I retired early from the profession I loved because the devolution of the health care system had made it impossible for me to care for my patients in a manner that met my standards. It also left me with a wound of “moral injury” which makes me leery of re-engaging with our health care 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 or interesting.
I subsequently joined Dr. LP’s private practice, where I learned how to run a private practice and began building an electronic medical record program, ComChart EMR, which would become an important tool in my office and a small commercial success that connected me with physicians across the country.
A few years later, I decided to build my own private endocrine-internal medicine practice.
Improving health care with health information technology
In the early-mid-1990s, I was curious about 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 working with the Massachusetts Medical Society with the hope of improving health care through health IT.
As I customized ComChart EMR, my practice became exceptionally efficient, and in the mid-late 2000s, my local hospital put a newly employed and recently trained endocrinologist (Dr. MA) into my practice.
The medical practice environment changes
In 2017, my health care environment shifted, indicating a need to become an employed physician at the hospital’s new diabetes and endocrine center. As part of the contract, the hospital permitted Dr. MA and me to continue using ComChart EMR, even though the physicians would have to use Cerner. The hospital also promised to allow the physicians 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’s entreaties to fix the clinic’s deficiencies and inefficiencies.
Despite it being obvious that ComChart EMR was a far more efficient EHR than 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 (i.e., bring the relevant information to the physician at the point of care), Epic had a steep learning curve, and it lacked some of ComChart’s features.
Roadblocks by institutional bureaucrats
The transition to Epic was poorly executed. The training was abysmal, and when I needed technical support, I was only able to contact a non-technical person who took the 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 of 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 of 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 and the resultant high level of stress, three of five endocrinologists 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.
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 health care system) but felt I should soldier on.
It is time to make a change.
Ultimately, my frustration culminated in a regrettably angry interaction with my associate, Dr. MA, who was the physician who was technically in charge of the clinic. In reality, the office was run by the institutional bureaucrats through their office manager, 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.
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.
When I returned to my tent that night, I wrote an email to the hospital president, which included the following:
“I am retiring two years prematurely because institutional constraints at [the facility] have 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 three other physicians and one NP have already resigned from [the facility].”
It has now been five months since I saw my last patient, and I believe I can begin to back at 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 health care 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 U.S. health care system.
I am also disappointed that the Massachusetts Medical Society and the American Medical Association have allowed OUR health care system to be taken over by the CHIPHIT complex. Long ago, the warning signs were clear that they should have taken a stand against corporate medicine and rallied U.S. 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 health care 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 U.S. health care system is not working and innumerable academic studies have demonstrated that the U.S. health care 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.
Even the CMO of one of the major health insurance companies in Massachusetts confessed to me: “Our health care 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 health care system. For decades, capitalism has serially transformed our health care system into today’s mess. Other nations have shown us how to design a less costly, higher quality health care system; capitalism is not the answer.
Now that I am fully retired, my wife has commented 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 being discussed were going to fix our dysfunctional health care 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 need 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 health care system. I hope my wounds heal quickly so I can assist them in the fight to build a better health care system for all Americans.
Hayward Zwerling is an endocrinologist who blogs at I Have an Idea.
