Dean’s essay immediately caught my attention due to my prior experience reporting on moral injury. I had spoken with workers in low-paying jobs who faced ethical compromises in their occupations. I interviewed prison guards who worked in violent penitentiaries, undocumented immigrants laboring in industrial slaughterhouses, and roustabouts on offshore rigs in the fossil fuel industry. These individuals were often reluctant to speak out or reveal their identities, well aware that they could be easily replaced. In comparison, physicians enjoyed privileges with six-figure salaries and prestigious positions, seemingly spared from the drudgery faced by other members of the labor force, such as nurses and custodial workers in the healthcare industry. However, in recent years, many physicians have found themselves subjected to practices typically associated with manual laborers in factories and warehouses, such as hourly productivity tracking and pressure from management to work faster.
Given that doctors are highly skilled professionals not easily replaceable, I initially assumed they would be more willing to discuss the distressing conditions of their jobs compared to the low-wage workers I had interviewed. However, the physicians I contacted were afraid to openly discuss these matters. One doctor wrote to me, “I have since reconsidered this and do not feel this is something I can do right now.” Another texted, “Will need to be anon.” Some sources I tried to reach had signed nondisclosure agreements preventing them from speaking to the media without permission. Others feared disciplinary action or termination if they were to upset their employers, which is particularly concerning in the growing sector of the healthcare system controlled by private-equity firms. An example of this occurred in March 2020 when emergency room doctor Ming Lin was removed from the rotation at St. Joseph Medical Center, in Bellingham, Wash., after expressing concerns about Covid-19 safety protocols. However, Lin’s actual employer was TeamHealth, a company owned by the Blackstone Group.
Emergency room doctors have been at the forefront of these trends as more hospitals outsource staffing in their emergency departments to cut costs. In a 2013 study, Robert McNamara, chairman of the emergency medicine department at Temple University, found that 62 percent of emergency physicians in the United States could be fired without due process. Furthermore, nearly 20 percent of surveyed doctors reported being threatened for raising quality-of-care concerns, pushed to make decisions based on financial considerations that could harm patients, and pressured to discharge Medicare and Medicaid patients or order excessive testing. Another study revealed that over 70 percent of emergency physicians believed the corporatization of their field negatively impacted the quality of care and their own job satisfaction.
While there are doctors content with their careers, especially those in high-paying specialties like orthopedics and plastic surgery, more and more physicians are recognizing that the pandemic exacerbated the strain on an already failing healthcare system that prioritizes profits over patient care. They observe how the focus on profitability continuously puts them in moral dilemmas, leading young doctors, in particular, to contemplate how to resist. Some question whether the sacrifices and compromises are worth it. Dean, the author of the essay, points out that the term “moral injury” was originally coined by psychiatrist Jonathan Shay to describe the trauma that arises when a person’s sense of what is right is betrayed by leaders in high-stakes situations. Dean states, “Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”
Recently, I had a conversation with an emergency physician, whom I’ll refer to as A., about her experience. A., who preferred to remain anonymous due to hearing about other doctors being fired for voicing concerns about working conditions and patient safety, described the emergency room as a “sacred space.” She loved working there because of the profound impact she could have on patients’ lives, even those who were not likely to recover. During her training, she had a poignant interaction with a patient who had a terminal condition and expressed sadness that his daughter couldn’t be present during his final hours. A. promised him that he wouldn’t die alone and held his hand until he passed away. A. noted that such interactions would be challenging today due to the emphasis on speed, efficiency, and relative value units (R.V.U.), a metric used to measure physician reimbursement. Some feel that this system rewards doctors for tests and procedures while discouraging them from spending ample time listening and talking to patients. A. explained, “It’s all about R.V.U.s and going faster. Your door-to-doctor time, your room-to-doctor time, your time from initial evaluation to discharge.”
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