want our physicians, like corporate employees, to be changing where they work every three to four years? Probably not. Most people around me, are saying, "I haven't had the same physician for more than three years. It's very frustrating. Nobody knows you."

Emily: There's all of these other ways in which the employer can get you. One of them was the non-compete clauses that if you're planted in a place with your family, and you're living your life there, and that's your community, and things don't go well at your job, so you decide to leave, some physicians are subject to this non-compete clause, which limits where they can go, so they really have you. There might have been some recent legislation updating that, that maybe loosened it, but no, you're shaking your head.

Wendy: No, no. If anybody's interested on 43cc, a podcast I do with Matt Ramsey, who is the character from Chapter 1, we do deep dives into what has happened with the FTC and non-compete clauses. Last April, the FTC published a rule that said non-competes are not okay except in these very fine circumstances. There were immediate lawsuits, there were immediate injunctions, and the injunctions are still making their slow way through the court, but it doesn't look like they're probably going to survive. What has happened is that some states have ruled at the state level that non-competes are not valid, but that's still going to be a patchwork of 50 different laws about whether or not non-competes will hold.

Emily: Yes, just another example of a law or a rule that's hindering competition.

Wendy: Right. It's hindering competition. It's keeping physicians from being able to speak up, because if you're afraid that if you speak up, you'll lose your job, and then you'll have to uproot your family with $300,000 in debt. What are you going to do?

Emily: In the book, you talk about solutions. Toward the end, there's a few different things that you throw out. I mean, one of them we talked about already, which is incorporating physicians into leadership roles, making sure to prioritize leaders and executives who are committed to values and not just profit, finding ways for clinicians to speak up, finding ways to regulate the monopolies, blocking mergers and things like that to make sure that competition thrives in the healthcare marketplace.

You talk about, of course, voting on issues like insurance reform and potentially making adjustments to prior authorizations, making adjustments to price transparency in hospitals. You talk about physician unions and other advocacy organizations, lots of different tools and levers that we can use as physicians to try to move healthcare toward a better place. You even say at the end of the book, reflecting on some of the stories of the doctors who came through the pages of the book, you say these doctors had to make a choice.

They could throw their hands up and tell themselves that working in healthcare in the US requires compromises, but if they succumbed to moral injury, they knew that they were consenting to their own destruction, so they chose to fight. I wanted to end on a positive note, or an inspirational note, or maybe just a call to action, or I don't really know what it is, but thinking about these physicians, these stories, this toolbox, these different ways that we have of making the system better, if there's any message that you'd like to leave our audience with.

Wendy: Yes. I say a lot that the bad news is that healthcare is pretty broken. The good news is healthcare is pretty broken, so wherever we start to make improvements, it will matter, and we'll feel it. The other reality is that we made all the decisions that created this construct of healthcare. We can make different ones. We can make different ones, but we have to find the will, and in order to find the will and to push legislation regularly, population and even just local changes, we need to find coalitions. We need to build those coalitions and build communities who are looking for change. That's part of what we want to do with our organization, Moral Injury of Healthcare, is to start building those coalitions toward better.

Emily: I think that's a great note to end on. I have been speaking with Dr. Wendy Dean about her book, If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First. Wendy, this book is extraordinary. Thank you so much for all the work that you do, and thank you for coming on the show.

Wendy: It's been my pleasure. Thank you so much.

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Emily: This episode of The Nocturnists was produced by me and producer and head of story development Molly Rose-Williams. Our executive producer is Ali Block, and Ashley Petit is our program director. Original theme music was composed by Yosef Munro, and additional music comes from Blue Dot sessions. The Nocturnists is made possible by the California Medical Association, a physician led organization that works to ensure the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.

This episode of The Nocturnists Conversations is sponsored by the Physicians Foundation, which supports physician well-being, practice, sustainability, and leadership in delivering high quality, cost efficient care. The Nocturnists is also made possible by donations from listeners like you. In fact, we recently moved over to Substack, which makes it easier than ever to support our work directly. By joining us with a donation of $2, $5 or $10 a month, you'll become an essential part of our creative community. I'm your host, Emily Silverman. See you next week.