The Metastasis of Moral Injury in Healthcare: A Personal Reflection
Author: Lara Kenney, MD
In 2018, my good friend Dr. Wendy Dean began to shed light on a critical issue plaguing the healthcare landscape: the concept of moral injury. As she advocated for its use to describe the epidemic of burnout among physicians, it became clear that our distress was deeply rooted in the structural failures of the healthcare system. This moral injury was not just a byproduct of long hours or overwhelming patient loads; it was an ethical crisis stemming from the roles we were forced to play within a system that often contradicted our core values as healers.
Like many of my colleagues, my journey led me to embrace the Direct Primary Care (DPC) movement. When I opened my practice in 2019, it felt like emerging from a long submersion underwater—a breath of fresh air, filled with the giddy relief of autonomy and fulfillment. I quickly recognized how profoundly unhappy I had been in the traditional healthcare environment. It was not merely burnout I had experienced, but a simmering anger and frustration rooted in witnessing the systemic failures that violated the oath I had taken as a physician.
Fast forward six years, and I find myself grappling with a sense of déjà vu. Over the past six months, the frustrations I thought I had left behind have resurfaced, proving to be profoundly disappointing. While I am no longer bound by the constraints of a broken healthcare system, its pervasive problems seem to loom larger than ever. Each time a situation requires intervention beyond the walls of my practice, I am met with the same bureaucracy, inefficiency, and sometimes outright maleficence that I sought to escape.
Dr. Dean’s 2019 article, “Reframing Clinician Distress: Moral Injury, Not Burnout,” sheds light on the root of this suffering. She articulated how the rules and regulations imposed by distant, top-down administrations create an environment where practitioners are forced to witness and partake in actions that fundamentally conflict with their professional ethics. The healthcare system, as it stands, has created a culture where moral injury thrives, leading to a degradation of both physician well-being and patient care.
The alarming reality now is that the malignancy of our healthcare system threatens to metastasize into the DPC movement, a model that was supposed to embody a return to focused, patient-centered care. The very principles that drew us to DPC—autonomy, fulfilling the patient-physician relationship, and mitigating the weight of corporate healthcare—are at risk of being overshadowed by the pervasive dysfunction of the broader system.
What can be done to safeguard our vision for DPC and prevent the encroachment of moral injury into our practices? Here are a few potential strategies:
1. Advocacy and Reform: Engage actively in advocacy for systemic reform. Collaborating with organizations that are dedicated to reshaping healthcare policies can amplify our voices and address the root causes of moral injury in the system. It’s not enough to just belong to the DPC Alliance, although you should. We need to be active voices in our State Medical societies and our professional societies, many of which we have avoided.
2. Community Building: We must continue to create and foster a robust community of DPC practitioners who can share experiences, strategies, and support each other through the challenges posed by a fractured system. We cannot allow the infighting that has happened in so many physician organizations as they’ve grown. We must remain focused on the collective goal.
3. Mindfulness and Self-Care: Encourage a culture of mindfulness and self-care within our practices. These practices can help us remain anchored in our purpose and resist the tide of frustration that threatens to overwhelm us.
4. Education and Awareness: Promote awareness of moral injury among colleagues and medical trainees. Educating the next generation of physicians about the intricacies of the healthcare landscape can empower them to advocate for change before they reach a point of burnout or moral injury.
As we navigate these challenges, it is crucial to remember that while the current healthcare system may feel like an insurmountable adversary, collective action and a commitment to our values can pave the way for a brighter future in medicine. We owe it to ourselves, our patients, and the integrity of our profession to remain vigilant against the forces that threaten to undermine the healing vocation we cherish.
Agree! The journey of a thousand miles begins with one step…
So true– 8 yrs in and my language is getting awful again. I think some is the reflection of what is happening to science/medicine at the fed level…
We have to remember that we are all patients, and if we don’t change the landscape, in our old age we will be stuck with the kind of care our current patients are desperate to be rid of. So many things work together to keep us from fulfilling our physician autonomy to be the best physicians we can be for our patients and ourselves–starting with prior authorizations and other administrative wastes of time, to being called “providers” and told that we are replaceable with lesser-trained individuals. I recommend joining with others to help combat the corporate systems, the legislation, and the insurance companies’ desire for money. DPC Alliance is one group. Physicians for Patient Protection is another. Together we can make great changes. Individually, it’s exhausting.
I have to reiterate DPC “WILL NOT WORK” in every geographic area. Go to a place with a lot of public aid and YOU WILL FAIL PERIOD!! I can’t stress that enough. The patients expect everything to be given to them. I worked in a group practice my entire career and the hospital paid me fairly no matter how much money we lost them. Didn’t matter to me. I did a good job and my patients knew that. Did office, call and hospital work which I think is becoming rare in primary care because the resident docs aren’t getting the training to do that now. DPC? Chose the area and the economics of the potential patients carefully or one will go bust!! Be careful.