An excerpt from If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First.

In late March 2021, during a lull between the third and fourth waves of the coronavirus pandemic, I drove to the small town three hours west of the Mississippi River where a physician I’ll call Rita Gallardo lives. Three hundred miles from the center of the contiguous United States, I was in the middle of the country, in every way. I turned off the dirt county highway at a big red mailbox that marked her lane and drove up a sheltered lane that gave way at the top to a sunny, gravel driveway bounded on three sides by the house and pasture fence. I parked under an ancient apple tree in full bloom, facing one hundred acres of trails and hunting ground that spilled away behind the house.

Rita grew up in a small town in the northwest. She went to medical school on a military scholarship and deployed to the Middle East during the early years of the War on Terror. She witnessed the toll of combat in the shattered bodies of young service members. Confined to a military base ringed by Hesco barriers and razor wire, her only escape from those horrors was dreaming of the life she might build later, when she could put this all behind her. She imagined a husband equally enamored of country living, a sprawling farm where she could indulge her love of animals and her children could roam free, and a small-town medical practice caring for patients as she would care for her own family.

That dream was her touchstone and it soon came to life with a husband, three children, and a practice in her husband’s small Midwest hometown.

Before taking the job, Rita spent months painting a picture for the administrators of the comprehensive oncology care clinic she envisioned, with nurses to give infusions, a specialty pharmacist, and a social worker dedicated to helping patients manage the psychosocial and financial aspects of their diagnosis. During those conversations, the administrators seemed excited about her vision for oncology care, but once she arrived, something seemed off. Just after her fourth work anniversary, the new clinic she had spearheaded opened with a full complement of staff: half a dozen nurses giving infusions, a specialty pharmacist, and a social worker. Her vision of creating a cancer clinic in the local community, so patients could get big-city care without the drive, was thriving.

But her relationship with the hospital was fraying. At her quarterly performance review, the administrator who was her supervisor reviewed her patient satisfaction scores (excellent), her outcomes (good), and her productivity measures (could be better). Then he raised the topic that seemed to be his sole focus these days.

“Dr. Gallardo, I’m concerned about your pattern of referrals. You’ve sent more patients outside the network than any of our other oncologists.”

Rita squared her shoulders and took a slow breath. In a measured tone, she responded, “I’m doing the very best I can with what we have, but I am not interested in any tips about changes that wouldn’t help my patients and would only help your bottom line.”

The administrator stared, his jaw slack, as Rita stood up and left the room. Walking down the hall and around the corner, she stepped out the back door and a blast of steamy late-summer air took her right back to the desert, where she had been the expert. There, the strength of the fighting force was at risk and her word had been law. She would have given almost anything to have a fraction of that autonomy now. To keep this job, she would have to comply with the administration’s expectations about productivity and referrals, but doing so would require surrendering her integrity

Leaving work that day, Rita realized her conflict with the hospital was bigger than the EMR. Since the late 1980s, hospital corporations and health care systems have been exerting ever more control over how doctors practice. Health care systems use various explanations for why they need so much control — to standardize operations across a huge corporation; to improve care measures — but the common denominator is money.

Rita’s professional development was shaped by the Army’s culture and professionalism, redesigned by tragic lessons from the Vietnam War. That training primed her to recognize conflicts between the bureaucracy of large health care organizations and the profession of medicine.

In the span of five years, she left two jobs when she felt pressured to practice in ways she felt were unethical, for the sake of a company’s profit. Out of options for employment and unwilling to uproot her family, she took an enormous risk and walked away from corporate medicine, striking out on her own and setting up a direct primary care practice. If she had been saddled with education debt, she might not have been able to choose this path.

The practice is both bare-bones and full-service. Rita is on call all day, every day, all year long. She doesn’t miss her fancy office, a big staff, or all the latest diagnostic equipment. Those things were meaningless when she struggled to get her patients the care they deserved, with the specialists she thought were best for their situation. But she’s paid a high personal cost for this freedom. Less than a year after I visited the farm of Rita’s desert dreams, she and Rudy decided to sell it when, too often, they found themselves scrambling to pay the mortgage. They downsized to a smaller farm with one-tenth the land and hope that sometime in the future, they can revisit the bigger dream.

Rita found a sliver of hope in direct primary care. It’s too soon to know whether she can really declare victory, but for now, she’s healing from her moral injury by healing her community according to the values she’s long lived by.

Wendy Dean is a psychiatrist. Simon G. Talbot is a plastic surgeon. They are the authors of If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First.