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"I think we need to stay relentlessly curious. And we need to understand what we're working in and recognize there is nobody who comes to work everyday and thinks I'm going to make somebody else miserable." - Dr. Wendy Dean

When service members returning from Iraq and Afghanistan were not responding to PTSD treatments, it became clear that they were not dealing with the anxiety and experiential avoidance caused by PTSD but instead the shame associated with perceived immoral conduct. This specific form of distress is called moral injury: "perpetuating, bearing witness to, or failing to prevent acts that transgress deeply held moral beliefs and expectations" (from If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First by Wendy Dean, MD with Simon Talbot, MD).

Whenever the business of medicine gets in the way of our ability to provide care to our patients, we experience some form of moral injury. It's hard to escape moral injury when we have all the responsibility and all of the accountability but none of the autonomy. And that is the system we work in. None of us are completely autonomous. A whopping 78% of US physicians are employed by hospitals, health systems, or other corporate entities, and the meager few of us who are independent are still beholden to insurers for compensation. Because medicine has become corporatized and consolidated over the last several decades, we have slowly given up our ability to provide care efficiently and affordably. Sixty years ago, hospitals were locally owned and operated and decisions made by experts in healthcare--the physicians. In the 1970's, doctors formed groups and outsourced operations to administrators, entering an era of skyrocketing administrative growth and costs in a system in which executives do not see themselves as responsible to clinicians or patients but to shareholders, who have one goal: to maximize profit.

But what can we do about it? In this conversation, I discuss the broken US healthcare system with Dr. Wendy Dean and Dr. Matt Ramsey and what we can do right now to make a dent in fixing this behemoth of a problem. We may have gotten into this profession to practice medicine and surgery, but it is part of our job to learn the bureaucracy and the business sooner rather than later. We have to understand where we are, and from there, maybe, just maybe, we can collectively come together to creatively solve this thing.

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