BY HAYWARD ZWERLING
- 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. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.
My Early Career
Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice.
My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.
I then joined Dr. LP’s private medical practice where I learned how to run a private practice. It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.
After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.
Improving Healthcare with Health Information Technology
At that time, early-mid 1990s, I was somewhat of a rarity in the medical community; a practicing physician who created and was using his own electronic health record program. Thus, I began writing articles about health information technology for the throw-away journals, blogging, giving lectures locally and nationally, and I became involved with the Massachusetts Medical Society. My intent was to improve our healthcare system though the implement of appropriate health information technology.
Because I was able to tailor ComChart EMR to my practices’ every need, my practice became extremely efficient and this was documented by innumerable patient comments I received over the years. Subsequently my local hospital put a newly employed and recently trained endocrinologist (Dr. MA) into my practice.
The Medical Practice Environment Changes
In 2017 it became clear that my healthcare environment had changed and if I wanted to continue to see patients, I would need to become an employed physician in the hospital’s newly created diabetes and endocrine center. As part of my contract negotiations, my local hospital agreed to allow me and Dr. MA to continue to use ComChart EMR even though they intended to have the other two physicians and two nurse practitioners in the diabetes and endocrine center use Cerner.
While working side by side with the other healthcare providers it rapidly became apparent that ComChart EMR allowed me to deliver healthcare far more efficiently and effectively than would have been possible using Cerner. Nevertheless the institutional bureaucrats eventually insisted that Dr. MA switch from ComChart to Cerner.
During my contract negotiations, the institution had promised me that the physicians that we would be allowed to run the newly created diabetes and endocrine center as they saw fit because “Its your office.” But that is not what happened. The hospital hired an office manager who answered to the hospital bureaucrats, and despite repeated complaints from the practicing physicians, the hospital bureaucrats continued to enforce their mandates because “we know what we’re doing.” They didn’t and we, the physicians, were not happy.
When my institution replaced Cerner with Epic I chose to switch from ComChart to Epic because, as an IT geek, I was interested to learn Epic and I knew it would make it easier for the physician who would eventually replace me.
Epic was a very well designed and comprehensive electronic health record (EHR) program but it had a steep learning curve. While Epic had many of ComChart’s features that were absent from Cerner, Epic lacked some of features that should have been present. I attempted to convey this information to Epic IT people, without much success. I was also pleased to discover that Epic shared the same design philosophy as I used in designing ComChart, which was to bring the relevant information to the physician at the point of care.
Roadblocks by Institutional Bureaucrats
Unfortunately, the transition to Epic was not well thought-out by the institutional bureaucrats. For example, when I called Epic technical support, I got a non-technical person who took my information and would pass it on to the Epic support team. There was no realtime technical support. Imagine a pilot has a problem, he/she calls the control tower who calls Boeing tech support, who then says “we will get back to you in a day or two.”
Having run an EHR company and practiced medicine, I know what is needed for EHR technical support. Epic’s technical support system was seriously deficient, interfered with my ability to deliver care to my patients, and needlessly made the practice environment more stressful.
Despite many meetings in which we discuss ways to improve the practice, the institutional bureaucrats remained intransigent; nothing significant ever changed. With time the physicians became increasingly unhappy, stressed, and hopeless.
By the time I decided to retire from the career I loved, three of five physicians had resigned from my clinic. I believe they left because they realized that the institution would never allow them to fix the daily deficiencies which made it difficult for them to provide care to their patients.
In my last few months as an employed physician I sent innumerable emails to the hospital president and other senior hospital bureaucrats explaining that they had built a medical practice in which it was impossible for me to take care of my patients. I pointed out that 60% of their professional staff had already resigned. 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 hospital bureaucrats about the dire nature of the clinic, 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.
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 it was just part of my job.
It is Time to Make a Change
Ultimately, my frustration culminated in a regrettably loud and angry encounter with my associate, Dr. MA, who was technically the physician who ran the clinic. In reality, he did not run the practice; the office was run buy the bureaucrats who made all the decisions. It was most unprofessional on my part but I was at my wit’s end. I subsequently apologized to Dr. MA. This encounter was probably the precipitating event that ultimately pushed me into considering that it was time for me to make a change.
Soon thereafter, while standing at the top of a spectacularly beautiful mountain pass in Alaska I had a moment of cognitive clarity. When I returned to my tent that night 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].
It has been five months since I saw my last patient and I now believe I can look back on the 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.
To this day I have not regretted my decision to retire from medicine even though I still believe that being a physician is among the greatest privileges in the world.
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 furious at the Massachusetts Medical Society and the American Medical Association for having allowed this to happen. I tried to warn both organizations of what was happening to our healthcare system – but to no avail. Long ago they should have taken a stand against corporate medicine and rallied US physicians against meaningful use, formularies, prior authorizations, insurance company mandates, and all the other daily insults which slowly whittled away the authority and hindered a physician’s ability to take care of their patients.
We now have a healthcare system in which the physicians are vendors; a healthcare system run by corporations whose primary responsibility is to their shareholders and to the bottomline. Quality healthcare is no longer the primary objective. 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 objectively that the US healthcare system’s quality is inferior, our costs are much higher, and patient satisfaction is lower than comparable industrialized countries – but that is beyond the scope of this essay.
A few years ago I was talking to the CMO of one of the big, three health insurance companies in Massachusetts. He candidly said to me: “Our healthcare system is not working. We need single payer even though that would put me out of a job.”
I am so tired of listening to the apologist for our healthcare system. I do not want to again hear that “capitalism” will solve our healthcare problems. Capitalism IS the cause of our healthcare problems. It as been the cause for the last five decades and it will continue to progressively convert more of our healthcare system from providing healthcare to enriching corporate America. If we continue to bang our head against this same wall then we assuredly will continue to complain about the same pains. Other countries have demonstrated how to implement a better healthcare system – none of them use a predominately capitalistic model. (Try asking ChatGPT, Bard, or Google: Which 10 healthcare systems provide the best quality and lowest cost. The US will not be on any list.)
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 feel 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 my recent experiences with the US healthcare system and my need to protect myself from incurring additional “moral injury.”
I have accumulated a wealth of experience and knowledge 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 our fight to build the healthcare system Americans need and deserve.
26 May 2023
Addendum: For physicians who want to learn more about moral injury, I refer you to FixMoralInjury.org.