Moral Injury in Healthcare with Dr. Wendy Dean
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🎙 Episode 2 | Endocrine Matters Podcast
In this eye-opening episode of Endocrine Matters, we sit down with the amazing Dr. Wendy Dean to dive into a topic that affects so many in healthcare—moral injury. Dr. Dean is not just a physician; she’s a leader, author, and podcaster who’s been shining a light on the emotional and ethical struggles doctors face in today’s medical world.
We chat about her powerful book If I Betray These Words, what moral injury really means (and how it’s different from burnout), and practical ways to bring humanity back into medicine. Dr. Dean shares her journey from psychiatry to becoming an advocate for doctors dealing with these challenges, and we take a deep dive into big issues like hospital consolidation, billing confusion, and why direct primary care could be a game-changer. Whether you’re a doctor, a patient, or just someone who cares about better healthcare, this episode is one you don’t want to miss!
This is a Must-Listen For:
Physicians and healthcare professionals navigating systemic challenges
Patients curious about how healthcare systems impact their care
Advocates looking to support doctors and improve patient-doctor relationships
Anyone interested in solutions for making healthcare more ethical and humane
Listen to the Full Episode
🎧 Press play below to listen:
Key Topics & Timestamps
Skip to specific parts of the episode:
03:12 – Defining moral injury and how it differs from burnout
09:46 – The systemic factors that perpetuate moral injury in healthcare
18:15 – Dr. Dean’s personal journey from psychiatry to moral injury advocacy
29:03 – The impact of hospital consolidation and vertical integration
41:27 – Patients’ misconceptions about billing and the challenges of transparency
54:12 – Why direct primary care is a win-win for physicians and patients
01:10:45 – How physicians can address moral injury and advocate for change
01:22:18 – The power of collective action and building coalitions in healthcare
Episode Highlights
Key Takeaways:
Moral Injury vs. Burnout: Burnout suggests exhaustion from the work itself, but moral injury stems from systemic pressures forcing physicians to compromise their ethical commitment to patient care.
The Cost of Healthcare Systems: Hospital consolidation, vertical integration, and profit-driven motives have created barriers to ethical care, leaving physicians struggling to fulfill their oaths.
Direct Care as a Solution: Dr. Dean advocates for direct patient care models, which offer transparency, stronger relationships, and better outcomes for both physicians and patients.
Building Trust in Healthcare: The importance of restoring the physician-patient relationship and challenging the systemic issues that harm both.
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Arti: [00:00:00] I am so excited to welcome Dr. Wendy Dean to today's show to discuss the critical and deeply personal topic of physician moral injury. Dr. Dean is a physician, a leader, an author, a podcaster, and most importantly, a genuine humanitarian who tirelessly advocates for both patients and physicians. Let's start with a clear definition.
Moral injury is a distress that occurs when clinicians are repeatedly expected to make choices that transgress their deeply held commitment to healing. I'll say that again because it's worth emphasizing. Moral injury is the distress that occurs when clinicians are repeatedly expected to make choices that transgress their deeply held commitment to healing.
Oof. That one hits hard in today's healthcare system. One common scenario that leads to moral [00:01:00] injury is when hospital systems pressure physicians to see a high volume of patients daily. This reduces the time we can spend with each patient, often leaving us unable to fully address their concerns or provide the care we know they need.
Physicians are left struggling with their ethical obligation to deliver compassionate, thorough care while facing administrative demands to prioritize efficiency and profitability. This tension causes emotional distress, or as we now understand it, moral injury. As physicians, we hold ourselves to an extraordinarily high ethical standard.
We know what our patients need. We certainly know more than non clinical healthcare and insurance executives. It's confusing and heartbreaking when these standards are not prioritized by the systems within which we practice. When profits are placed above the lives of our patients, the very people we take an oath to serve, it feels like a betrayal.
Burnout is often discussed in healthcare, and while it's real, [00:02:00] Dr. Dean's introduction of moral injury has been a game changer for me. Burnout is a state of emotional, physical, and mental exhaustion caused by prolonged stress, and while physicians can certainly experience this, it doesn't fully capture the issue.
Burnout makes it sound like we've been worn out by the work itself, but for many of us, it's not the work of caring for patients that drains us. It's the system. Seeing patients, building relationships, and helping others is what lights us up. It's why we entered medicine in the first place. What's driving so many physicians out of clinical practice isn't the patients.
It's the maligned incentives of healthcare systems that prioritize profit over people. When we are confined to these systems and their profit driven motives, moral injury ensues. Dr. Dean's book, If I Betray These Words, dives deeply into the historical roots of our broken healthcare system, shares powerful stories, and provides a heartfelt exploration of moral injury that moved me to tears [00:03:00] more than once.
Her work has been transformative in helping us understand and name the emotional burden we face as physicians. I'm thrilled to have Dr. Dean on the show today to share her insights and expertise. She's done incredible work in the moral injury space, and there's so much to learn from her. I hope you find this conversation as enlightening and moving as I did.
Be sure to check out the show notes for links to her book, her work, and anything else mentioned in this episode. Let's dive in.
Well, I am so grateful to have you here. You have demonstrated such leadership and courage in discussing things that many people are either not aware of or not really aware of. not able to discuss or not brave enough to discuss. And, um, first I just wanted to hear your story and what, what brought you here.
Wendy: Yeah, well, thank you so much for having me here and for your interest in the topic. [00:04:00] Um, this was not what I planned to do with my life. It's, it's sort of, uh, I feel like. This initiative chose me, um, and it started back when I was practicing psychiatry and I had to make a decision. Either I was going to accept insurance and start doing every 15 minute or 10 minute appointments.
And I really, I thought about it and I said, you know, that doesn't feel to me like what's good for my patients. But the only way to make my practice sustainable was to do that. So I had a choice. I could either, I could either do what wasn't right for my patients, or I could leave practice. And so that's what I did.
And I ended up going to work for the U. S. Army. Again, nothing I ever imagined I would do with my life. Um, I did not wear a uniform, but I was working for them as a civilian. And I was seeing clinicians across the country who were struggling. They loved their [00:05:00] jobs. They loved their patients. You know, they love their work that they did, but everything that got in the way of the care that they could provide was just grinding them down.
And when I asked them if it was burnout, they would say, I don't have better language for it, but it doesn't feel right to me. I mean, I knew what I was signing up for, that I was going to work long hours and see impossibly hard things. And yet, what, what is breaking my heart is I can't get my patients the care they need.
They felt like they were breaking a promise, and to me that, that was something different. And so as I started looking into that, I realized there was this other concept called moral injury. And, Almost, it was something I started talking with Simon Talbot about, and he's a, he's a surgeon that I had worked with for a couple of years already.
And we decided that we would write this paper thinking that it would just go [00:06:00] in the bin with all the other burnout, occupational distress papers. And then we could go on with our lives. And instead it, it blew up. Um, and what that said to me was that people were hungry for better language. And this deeply resonated with something they were experiencing that they didn't have language for before.
Arti: Yeah, I can completely understand that sentiment of, do I continue to practice in this way that I feel is actually abusive to my patients? You know, like, I think we go into medicine with this idea that, yes, I'm going to work hard, but I'm going to provide a great service to my patients and my community.
People are going to like me for that, you know, and I think we get in and it's all of a sudden like, well, actually, in this [00:07:00] system, you're going to play by somebody else's rules, and you're not going to be in charge of the care that you provide as far as the time you get to spend with your patients, the support you can give them.
I mean, I had the same experience when I graduated from fellowship. I joined a practice where 15 minutes almost was a luxury, and that's. Right. It's just insufficient for somebody living with a chronic disease like diabetes or even thyroid disease. People are so confused because of so much confusing information on the internet and it almost becomes this adversarial relationship in the clinic because you're so time pressed that you don't have time to actually demonstrate your expertise and build the trust that patients need to believe you that what they're, what they might be.
Reading is flawed or to engage in a, in a plan that requires their input, you know, [00:08:00] psychiatry. is similar in that like you need the patient to be on board. And it's not just, you know, being a prescription monkey. It's actually getting these patients to hear what you have to say and at the same time hearing what they have to say.
I think so many patients now have that experience of not feeling heard and it's really driving apart the doctor patient relationship that is so sacred. To us and, and to our patients and so important for care, um. It
Wendy: also determines outcomes. Absolutely. So, there's, there's some data that shows that the best predictor of good outcomes, especially in psychiatry, is the relationship that you have between the patient and the clinician.
So if we're wondering why we're not getting great outcomes, maybe it's because we don't have great relationships and patients aren't willing to adhere to our treatment plan because they don't
Arti: know if they should trust us. And we've [00:09:00] culturally created this crazy environment that it's like, Oh, the patient's noncompliant.
It's the problem is the patient. And it's not, I've seen now hundreds of times that patients that were not doing well in a different setting, come see us in a, in a setting where they have a long time with their doctor. They can call us and text us in between visits. And they get educated because we spend an hour with them, you know, in their first visit.
And they do better. Like, we have the outcomes to show it. We have validated outcomes at this point that shows that the same exact patient gets better with great care. So I think it's very important to flip the script on patients with, you know, chronic diseases that we have this cultural bias that, oh, you did it to yourself.
And that's just not true. Nobody wants to be sick. People want to be healthy and they want solutions. And it's our job to help them find those solutions. And yeah, and they want, they want somebody
Wendy: [00:10:00] to partner in their care. Yes. Not dictate it. not step aside. They want somebody who's going to partner with them.
Arti: And not a top down approach. You know, it's I say this, so you do it. That just, we know it doesn't work. It has never worked and it never will work. So we need to really be rebuilding how, how we develop our relationships with our patients. Um, and you know, As a physician, you know this, the beauty of our career is that relationship too.
So it's a win win, and I think the only reason that we feel frustrated with complex patients is because we have to deal with them in five minutes. You know, when you have the time to dive in with those patients, then you also gain from that. And I feel that the system that we're in has stolen that beauty of the relationship, [00:11:00] not just from our patients, but from us as well.
And so for our listeners, Most people maybe haven't heard of moral injury or don't exactly know what that term means. Would you mind explaining that to us? Sure.
Wendy: So what it really comes down to is the definition that Jonathan Shay came up with in the early 90s was betrayal by a legitimate authority in a high stakes situation.
Um, Brett Litz and his colleagues said that it was, um, bearing witness to an act that caused you to transgress your deeply held moral beliefs or expectations or participating in it. And we see it as sort of, that's a continuum. The betrayal leads us to, um. A decision tree where you choose to stand up and push back on that betrayal, or [00:12:00] you acquiesce to it, which leads you to a risk of moral injury.
And when we talk about those deeply held moral beliefs in healthcare, we view those as the oaths that we took to put our patients first. And so when you're asked to put your patients through step therapy because they've changed insurance, you did that just last year and finally landed on something that the patient could tolerate.
And oh, by the way, we need, since they, their employer decided to change insurance plans, now you need to do it again. To the patient who has an acute. injury and doesn't want to go through physical therapy or doesn't deserve to go through physical therapy for six weeks, um, because it's just going to end up in a delay in care.
When we can't refer our patients outside of our healthcare organizations because they don't want the revenue to go [00:13:00] outside, even though we know that's the best care for them, all of those are incidents of potential moral injury.
Arti: You said this beautiful line in your book that said it's now customary to ask if your doctor is in network before you ask if that doctor is the right doctor for you and the particular condition that you have.
You know, I thought that was just so well put and it's so customary and usual and natural for us to go there first now that we don't even realize. realize that that's not how it should be.
Wendy: Right, it's I
Arti: right.
Wendy: I remember having a conversation with a 26 year old shortly after I started doing the work on moral injury And I said to her can you imagine what it would be like to walk into your doctor's office?
You still only have 15 minutes [00:14:00] that doctor Is focused, laser focused on you, does not look at a screen, does not answer a text, is just in there with you, listening to everything you're saying, and she got speechless. She's like, I can't even imagine what that would be like. So for her entire, her entire adult life, she'd never had a physician who could do that.
That's heartbreaking. Like, the relationship in itself is healing, and we're, and we're not, we're not standing up for that.
Arti: You know, I had a similar experience with a young person who was helping me with my website copy. And she had recently, uh, And she joined her husband's health insurance and they had like a company physician, a primary care physician, and she'd been struggling with migraines since her [00:15:00] teens.
And she said that she saw that company doctor and he sat and listened to her intently for an hour and they came up with a plan. that she was involved in, and not only did she resolve her issues, but she was like, I just never knew that it existed, that a doctor could sit there and listen to you intently.
And I thought that, you know, when you go in for five minutes, they get all the information that they need because they went to medical school. That's all they need and that's why they spend it with that much time with you. And she was like I had no idea that it was because of constraints put on them by an external force that That that was why the time was so short.
I just thought that was the necessary amount of time And I had the same same feeling of [00:16:00] sadness that patients don't know that we can do better and we can do better and in so many circumstances we're not doing better and it's terrifying for doctors to stand up for themselves and their patients, um, which I hope through this podcast, we can encourage people, physicians to do because it is possible to stand up for our patients.
And we are in a very special, um, we have the privilege to do it and it's hard and it takes risk in this circumstance, but I feel like the time is here to, to do so. Um, But Wendy, would you mind telling us, you've been in practice longer than me and you've seen some changes in health care, um, through the years.
So, [00:17:00] I would love to hear sort of your historical perspective on how health care has changed and how we got here.
Wendy: Well, um, just a reminder, I left practice about, you know, oh gosh, 12 years now. Um, but I, I think there are a couple of really big changes. One is that we've consolidated and vertically integrated all of our healthcare systems.
Um, so they are giant conglomerates of mega corporations that has layers and layers and layers of bureaucracy between the front lines and those who are making decisions. So that's one issue. But the other is that because of, because of some of the changes in reimbursement structures, and because of that consolidation and vertical integration, it has become much, much harder.
Oh, also with the regulatory oversight, um, it's become much harder to be an independent physician. And so, whereas in the 1980s, [00:18:00] 20 percent of physicians were employed, now 80 percent are employed. And when you own your own practice, you get to decide who does the scheduling and how they do it, um, what tests you order, sort of that, that whole, the whole operations of your practice are under your control.
When you get out into corporate health care, that's no longer under your control. So folks start having to follow the corporate line. And although it seems like it's easier because it's a guaranteed salary, you think that it's a little bit more stable. By the way, maybe it's not. The flip side of it is that you give up control of what your priorities are, whether it's time with your patients or income.
Somebody else is making those determinations for you.
Arti: So for our listeners who don't know what hospital [00:19:00] consolidation is, can you explain that a little bit more? And vertical integration? Yeah.
Wendy: Sorry. No,
Arti: that's okay.
Wendy: So, um, hospital consolidation is where, um, one healthcare entity buys up all of their competitors in a certain region.
And now it's even going cross states. Um, it used to be just within a local area and with typically within one state, but now it's, we're having cross state mergers. We're having multi state mergers, um, so that healthcare corporations aren't just your, they don't, you can't even affect local control. You can't even affect regulations within your state.
Now you have to be thinking about if you want to change it, you have to be thinking about regulations across many states. Um, and then vertical integration is where healthcare systems roll up. all of the different, um, entities that impact care. So for [00:20:00] example, an insurer, I don't know, there's a big one in the news right now.
Maybe let's talk about UnitedHealth group, um, has UnitedHealthcare, which is an insurer. They also have Optum, which, which, uh, employs 10 percent of the physicians in the U. S. right now. They have a pharmacy benefit manager. So, and they, you know, on and on and on. There's a whole long list, but you get a sense of what that means.
Nose to tail, they own healthcare delivery and they keep you, they sort of keep you in that gated community of, United Health Group care so that they keep all the revenue internally.
Arti: So why do you think this has happened? Why do you think so few physicians are now practice owners or in non hospital based private practice?
Wendy: I think a lot of it has to do with two things. [00:21:00] One is the cost of practice and the requirements for EMRs and the regulatory burden. of clinicians practices have skyrocketed. But I also think reimbursement structures are working against physicians. And, you Um, site specific reimbursement in particular where hospitals can charge differently than independent practices can.
And it's just becoming, you know, it's also that independent practices, small independent practices have no negotiating power. They have no market share. So when they go to the table with the insurers, the insurers can decide what to give them and they don't have any recourse except to walk away. Which is becoming more and more a viable option.
Arti: How do you think, or why do you think we don't have any protections? Why is it, you know, you would think that, I know this isn't true, but [00:22:00] in theory, if you were to see, I'm an endocrinologist, so we'll say endocrinologist, you would think that if you see an endocrinologist for X amount of time for X condition at Practice A that is independent and versus practice B that is owned by a hospital system.
Those two practices should be paid the same amount by your insurance for the same equal work. But they're not. So can you explain that a little bit and maybe your thoughts on why this has happened? Um,
Wendy: that could take. I mean, there could be a there. I'm sure that there are courses in that, right? So, um, uh, and I think that there are probably people who are better, better equipped to address it than I am.
But what I think it boils down to is lobbying and [00:23:00] who gets the regulations through, um, you know, it's, it, it really, the rulemaking in healthcare. It's quite frustrating, um, and physicians as a group, although people listen to us, we are, we're a small number. There are only a million of us in the country.
There are 3 million nurses, there are 330 million patients, and our pockets are not very deep. Um, health system pockets are quite deep. Um, the American Hospital Association has deep pockets for lobbying. So, you know, I, I think just.
Arti: Do you think there's anything, like, I know that physicians traditionally haven't been able to unionize or anything like that. I also think that sometimes we as physicians, struggle to come together, um, because [00:24:00] we have varying interests and varying specialties have varying interests. Um, and so do you think that there's anything that we can do to change the course?
Wendy: Yeah, we can start working together. We can start having each other's backs. You know, I talk about this all the time. If a surgeon doesn't have a primary care physician to take care of their patients and optimize them for. surgery. They're not going to be doing surgery very often, right? Like if they don't have a good anesthesiologist, they're also not going to be doing surgery as often.
You know, they're not going to be doing the same volume, the same number of complexity of cases, all that. We need to be taking care of our own, right? We need to have each other's backs. We need to be fighting for the other specialties. One of the things that we need to keep in mind is that the CPT coding process pits us against each other.
And if you've never been to a [00:25:00] CPT coding meeting for billing purposes or to the RUC, it's a really interesting process. It is free. All you have to do is register and show up and you can watch what happens. And it's understandable. There is a finite pool of money lobbying for what reimbursement each code will get because it's a zero sum game.
It pits us against each other. The wealthier specialties have better people arguing for their case. But you know, at some point we need to stop, take a step back and say we're all in this together and we all have the same goal, which is to take care of our patients. Now I also want to make a comment about the unionizing piece.
Any employed physician can unionize. That's always been the case. But in the eighties, only 20 percent of us were employed. So it seemed like, you know, and when you're [00:26:00] in independent practice, you can't unionize, but now 80 percent of us are employed. It's time for us to think about that as an option. And I've done a fair bit of work with unions and unionizing groups, and it is a way to have a collective voice.
I don't think it's the only way, but it is a way. You know, traditionally it was medical societies that brought together our collective voices. But what's interesting is a lot of health systems have now captured the medical societies by paying physicians dues. So one of the ways that we could take some of that voice back is to start paying our own medical society dues.
Arti: That's very interesting. I hadn't really thought about the, the dues because as an independent physician, I pay my own dues, but, um, actually, I'm glad that you brought up the RUC because we are going to be recording with Brian Klepper, um, who is a RUC expert. Um, he's kind, he kind of, he's not a [00:27:00] physician, but he's in healthcare and he learned about the RUC and essentially became obsessed with learning about it and telling people about it.
And we're going to be doing a deep dive, uh. right after this talking with him. So, um, you know, physicians don't know about that. Like, you know, I, I gave a talk to a group of over a hundred endocrinologists in Texas. And when we asked them sort of basic healthcare finance questions, nobody knows, like maybe one person in the room raised their hand.
Um, do you think that physicians have been intentionally kept in the dark about healthcare finance?
Wendy: I think that's one of the reasons that physicians choose employed, employed practice, so that they can ignore that side of it and just say, you know what, I'm just here to do the doctoring. There's somebody else who's going to do all the messy stuff of the money.
And the reality is they're still billing in your name. So you [00:28:00] really should know how these things work, because even though you sign away your rights to that, you still have responsibilities for how someone is billing in your name. If they're up, up coding in your name, that's going to be a problem. Right?
So it really behooves us to know how, how the money flows, how it impact our practice. Um, and, and I, I realize that most physicians have a precious little interest in that. Um, but it, we ignore it at our peril because it is how, it is what moves corporations.
Arti: Absolutely. I agree. And I'll admit that when I graduated from training, I was kind of in that boat like, okay, I'm going to join a big practice.
I just want to know, do what I know, which is practicing. care of patients and, um, I want the [00:29:00] billing side of it to be taken care of for me. And what happened to me was I was in a private practice that was physician owned, but with that there was some Like I did get to see my patient's super bills, and I was like you're paying how much to see me or you know I got to really see how things can work and where patients were on the totem pole of importance and what I realized is they're at the bottom or not even on it when it comes to Extracting as much money as they can You can out of, uh, of a patient or a patient encounter in health care.
It's very common for physicians to have conversations on how you can extract the most money out of an interaction, like how to how to code this to make the most off of it. And we, for some reason, We have, I don't know, brainwashed ourselves to [00:30:00] think that that is appropriate or okay or, um, or maybe it's because we have a set amount of RVUs that we have to meet and, um, but it's very non transparent and I think that that non transparency leads us to act in a way, if we were just actually talking about dollars and cents that anyone can understand, we would have that ethical goal.
Dilemma about it, but they hide things behind ICD 10 codes and CPT codes and ENM codes and all of these codes. So there's this big gap between what we're writing down and what we actually understand.
Wendy: Yeah. Well, I, I, I think there's a, I think there's another, there are a couple of other issues here. Um, one is that healthcare is a very thin margin industry.
Like it, it's right there with groceries. [00:31:00] So there is some reason to be worried about the margin, not everywhere, but in some places there is reason to be worried about the margin. At the same time, hospitals, part of the reason that clinicians don't know the bill, the patient's bill looks like is because the negotiations with their insurers has been kept proprietary.
So even if a clinician asks. What is billed and what that patient will be responsible for. They may be told, we can't tell you that's proprietary. Chargemasters are kept under lock and key. Like nobody can get at those because they're proprietary. I mean, there is, there is a move towards transparency now, but it's, but it is hard one and, and they're coming kicking and screaming.
Right. Um, but I think the other part of it is when you hear people talking about the cleverness of how they bill, that's rewarded. That's [00:32:00] incentivized in big systems. And, and also, I mean, let's just be real. In every group, there are folks who are right. Self, more self interested than others. There will always be those folks.
There are those folks in medicine, there are those folks who are physicians. But our systems are starting, money is sort of the coin of the realm and how you get noticed and how you get incentivized in healthcare now. So it's natural that we start talking in those terms. But I think we need to start taking that back and it's super easy to start taking it back and talking about the patient experience and being, going back to being the patient's advocate.
Arti: Yes, I think we have gotten accustomed to productivity, productivity, productivity, and that being the badge of honor. You're the most productive physician. And yes, you can be productive and take great care of your patients, but oftentimes [00:33:00] productivity comes at odds with taking great care of patients. And unfortunately, those who.
Have some of the best relationships with their patients or spend the most time with their patients They are their outcomes are not necessarily their clinical outcomes or satisfaction Outcomes are not necessarily tracked or given value to and they're and I'm doing air quotes now lack of productivity is A marker that they're not doing enough to their employer or their hospital system You had some incredible stories in your book about, um, about physicians who Advocate for their patients and get reprimanded by their systems.
Would you mind sharing one of those or a couple of those that you kind of [00:34:00] hold, hold dear to your heart?
Wendy: Yeah.
Arti: So
Wendy: I think the, the one that I find most hard, I mean, so there was, there was one of a physician who died by suicide, which was heartbreaking, but the one that, that, and of course that it's tragic.
It should never happen. Yeah. But I think the one that comes up for me again and again and again is Rita Gallardo, who was a, she's an oncologist. She went back, she intentionally, so she served in the military, when she separated from the military, she did her fellowship in oncology and intentionally went to practice in a small Midwestern town, very rural place.
And there were two hospital systems in the, in the area. So she went to work for one of them. And After a couple of years, they, they, where she had started up a [00:35:00] clinic, she was going gangbusters. Um, the clinic was incredibly successful and busy and yet they were not allowing her to refer her difficult patients or patients with rare cancers outside of the system.
to another, to another hospital system. So she quit that job. She went to work for the other hospital system. And within a year, the same thing was happening. And the whole point was they wanted to keep the revenue inside their hospital system, no matter what was right for the patients. And so she left and, you know, to quit two jobs within the, within the span of three years in a small place where you just want to serve the community, right?
What a loss. What a loss. For the patients, [00:36:00] right? It's just Correct! For the community, for the, for, for a small rural community where she was saying I want to be able to keep patients here for their chemotherapy rather than putting them in a car for an hour and a half to travel to get it. And she ended up starting a direct primary care practice and is now doing direct specialty care for some of, for some of her cancer care.
But you know, it's, she gave up a lot to do that. And it's been a, it's been a tremendous sacrifice for her and her family. Um, and I, I just think why, why, why can't we do this better?
Arti: Yeah, why does it have to be so hard to do the right thing? There's this whole, um, I guess narrative about doctors, um, when, when [00:37:00] people receive a bill from their hospital system or somewhere, their immediate reaction is, my doctor billed this much.
And I think it's, hopefully people are starting to see that it, it's actually not a doctor actually never bills a, a number. It's always a code, um, in those types of sys systems. Um. But I think that we are the face that people see of the healthcare system, and it makes it very challenging in circumstances where, you know, the perception could easily be, you know, she, she left, you know, she was taking care of me and she decided to leave to go Start a cash clinic, you know, and I think that sometimes Hospital systems kind of run with that narrative of oh, this is this [00:38:00] is the doctor's fault that you got the bill Well, your doctor shouldn't have coded that and I think it creates that again that adversarial relationship that inhibits care but I think that Her story, I, I, that resonated, that, her story resonated so much with me because I felt like, you know, I do have a direct care practice myself and people are so uncomfortable with the idea of direct care that, and they're, were almost like brainwashed into thinking that insurance is the right ethical way to practice medicine and these big hospital systems are like the right ethical way because that's what most people see now.
Um, I would love to kind of hear your thoughts about that and your thoughts about direct care and how you think that people, [00:39:00] how you think we might be able to show people the reasons why doctors might be choosing that route.
Wendy: Well, I, um, to go back to the very beginning of your statement, people think that the doctor billed because the bill comes in the doctor's name.
Yeah. Because we do, our hospital systems bill in our name. And I wrote an article in the AMA Journal of Ethics about this. What physicians obligations are because hospitals are billing in our names. So until we can change that so that employed physicians are not You know, the hospitals are not billing for physician services under our name when we're employed, which I, you know, I think there are some places where our current regulations and our current requirements in health care have not kept up with how practice has changed.
So we should start changing some of those. One is billing under the physician's name when you're an employed physician and have zero control over what goes on your [00:40:00] bills. Until then, Go find that AMA Journal of Ethics article and understand what your obligations are. But I, I, I also think that moving towards direct patient care, direct primary care, is one of, it could be a win win for patients and physicians.
So, when a patient has that direct connection to a physician, it's It's easier for the physician. They know their patients inside and out, right? They know, they know their history when they've seen them for some time. It's quicker for the patients. It's quicker for the physician. But it's also a more trusting relationship.
You've known me for a long time. You've stuck with me through thick and thin. And when you look at pricing for direct primary care versus for what insured care costs, [00:41:00] it's quite eye opening.
Arti: I think that eye opening is the best word about this whole space because, you know, I think that actually being blind to what is going on is self preservation for You know, once I started seeing the billing and started talking to my patients about how much they were being charged, and I had experiences in my own life where, um, it was like, well, the, the price with insurance is 1, 000, but the price if you pay cash is like 600, but then it won't be, you know, a part of your deductible.
You know, I started, the, the veil was just lifted and I started to see. What this whole non transparent system was doing to the cost of health care for, for my patients and for me, I just couldn't unsee it like I was, I just felt like [00:42:00] I, I cannot practice in a way that I can't control my patients care and I have no light into what they're being billed.
And, um, You know, I think for me, I, I, it was either leave practice completely or do something more transparent. And I had just finished my training and I felt like I was, a lot of patients were asking to switch to my clinic from some other docs. And I was like, I think I'm good at this. I think it works.
And there's a huge shortage of endocrinologists, I, I felt like, and I want to do this, but I need to do it in a way that makes sense, and, um, I can see where my future is going in this setting, and I don't like it. And so, I think that veil, though, is people who maybe don't feel that they have the option to completely jump off the deep end, um, they, [00:43:00] they have to maybe hide behind that before Otherwise, I don't know how you do it.
There's,
Wendy: there's actually a term for it that I talk about in chapter four, which is betrayal blindness. So in order, in order to keep doing these things that Don't that you that you feel complicit in you can't allow yourself to see them It's a it's sort of this psychological defense strategy So there's betrayal blindness and as you said once the scales come off your eyes, then you're forced to make a decision Do I continue to be complicit or do I walk away?
And if I walk away, what do I do or you know? Can I fight it? Is there a place for me to fight while remaining in this?
Arti: You know I have this idea that All hospital administrators should have to do a year of residency before they can become a hospital administrator. Can you imagine how much things would change [00:44:00] or we'd hope that things would change?
Do you think, do you think they would change?
Wendy: So, uh, I think they would. What I would like to see, because I don't think we'll ever get that through, is that hospital boards And executive teams have to spend a certain number of hours every quarter in clinical spaces. You know, the good news is that clinical spaces run 24 7, 365.
So whenever you're, whenever you got a couple of hours drop in.
Arti: I think there's this whole idea from physicians that hospital administrators are these horrible people and, you know, some maybe, but I do think that everybody is. There's a lot of gray area and there's a lot of separation between the patient and that CEO or CFO that's making decisions that impact the patients, but doesn't have the [00:45:00] human experience to have to reconcile.
Wendy: 43cc all the time, all the time. So, uh, And what I think is we're all doing the, our level best to do what we were trained to do. We actually have a paper coming out or that that's, uh, in review about executive, the executive experience during the pandemic. And almost 40 percent of them experience endorsed moral injury.
So it's not just a clinician problem. It is also an executive problem. And I would guess that if we did this study in the insurance agency, we would find the same thing. Um, we're all suffering and it should be a place that we can come together and say, if we're all suffering in this way, let's work together to make change.
Arti: Absolutely. And I think everything you just said kind of culminated in the past week's events with the [00:46:00] CEO of UnitedHealthcare. It's just incredibly tragic that this person, who is the face of a company that probably has harmed or been part of the harm of many people, but who is also a father, a husband, a member of his community, lost his life because of this gigantic gap between the patient experience and the decisions being made that affect them every day.
Wendy: And we need to, we need to pay attention to that, right? We're, we're complex beings. We can hold two things at once. Murder is bad, but so is the conduct of some mega corporations. And with the schadenfreude that people expressed, that morbid glee, you know, that's a, that is a call to, to try to right the system, to restore some [00:47:00] moral balance.
And we're, we ignore that or dismiss it at our peril.
Arti: Yes, and it's, it's, The public response has been scary in some ways, you know, how many people are almost on the shooter's side. Um, it, I think it just shows us how, how many people's lives have been harmed by, by the current healthcare system. And, and I do think that as physicians, we have a voice.
We do have a voice and We can choose to ignore it, or we can choose to use it, and if we choose to use it, especially if we choose to use it collectively, we have so much good that we can do for patients, and so much change that we can [00:48:00] have. I mean, I'm sure you saw that, um, that Anthem, Blue Cross Blue Shield, was trying to limit anesthesia time for surgeries.
Yes, we did a, we did a, an episode about that. I would love to talk to Matt about that. I just would love to, to hear what he has to say in All Flourish, because You will, 43CC, next week. Yay! Okay, I can't wait for that episode, but it's just so obviously stupid. Like, I don't have a better word for it than that.
It's Um, obviously has, opens a, a rabbit hole, uh, to horrible things happening to patients. Um, as far as billing and, uh, and surgical complications or, or issues. Um, but I thought that I was, I did have a point with this, but, um, I think that the out, oh, the outpouring [00:49:00] from social media, I mean, it was terrible timing, right?
Everybody's already up in arms about insurance companies and then they come forward with this, um, sort of asinine recommendation. They had done
Wendy: this in early, they had posted this in early November. So somebody picked it up, I think, and. added that fuel to the already pretty raging fire that was happening on social media.
Arti: But I do think what that shows us is that we do have power. We have, we can use our voice for for change, and, and who knows, they might come back and do the same thing once things settle down. Um, but, the more we engage more physicians and, and the public in these issues, and the more we get fiery about it, I, I think that we do have potential for change.
Wendy: My. My concern, though, is why do we have to [00:50:00] adjudicate everything in the public square? The American, the, um, American Society of Anesthesiologists had already met with Anthem to try to talk some reason into them, and they refused. And so, you know, six weeks later, the public gets wind of it and raises an outcry.
It's a perfectly timed incident where the executives of health insurers are a little bit wobbly. And they retract it. But why do we have to adjudicate everything in the public square?
Arti: Yeah, this should have been something that, that, that people in the know really should have been able to put forward a a argument that is based on science and evidence, um, to get, make a company do something that's reasonable.
But it actually, the, the public relations scare is more of a [00:51:00] scare to them than the actual patient harm, which I think, I think is something to note, right? They didn't do it because they thought it was right for the patients. They did it because of their reputation being on the line. Um, And I think it's important for us to say, hey, like, These companies actually don't care about your well being, but when it comes to their bottom line being at risk, that's when they will consider making change.
And are we okay with that? I don't think we are, right? Um, but I do think that that is an excellent point. Like, why does it have to come to this? Why can't we do the right thing? Behind the closed doors, you know, like why when nobody is looking why can't we do the right thing? So as we wrap up, I wanted to know were there any conversations that you had with?
Administration or executives or even other [00:52:00] physicians? I'm sure there are many so maybe pick your favorite That you didn't put in your book that you think are important to share Well,
Wendy: we talked about one of them already which is that Executives and administrators, managers are feeling the same thing. I think that's really important for us to, to keep in mind.
Um, but the one, one of the really touching interactions that I had was with a CEO that I'd been working with for a couple of years and. At one point he took me aside and said, I see how we're betraying our physicians. And to me, that was a, that was a moment of, okay, you know, all, all of this raising awareness advocacy is, is actually making an impact.
So, you know, and, and the thing to keep in mind about moral injury is it's [00:53:00] been in the lexicon for six years now, not very long. Um, so the fact that people are even talking about it, thinking about it, Starting to think about framing distress in this way, and even, even more so that we're, that we're even beginning to build solutions around it, um, is like lightning speed.
So kudos to everybody who is doing this work with us and who's helping to raise awareness as well.
Arti: Absolutely. And then if you had one thing that people could do in health care, or I guess physicians, if there's one thing that physicians can do to help reduce moral injury, what would you recommend? The bad news
Wendy: is that health care is pretty broken.
The good news is that healthcare is pretty broken. So no matter [00:54:00] where you start to fix it, it's going to get better, right? So pick the thing that really, that really chafes you and do a deep dive, learn about it and then figure out how it can be better where you are. When you fix that, move on to the next and also make sure you build coalitions along the way.
They're critical.
Arti: I think that is beautiful. I think it's start somewhere, start some, do something. What, and what you do may be different from what the person next to you does, and that is perfectly okay. Everybody has their own space and their own passion, and ultimately, I think all of us want to do good in the world and good for our patients.
And so, whatever it is that you choose to move on is, is good and moving us in the right direction. I love that. So, um, Wendy, tell us the name of your book, where we can find it. And there are so many wonderful things [00:55:00] that you do. So, um, if you can pick the, the things that you would want to share with our audience, um, the most, please tell us where they can find those things.
And, um, and I'm, they're going to be so excited to, to read. Your book and and look at the rest of your work.
Wendy: Yeah, so, um, the book is called if I betray these words and You can find the book and our podcast moral matters on our website fixed moral injury org And then I have another project with Matt Ramsey who's an orthopedic surgeon doing a podcast called 43 CC Which is the truth about health care with a shot to dull the pain and you can find information about that at 43ccpodcast.
com
Arti: So Wendy's book is absolutely brilliant. I have read it cover to cover. I highlighted it. There are points in it that are just so, [00:56:00] so, that just resonate so much with all physicians. So I think that any physician would absolutely resonate with that book. And 43 CCs is actually the amount of alcohol in a shot.
So such a clever name for their podcast, but it's, um, a very thoughtful, but also digestible podcast that I highly recommend that you guys listen to. And Wendy, thank you so, so, so much for your time and for coming on the show. I'm just beyond thrilled to have had this conversation with you and looking forward to conversations in the future.
Oh,
Wendy: so much. It's been my [00:57:00] pleasure.
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