The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal

The New York Times

Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”

The info is here, paywalled.

Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:

• Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
• Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
• Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.

The article concludes by calling for a number of reforms to the healthcare system, including:

• Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
• Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
• Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Are We Causing Moral Injury to Our Physician Workforce?

Carolyn Meltzer
theneuroethicsblog.com
Originally posted November 5, 2019

Here is an excerpt:

The term moral injury was coined by psychiatrist Jonathan Shay, MD PhD, who, while working at a Veterans Affairs hospital, noted that moral injury is present when 1) there is a betrayal of what is considered morally correct, 2) by someone who holds legitimate authority (conceptualized by Shay as “leadership malpractice”), and 3) in a high-stakes situation (Shay and Monroe 1998). Nash and Little (2013) went on to propose a model that identified the types of war-zone events that contributed to moral injury as witnessing events that are morally wrong (or strongly contradicted one’s own moral code), acting in ways that violate moral values, or feeling betrayed by those who were once trusted. In a fascinating study using the Moral Injury Event Scale and resting-state functional magnetic resonance imaging (fMRI), Sun and colleagues (2019) were able to discern a distinct pattern of altered functional neural connectivity in soldiers exposed to morally injurious events. In fact, functional connectivity between the left inferior parietal lobule and bilateral precuneus was positively related with the soldiers’ post-traumatic stress disorder (PTSD) symptoms and negatively related with scores on the Moral Injury Event Scale.

Moral injury has been recently applied as a construct for physician burnout. Those who argue for this framework propose that structural and cultural factors have contributed to physician burden by undervaluing physicians and over-relying on financial metrics (such as relative value units, RVUs) as the primary surrogate of physician productivity (Nurok and Gewertz 2019). Turner (2019) recently compared the military experience to that of physician providers. While one may draw similarities between the front line of healthcare delivery and that experienced by soldiers, Turner argues that a fundamental tenet of military leadership - that leaders eat last – provides effective support for the health of the workforce. In increasingly large healthcare organizations managed by administrators who may be distant from the front line and reliant on metrics of productivity, the necessary sense of empathy and support from leadership can seem lacking.

The info is here.

More than 300 overworked NHS nurses have died by suicide in just seven years

Alan Selby
The Mirror
Originally posted April 27, 2019

More than 300 nurses have taken their own lives in just seven years, shocking new figures reveal.

During the worst year, one was dying by suicide EVERY WEEK as Tory cuts began to bite deep into the NHS.

Today victims’ families call for vital early mental health training and support for young nurses – and an end to a “bullying and toxic culture” in the health service which leaves them afraid to ask for help in their darkest moments.

One mum – whose trainee nurse daughter Lucy de Oliveira killed herself while juggling other jobs to make ends meet – told us: “They’re working all hours God sends doing a really important job. Most of them would be better off working in McDonald’s. That can’t be right.”

Shadow Health Secretary Jonathan Ashworth has called for a government inquiry into the “alarming” figures – 23 per cent higher than the national average – from 2011 to 2017, the latest year on record.

“Every life lost is a desperate tragedy,” he said. “The health and wellbeing of NHS staff must never be compromised.”

The info is here.

The U.S. Healthcare Cost Crisis

Gallup
Report issued April 2019

Executive Summary

The high cost of healthcare in the United States is a significant source of apprehension and fear for millions of Americans, according to a new national survey by West Health and Gallup.

Relative to the quality of the care they receive, Americans overwhelmingly agree they pay too much, and receive too little, and few have confidence that elected officials can solve the problem.

Americans in large numbers are borrowing money, skipping treatments and cutting back on household expenses because of high costs, and a large percentage fear a major health event could bankrupt them. More than three-quarters of Americans are also concerned that high healthcare costs could cause significant and lasting damage to the U.S. economy.

Despite the financial burden and fears caused by high healthcare costs, partisan filters lead to divergent views of the healthcare system at large: By a wide margin, more Republicans than Democrats consider the quality of care in the U.S. to be the best or among the best in the world — all while the U.S. significantly outspends other advanced economies on healthcare with dismal outcomes on basic health indicators such as infant mortality and heart attack mortality.

Republicans and Democrats are about as likely to resort to drastic measures, from deferring care to cutting back on other expenses including groceries, clothing, and gas and electricity. And many do not see the situation improving. In fact, most believe costs will only increase. When given the choice between a freeze in healthcare costs for the next five years or a 10% increase in household
income, 61% of Americans report that their preference is a freeze in costs.

West Health and Gallup’s major study included interviews with members of Gallup’s National Panel of Households and healthcare industry experts as well as a nationally representative survey of more than 3,537 randomly selected adults.

The report can be downloaded here.

Not “burnout,” not moral injury—human rights violations

Pamela Wible
www.idealcare.org
Originally posted March 18, 2019

Here is an excerpt:

Moral injury now extends beyond combat veterans to include physicians in 2018 when Dean and Talbot announced their opposition and alternative to the label physician “burnout.” They believe (as I do) that physician cynicism, exhaustion, and decreased productivity are symptoms of a broken system. Economic forces, technological demands, and widespread intergenerational physician mental health wounds have culminated in a highly dysfunctional and toxic health care system in which we find ourselves in daily forced betrayal of our deepest values.

Manifestations of moral injury in victims include self-harm, poor self-care, substance abuse, recklessness, self-defeating behaviors, hopelessness, self-loathing, and decreased empathy. I’ve witnessed all far too frequently among physicians.

Yet moral injury is not an official diagnosis. No specific solutions are offered at medical institutions to combat physician moral injury though moral injury treatment among military may include listening circles (where veterans share battlefield stories), forgiveness rituals, and individual therapy. The fact is most victims of moral injury struggle on their own.

With no evidence-based treatments for physician moral injury and zero progress after forty years of burnout prevention, what next? Enter the real diagnosis—human rights violations—with clear evidence-based solutions.

The info is here.

Why Are Doctors Killing Themselves?

The Practical Professional in Healthcare
October/November 2018

Here is an excerpt:

The nation loses 300 to 400 physicians each year, the equivalent of two large medical school classes, and more than a million patients lose their doctor.  According to a new research study encompassing data from the past ten years, physicians are committing suicide at a rate that’s more than twice as high as the average population—higher even than for veterans.

With a critical shortage of physicians looming and advocates like Pamela Wible calling attention to the problem, the increasingly urgent question remains: Why are doctors killing themselves? And what can be done to help?  In response, researchers are ramping up their efforts to understand the causes of
physician suicide; leading hospitals, medical schools and professional organizations are pioneering new programs and interventions; and regulators are reconsidering how they might revise the licensing/renewal process to support their efforts.

The info is here.

There are several other articles on physician self-care, which applies to other helping professions.