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First used in the context of Vietnam War veterans, the term "moral injury" refers to the psychosocial, behavioral, and spiritual distress that comes from perpetuating or witnessing events that contradict one's deeply held moral beliefs. In recent years, moral injury has increasingly been used to describe one of the main challenges clinicians face in modern medicine -- the challenge of knowing what care patients need but being unable to provide it due to constraints beyond the clinician's control, such as limited time or misaligned financial structures. Even more than emotional exhaustion and detachment, moral injury leads to profound shame and guilt.
One of the leading voices addressing moral injury among healthcare workers is Wendy Dean, MD, a psychiatrist who has written widely on the issue, most recently in her book, If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First.
In this episode, Dean tells Henry Bair and Tyler Johnson, MD, about her own winding journey from orthopedic surgery to general surgery and finally to psychiatry, discusses where moral injury comes from and what it looks like, and explores what clinicians can do to address it.
In this episode, you will hear about:
- 2:35 Dean's early interest and winding path in medicine
- 5:12 How Dean's desire to become a surgeon was deterred by gender discrimination
- 13:22 What led Dean to psychiatry, and then eventually out of clinical medicine entirely
- 18:03 A discussion of what moral injury is and why Dean began to study it
- 24:19 Examples of how moral injuries occur in the day-to-day of medical practice
- 38:57 How physicians and hospital administrators can address moral injury, citing, as an example, the case of Raymond Brovont, MD
- 42:22 Dean's advice on how to navigate and push back against seemingly insurmountable bureaucracy
- 47:39 Moral Injury in Healthcare, the nonprofit Dean founded
- 53:04 What setting personal and professional boundaries looks like in medicine
- 57:37 Dean's advice to students and clinicians about fighting burnout
The following is a partial transcript (note errors are possible):
Johnson: Well, we're so glad to welcome you, Dr. Dean, to the program this morning. And we really appreciate the insights that you're going to offer and the kind of moral mission that you're on, which we'll talk a little bit more about. So thank you for being here with us.
Dean: Well, thank you so much. And Wendy is fine.
Johnson: Okay. We'll go with Wendy from here on out. So, Wendy, could you first start off by telling us, how did you end up in medicine? What's your origin story or superhero story?
Dean: Okay. It's not a superhero story for sure. I never had ambitions other than medicine. Which is really odd because I come from a family that doesn't have any medical background. My family is littered with plumbers and salesmen and no one in medicine. And apparently I told my parents when I was in, I was about 8 years old, that I wanted to be a doctor and my dad nearly drove off the road.
Johnson: And here you are.
Dean: And here I am. Yeah.
Bair: Yeah. May I ask why it was that your father reacted the way he did?
Dean: You know, that's a great question. I never asked him. I think it was just so outside of his interest or experience. And for a kid of 8 years old to to say so plainly, this is where I'm going, I think was just, was a surprise to him. I was also really into horses, so I think he expected me to say, I want to go to the Olympics or I want to be a vet or whatever. But no.
Johnson: So, okay, so you have the ambition from the time that you're really small. Tell us, though, then, the story of how did that ambition get translated into reality? So where, you know, how when you were in college, did you just, was it really just a straight shot? You came in as a freshman in college and knew you wanted to be a doctor and then that's what you do when you were graduating and you just went all the way on through?
Dean: That is exactly what happened. From the time I was in high school, that was my goal. And so my nose was to the grindstone. I was pushing it the whole time. I was the kid who was doing internships when I was in college with pediatricians and orthopedists. I was volunteering in hospitals. I was working in pathology labs during the summer of college. All the things. I did all the things. I was, I worked for the athletic trainer in college. I worked for an ob/gyn in town, like, I did all the things.
Bair: Yeah, you were like creating your own clerkships. It's like all those specialties. It's pretty impressive. Like, medical students don't even get to do pathology. So you found your way there, too?
Dean: It was great. I mean, it was a histopathology lab, so I got to learn how to cut slides and how to stain them. And so I came in like knowing those special stainings and what it entailed. And how come it took 2 weeks?
Johnson: Well, okay, so, as those who are, you know, at least partway through their medical training know, you can kind of, if you decide I want to be a doctor, you can kind of ride the train up through medical school, right? Then you get to your third year or whatever, you know, depending on where you are, but your year of core clerkships, you try a little bit of everything. In your case, I guess you started that during college, but whatever. Now it comes time to do residency and/or fellowship, whatever your advanced training. Tell us a little bit about how you thought about -- so you're in medical school, how did you think about what you wanted to specialize in and then what did your post-graduate training look like?
Dean: Okay, so, this is where people may not want to follow my path.
Johnson: That's okay.
Dean: Yeah. So I went into medical school intent on being an orthopedist, and I was in medical school in the late 80s, early 90s. That was a rough choice for a woman then, right? It's still not an easy path for a woman now, but it's way easier than it was. I ended up realizing that that was probably not going to be the fight I wanted to fight for my entire life. So I ended up in general surgery with the intent to go into plastic surgery.
And the more I looked at an 8-year training path -- because there were very few 3+3 programs at the time, so I would have to be a general surgeon and then go into plastics -- and then what my life would look like once I got out, I realized all these other things that I'd like to do in my life would fall by the wayside. But I tried it anyway.
And 3 years into my general surgery residency, I realized I can't tolerate having so little control over my life. Because if someone doesn't turn your OR room on time, you're stuck there until 9:00 at night and you don't have control over that. So I ended up leaving surgery, as much as I loved it, as much as I still do to this day, decades later, miss it. I left and I went and worked in emergency rooms for a couple of years, thinking that I was going to leave medicine entirely and eventually decided that that probably wasn't the best path. So I went back and did a psychiatry residency because the patients who came into the ER who were psychiatry patients were sort of, I didn't think I'd ever get bored. And that's kind of my kryptonite.
For the full transcript, visit The Doctor's Art.
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