Exposing Moral Injury with Wendy Dean, MD
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What is moral injury in healthcare and how does it differ from burnout?
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This is The Nocturnist Conversations. I'm Emily Silverman. What happens when doing the right thing in medicine becomes impossible? When it's not the science, but the system itself that stands between a doctor and her patient's well-being. My guest today is Dr. Wendy Dean, a psychiatrist, writer, and co-founder of the nonprofit Moral Injury of Healthcare. The beginnings of her groundbreaking work came not in the clinic or in the boardroom, but in her own garden, hands in the soil, when she first connected the struggles that she and her colleagues were facing to the concept of moral injury. In her powerful book, If I Betray These Words, Wendy explores the dissonance that clinicians feel in a healthcare system increasingly driven by profit over people.
We talk about the origins of the term moral injury, how it differs from burnout, and why the very oaths that draw physicians into medicine can, when betrayed, become a source of anguish. In this episode, we'll hear about a doctor who was fired over dinner for refusing to put patient safety at risk, a beloved pediatrician who was sent away for a psychiatric evaluation and never returned, how corporate consolidation is quietly gutting primary care from the inside out, and the brave clinicians fighting back with lawsuits, new care models, and bold acts of defiance. This conversation is heartfelt and unflinching. It'll make you rethink what's broken in healthcare and what it will take to fix it. But before we dive in, take a listen to Wendy reading an excerpt from her book, If I Betray These Words.
Here's Wendy.
The deadline for choosing a title for this book arrived unexpectedly as I was deep into writing chapter six, which is about a doctor who takes his own life. In a flurry of communications with a publisher and editor that grew more frantic by the hour, we tried to distill the essence of the work to a word or two. The collected stories deserved exactly the right title, but despair about a flurry of imperfect ideas melded with the grief I was feeling about the character in chapter six, and I was lost. As I often do when stuck in a morass, I paused and returned to the source document, so to speak, to the oath we take as physicians in its many forms. This oath represents what each of us believes is our duty to society in joining this profession and embarking on a lifetime of tending to strangers in their moments of greatest vulnerability and need.
It is the commitment that calls us to be our best selves. I read the Declaration of Geneva of the World Medical Association, the Oath of the Healer, the American Medical Association Code of Medical Ethics, the Osteopathic Oath, the Maimonides Prayer, and many versions of the Hippocratic Oath. Similar themes ran through them all. Gratitude toward teachers, a commitment to lifelong learning, an obligation to nurture the next generation, selflessness, one's duty to patience above all else, honesty, humility, confidentiality, love. But when I discovered a 2010 translation of the Hippocratic Oath by Amelia Arenas, published in Boston University's journal Orion, I found the titles. This version of the oath echoes the themes of all the rest, but the last lines took my breath away.
I pray that the attention I give to those who put themselves in my hands be rewarded with happiness. And in honor of the knowledge I've received from my teachers, I swear to care for anyone who suffers, prince or slave. If I ever break this oath, let my gods take away my knowledge of this art and my own health. Here speaks a citizen, a servant of people. May I be destroyed if I betray these words. The covenant we make is not simply about how we will do a job. It is also about who we will be when we don the mantle of physician.
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