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Join Wendy Dean, a psychiatrist with expertise in physician well-being and the intersection of medicine and corporate interests. Wendy shares insights into the challenges physicians face when their values clash with the corporate direction of health care institutions. We explore the erosion of traditional medical ethics, the impact of corporate ownership on patient care, and the phenomenon of “moral injury” among health care professionals. Through personal anecdotes and professional analysis, Wendy offers strategies for preserving the sanctity of the doctor-patient relationship in an increasingly corporatized health care landscape.

Wendy Dean is a psychiatrist.

She discusses the KevinMD article, “From compassionate care to corporate medicine: Physicians speak out.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Wendy Dean. She is a psychiatrist, and today we’re going to talk about the KevinMD article “From compassionate care to corporate medicine: Physicians speak out.” Wendy, welcome to the show.

Wendy Dean: Thanks so much for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Wendy Dean: Oh, so my journey is very eccentric and a winding path. I left medical school and went into surgery, decided that I needed to find another way to practice medicine, ended up in psychiatry eventually, and then left psychiatry because I couldn’t practice medicine the way I expected that I would be able to.

And eventually ended up going full-time into addressing clinician distress, because I saw clinicians across the country who were struggling with many of the same things that I had struggled with in my own career. But I thought I was alone in that, and as I talked to more clinicians I realized we aren’t alone, we just are having a hard time talking about it with the language.

Kevin Pho: So together with your colleague Simon Talbot, the term moral injury, you’ve kind of popularized that. I think that whenever we hear that term of moral injury in health care, I always think back to you and all the writing that you’ve done on it. So talk more about that connection, what moral injury is, and how you see it in health care today.

Wendy Dean: Yeah. So moral injury is really that sense of, we made a promise, we made a commitment and a covenant with society that we would care for patients, putting their needs first, without self-interest.

And yet, when we get out into practice, especially if we’re in an employed practice, we have competing allegiances. We have this promise that we made to our patients, and yet we also have to be loyal to our organizations, we owe them some sort of obligation. And how do you parse that when corporate interests may be for-profit rather than patient care?

When we don’t have an open conversation about how to align those two different goals, then we end up with a clinician themselves having to make that decision. And it becomes a very fraught decision and conversation between our competing interests. So that’s really where moral injury comes in.

And what we found is that clinicians have had this experience but haven’t had the language for it. And also, by the way, folks outside of medicine also are having a similar struggle. And so when you give people the accurate language to describe their experience, it’s easier to not only understand it, put it outside of yourself, and relieve yourself of that self-blame, but you can also start thinking about more accurate and effective solutions to that challenge.

Kevin Pho: So moral injury in health care is now in the common vernacular. You said that now we have the language to express that tension a lot of physicians feel over the last few years or so. What are some specific ways having that language has moved the needle?

Wendy Dean: Well, I think the first way it’s moved the needle is, people no longer feel alone. They’ve been feeling this, but having a sense of shame or guilt about it. And once, I, as a psychiatrist, talked with Simon, who’s a plastic surgeon, years ago, and we both realized we had the same experience of medicine, that relieved a lot of our guilt about the fact that we just weren’t enough, we couldn’t fix this. So that’s the first way that it’s made a difference.

The second way is to reframe the challenge that we’re facing, to say, yes, we have this demand resource mismatch of burnout, but we also have the relational ruptures, the betrayal, that comes with moral injury. So how do we address both of those separately? They require different interventions.

We have not yet moved in a large scale way to addressing the relational ruptures, but really the phrase has only been in the health care lexicon for about five years, so we’re still on the very early end of the journey. But I do think that it will allow us to start talking about, how do we realign values, how do we make sure that we’re taking care of clinicians and honoring that covenant they made with society to care for patients to the best of their ability?

Kevin Pho: So you mentioned that tension that physicians have, especially in corporate medicine, and you and your co-authors wrote about that in your KevinMD article, “From compassionate care to corporate medicine,” your co-authors being Jason Liebowitz and Kenneth Prager. Tell us more about this article, for those who didn’t get a chance to read it on KevinMD.

Wendy Dean: This came out of some really deeply felt sadness about the evolution of medicine over the past, actually, half century.

So Jason made the dark future legible in describing his own experience of coming out as a fairly recent graduate, not super recent, but in the last decade, and what his experience was in finding his dream practice, that was then bought by private equity and transformed significantly.

Ken Prager described his experience and some of the sorrow that he feels in watching his younger colleagues practice in a way that’s very different from how he has been allowed to practice.

And then I went through some of the explanation for how that’s happened and why it’s happened and what we can do about it.

Kevin Pho: So I know Ken and Jason aren’t here, but just for my audience to feel what they were experiencing, maybe just give some anecdotes about what they shared in the article.

Wendy Dean: Yeah. So Jason said that when he joined his practice right out of residency, he’s a rheumatologist, and when he joined his practice he was practicing exactly how he expected to. He could take care of his complex patients, he had some flexibility in his schedule and some autonomy in how he practiced.

And when his practice was bought by private equity, not only did he experience a significant pay cut, but he also experienced a drastic change in the productivity pressures that he was expected to practice under. And he also had a non-compete clause that would have required him to move outside of, you know, 100 miles away from where he was living then, in order to continue practicing.

He felt constrained in every way, and he felt his attention pulled from what he should be devoting to good patient care, to worrying about, can I pay for my child’s child care? Where am I going to have to move, can I sell my house if I need to leave this practice if it’s untenable and I feel like I’m compromising my moral obligations?

And Ken Prager said he has the luxury of taking as much time as he needs with patients because of his long tenure at the organization, but that he watches his younger colleagues struggle with much the same thing that Jason has struggled with.

And so it’s a longing for us to return to this deep connection and reverence for the patient physician relationship, which I know many other clinicians experience as well. Nurses experience it, physical therapists I’ve talked to experience it, social workers, nurse practitioners, physician assistants, they all experience the same sort of tension.

Kevin Pho: So what are the options that they can do in these situations? Jason, being a younger physician, and perhaps after being bought by private equity, changed his practice to something that he may not have envisioned. And with Ken, to deal with these corporate and business aspects of health care, what options are available to these physicians to navigate that tension?

Wendy Dean: So I think, unfortunately for Jason, he wasn’t a partner, so he didn’t have a choice in whether or not his practice was bought. What he’s doing is trying to educate his fellow physicians on the perils of selling out to private equity, of being part of a private equity practice.

Ken Prager is also doing what he can. He has less to lose, and so he’s more willing to speak out and be a louder voice.

And I think those are the things that we need to start doing at the very beginning. And in fact, the FTC right now has a call for public comment, a request for information about the impact of corporate greed in health care. And anyone can make a comment, whether you’re an administrator, a physician, a nurse, or a patient. The FTC wants to know what your experience has been with corporatized health care. It’s a great way to get our voices heard.

Kevin Pho: So short of those advocacy measures, a lot of physicians, like you said, feel that tension. And through your work with moral injury, what are some things that they could do within themselves to help navigate that tension? And I know the advocacy is so important, speaking out and telling these stories on podcasts and on social media is important, that people know about it. But for physicians themselves who are caught in that position, is there anything that they can do while they’re still in a job?

Wendy Dean: Yeah. So I think everyone wants to know how we can fix ourselves, because that gives us a sense of control.

Our feeling at Moral Injury of Healthcare, though, is that moral injury is by definition a relational rupture, it is a fraying of our community, and it’s going to be very difficult to repair that in a one-on-one situation or individually.

So the first place to start is, this isn’t about you. This is about the system in which you’re working, where you’re working, how you’re being asked to work. So relieving yourself of that blame is the first place to start.

But then this is really about recommitting to the culture and the profession of medicine. This is about fighting for what we promised we would practice, how we promised we would practice. It’s about finding like minds, coalitions, finding ways to speak out that are safe. Maybe you do that in numbers, maybe you advocate with your society to speak on your behalf.

But in order to reestablish and repair that sense of community and those relational ruptures, we really need to do that as a group and as a whole, not one by one.

Kevin Pho: Is there anything that we could do from a training standpoint? Because a lot of younger physicians, as you said, may not be expecting the corporatization of health care. Do they get any exposure to some of these business aspects during the training phase?

Wendy Dean: Less so than you would hope. And I do think that that is one of the primary ways that we should be preparing our young colleagues to come out into this environment.

When we think that we’re protecting them, we in fact may be betraying them, because we’re not preparing them for the environment that they’ll practice in. So the first thing we need to do is to teach them about these business aspects.

The other thing that we can do is to give them a solid ethical framework in which to place the challenges that they’ll face. If they have had practice at thinking through some of these ethical challenges, not just a patient that’s difficult, but how do you face these tensions between the business side of health care and the clinical side of health care?

If we can do that for them, and give them the framework in which to talk about and make these decisions, and help them understand the moral framework as well, what their individual moral values are, their professional obligations and societal promises, I think we’ll do a much better job at preparing them to go into the workplace they’re going to be facing.

Kevin Pho: Talk about private equity in general. More private equity is buying up physician practices. I read they’re buying up emergency department practices, radiology practices, dermatology practices. Go into more detail in terms of how that really amps up that tension between patient care and the numbers and revenue generation, and the position it places physicians in. Talk more about that.

Wendy Dean: Yeah. So I think this is a whole dissertation, and there are lots of books out there right now that would explain it better than I can in three minutes.

But the bottom line is that private equity companies are in health care because they see it as a deep well of income. And private equity companies only buy something that they think they can turn quickly, within three to five years, and make a substantial profit, usually 30 percent or more.

So just know that if private equity is sniffing around your practice, it’s because they think they can make money at it. And they will do whatever it takes to make that return, because that’s their obligation to their investors.

Kevin Pho: In terms of speaking out, is there any risk to voicing physician dissent against corporations who may own their practices? I know a lot of physicians are a little hesitant to do so. Are there any risks to do so?

Wendy Dean: There are for sure risks, and this is part of the challenge of being employed by a corporation. You then become a part of that corporate machine, which often requires loyalty to the organization.

If you speak out, make sure you know what you are allowed to say, how you can say it safely. I also recommend that people don’t ever do it alone, that they do it in groups. So find your coalition.

There have been physicians, it was in the news during COVID, who lost their jobs for speaking up, and I don’t underestimate the risk of that. And neither does the FTC. So the FTC allows people to comment anonymously, because they know the tremendous risk. But there are also organizations like ours, like Moral Injury of Healthcare, that are willing to speak on physicians’ behalf if they don’t feel safe speaking themselves.

Kevin Pho: We’re talking to Wendy Dean. She’s a psychiatrist, and today’s KevinMD article is “From compassionate care to corporate medicine: Physicians speak out.” Wendy, let’s just approach it from a different way. Tell us a success story, perhaps from your work with moral injury, or something that you’ve heard in terms of physicians speaking out and moving that needle in favor of them. So maybe we can end with something more uplifting. Give us a success story about how you’ve moved the needle, or how we’ve moved the needle.

Wendy Dean: So in my book, in one of the chapters, I talk about an emergency room physician, Ray Brovont, who worked for a private equity backed physician staffing organization that staffed the emergency room in a Missouri hospital.

And he disagreed with their staffing plan. He spoke up about it for three years, and was concerned about patient safety. In fact, a patient died. He got louder, and he was fired.

In response, he sued them. He sued his employers for wrongful termination. And after a four-year legal battle, he won. And on appeal, he won again.

So what that says to me is, we know the right thing to do. If we know how to document, and we know the tactics that we need to use in order to fight back, it’s possible that we will win, even David against Goliath.

Kevin Pho: And my final question, Wendy, just leave us with some take-home messages that you want to leave with the KevinMD audience.

Wendy Dean: This isn’t about you. This is about where and how you’re asked to work. And there are plenty of other people out there who are struggling with the same thing. So find them and build a coalition, so you can speak up in safety.

Kevin Pho: Wendy, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Wendy Dean: It’s been my pleasure. Thank you.