Moral Injury: A Physician’s Premature Retirement

Synopsis:

  • After a 3 decade career in a solo private practice the healthcare environment shifted
  • As an employed physician, my institution’s policies hindered my ability to care for my patients
  • The consequent moral injury left me unwilling to re-engage with the healthcare industry

I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. It left me with a wound of “moral injury” which makes me leery of re-engaging with our healthcare system.

My Early Career

My first post-training job (1989) as a physician was in a BCBS clinic. After two years it became clear that taking care of young, healthy patients was not much fun nor interesting.

I then joined Dr. LP’s private practice where I learned how to run a private practice and began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, a hobby that earned me some money, important tool in my office, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.

After a few years, I decided to build my own private endocrine-internal medicine practice.

Improving Healthcare with Health Information Technology

In the early-mid-1990s I was curiosity in medicine; a physician in private practice who created his own electronic health record (EHR) program. Thus, I began writing about health information technology, lecturing, and became involved with the Massachusetts Medical Society in my attempt to improve our healthcare system though the implement of appropriate health information technology.

As I customized ComChart EMR, my practice became exceptionally efficient and my local hospital put a newly employed and recently trained endocrinologist (Dr. MA) into my practice.

The Medical Practice Environment Changes

In 2017, my healthcare environment shifted and I needed to become an employed physician at my hospital’s new diabetes and endocrine center. The hospital agreed to allow Dr. MA and me to continue using ComChart EMR, even though the other physicians would have to use Cerner. The hospital reassured me that the physicians would be allowed to run the newly created diabetes and endocrine center because “It’s your office.”

That is not what happened.

The institution installed an office manager who was a direct report to an institution bureaucrat and they repeatedly ignored the physician entreaties to fix the clinic’s deficiencies and inefficiencies.

Despite it being obvious that ComChart EMR was a far more efficient EHR vs Cerner, the institution eventually forced Dr. MA to switch to Cerner.

When the institution switched from Cerner to Epic, I too transitioned to Epic as I was interested to learn the leading EHR and it would make it easier for the physician who would replace me when I retired.

While Epic is a very well designed and comprehensive EHR, and it shares ComChart’s design philosophy (bring the relevant information to the physician at the point of care,) Epic had a steep learning curve and lacked some of ComChart’s features.

Roadblocks by Institutional Bureaucrats

The transition to Epic was poorly executed. Training was abysmal and when I needed technical support, I could only contact a non-technical person who took my information and passed it on to the real technical support team. This inability to solve an IT problem at the point of care significantly disrupted my ability to take care for my patients and heightened the stress level in an already stressful practice. Eventually I, and many others, stopped wasting our time calling tech support.

The Epic IT group also refused to add many of the features which I told them would improve my (and others) ability to take care their patients. I explained that I created an extremely highly rated EHR and I knew what physicians needed, but they thought they were the “experts.”

Given our inability to fix our practice environment three of five endocrinologist in the clinic resigned.

When I confronted an administrator about the clinic’s serious deficiencies, their response was, again, “we’ve got this under control” or “we’ll talk about this in the future.”

When I complained to one of the institutional bureaucrats about the dire situation, they responded “Are you accusing me of being incompetent?” I replied that they were as competent as I would be if I were the institution’s senior attorney or CFO. *See addendum

Toward the end of my medical career, my wife made it clear that she thought I was under too much stress and was very unhappy. I attributed this to “physician burnout” (practice environment, Covid, new EHR, abysmally designed healthcare system) but felt I must soldier on.

It is Time to Make a Change

Ultimately, my frustration culminated in a regrettably angry interaction with my associate, Dr. MA, the physician who technically was in charge of the clinic. In reality all the important decisions were made by the institutional bureaucrats and implemented by their office manager. It was most unprofessional on my part but I was at my wit’s end. I subsequently apologized to Dr. MA. 

In hindsight, this encounter was probably the precipitating event that pushed me to consider accelerating my retirement plans.

Soon thereafter, while standing at the top of a spectacularly beautiful mountain pass in Alaska, I had a moment of cognitive clarity and when I returned to my tent that evening I wrote an email to the hospital president which included the following:

I am retiring 2 years prematurely because institutional constraints at [the facility] has made it impossible for me to provide care to my patients in a manner that meets my professional standards while simultaneously inducing an unacceptable level of stress which occurs when I am unable to meet my own standards. I believe it is for similar reasons that 3 other physicians and one NP have already resigned from [the facility]. 

Now that it has been five months since I saw my last patient and I believe I can begin to assess these events with a bit more objectivity.

The Hurt and Consequences of Moral Injury

Recently two physicians told me about “moral injury.”

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury… The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient… Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. 

I now understand that the reason I retired two years prematurely was an attempt to protect myself from additional moral injury.

I remain furious that our healthcare system is not what it should be. I am mad at the CHIPHIT complex, (the Consolidated Healthcare institutions, the Insurance companies, the Pharmaceutical companies, the Health Information Technology companies) and the Federal Government, who were all complicit in creating the current  version of the US healthcare system.

I am also disappointed that the Massachusetts Medical Society and the American Medical Association have allowed our healthcare system to be taken over by the CHIPHIT complex. Long ago the warning signs were clear that they needed to take a stand against corporate medicine and they should have rallied US physicians against meaningful use, formularies, prior authorizations, insurance company mandates, and all the other daily impediments which hinder a physician’s ability to take care of their patients. 

Our healthcare system now treats physicians as vendors while corporations prioritize profits over quality care. And the situation is about to get much worse as venture capital firms are buying up lucrative medical practices.

The vast majority of physicians, PAs, NPs, nurses, pharmacists and patients would agree that the US healthcare system is not working the way it should. I could cite innumerable academic studies showing that the US healthcare system’s quality is inferior, our costs are higher, and patient satisfaction is lower than comparable industrialized countries – but that is beyond the scope of this essay.

A few years ago the CMO of a one of the major health insurance company in Massachusetts confessed to me: “Our healthcare system isn’t working. We need single-payer, even though it would cost me my job.”

I am also weary of listening to some espouse the benefits of a more capitalistic healthcare system. For decades, capitalism had serially transforming our healthcare system into today’s mess. Other nations have shown us how to design a less costly, higher quality healthcare system; capitalism is not the answer.

Life after Practice

Now that I am retired, my wife has commented many times that I am less stressed and happier.

And I am glad I retired when I did.

A few weeks ago I attended my second MIT Grand Medical Hackathon. I reluctantly left the conference early because I did not believe that the problems discussed were going to fix our dysfunctional healthcare system. In hindsight, I wonder if my decision to leave the conference prematurely (I was/am very ambivalent about my decision to leave) was partly a result of an attempt to protect myself from incurring additional “moral injury.”

I have accumulated a wealth of experience which would be helpful to those who are trying to fix our healthcare system. I hope my wounds heal quickly so I can return to assist them in building the healthcare system Americans need and deserve.

Hayward Zwerling, M.D.

26 May 2023

Note: For physicians who want to learn more about moral injury, I refer you to FixMoralInjury.org.

 

*Addendum 6/26/2023

When I was wrestling with bureaucratic intransigence, I told more than one bureaucrat that my professional priorities are, in order of importance:

  1. My patients 
  2. My professional responsibilities to my profession and colleagues, regardless of institutional affiliation.
  3. My institution

It is my opinion that many of the next generation of US physicians have not adopted the same prioritization of professional responsibilities which I held sacrosanct and institutions are indeed looking to hire the more “compliant” physicians.

 

Addendum 5/28 & 29/2023: Minor editorial revisions for brevity.

 

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