Original Launch: Feb 2, 2023
See what is happening now at www.healthimpactlive.com
YouTube Video: https://youtu.be/pm0fqWhgOFw
Strikes by healthcare workers worldwide, like the one that just ended in NYC, have nearly doubled in the last two years. Many decry severe staffing shortages drive patient safety fears. A recent NY Times article discussed how Ascension created its staffing mess; it doesn't blame the pandemic or the great resignation but targets leadership for bare-bones staffing. It’s true that pre-pandemic staffing practices, which left organizations badly strained by the virus, are partly responsible for the crisis. But it is as much about what Ed Yong wrote in the Atlantic in 2021, “Healthcare workers aren't quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs.” For too long, employers failed to heed warnings about the dangers of dysfunctional systems. Instead, they relied on frontline staff's altruism, resourcefulness, and patient-first commitment to make those systems work. The pandemic laid bare the inherent betrayal in that approach, needlessly putting staff and patients at risk. Organizations must go beyond offering individual solutions and psychological support to reverse the exodus from healthcare. They must commit to operational transformation focused on facilitating frontline care and repairing the disaffection with their workforce.
Speaker: Wendy Dean, MD, President, and Co-Founder, The Moral Injury of Healthcare
Keynote Burnout Isn’t the Whole Story – And Repair Is About More Than Individual Resilience
Janae Sharp: I am really looking forward, looking forward to asking you all the hard questions. , how about physician mental health? For those of you who are new, I'm Janae Sharp. I'm the founder of the Sharp Index, and I met Wendy Dean several years ago, and I want to talk, about your perspective, because I hear a lot of perspectives about mental health and then if you have anything to share or if we can really break it down to give people something new.
Yeah. That's what, that's what the goal is today, right? So tell me, how did you come to be known as the person who does things with moral injury? And positions.
Wendy Dean: So that, that was, it's a great story. I mean, it's not a great story, but it's because it didn't come out of a good place. But I was, I was working for the US Army as a civilian doing research funding oversight, and just down the hall from where my office was, was the office that was working in neuropsych health, which included their suicide prevention.
Program because that was the time when the d o d had the crisis of deaths by suicide in veterans and active duty. And so they had a hundred million dollars to study the problem, to look at ways to prevent it. Their leadership was alarmed. We shut down the army for an entire day. 3 million people stopped working to figure out to learn what were the symptoms.
That you could pick up in your colleagues and what were your resources if you saw that? What did you do? The entire army shut down and I started looking at the clinicians that I was interacting with across the country doing who had these research funding projects that they were doing, and they were not happy.
These folks on paper were at the tops of their game. They were at prestigious universities. They had CVS a mile long. They had hundreds of publications, and they were struggling. And I started asking them, are you burned out? And almost 2 0 1, it was, it, it got to the point where it was kind of uncanny where they, the wording was almost the same from everyone.
I don't know. That just doesn't sit right with me because I knew what I was signing up for. I knew I was gonna work long hours. I knew I was gonna see impossibly hard things. What I didn't know was how hard it was gonna be for me to get my patients the care they needed. And I started talking to Simon Talbot in particular, and he and I are co-founders and co-partners in his work.
And we realized that he's a plastic surgeon. I'm a psychiatrist, and so, you know, we couldn't. More different in the spectrum of the healthcare, the kind of healthcare we provided, and yet we had the same experience in healthcare and we realized as we, as we shared our own stories, this isn't about us, this isn't that I'm not resilient enough.
This isn't that I am not efficient, that I can't figure out how to do better workarounds. I'm doing all of that. It's that there are barriers I can't get. List because of how healthcare is structured.
Janae Sharp: What are those?
Wendy Dean: I mean, there's a laundry list. Many Are they, there's a laundry list. It's regulation, it's legislation, it's policies in the hospitals.
It's check boxes for reimbursement. It's all of those things. It's prior authorization. So, so all of those things get in the way of getting, getting my patient what I know they need. Right? What's I know is available, but I can't get to it.
Janae Sharp: I do have a question about that because I get to talk to a lot of people and people say things to me that maybe they shouldn't.
You're a polarizing figure. And even the, even the topic, like a lot of people are like, she said it, I, I didn't know how to put it into words. And then other people are like, I don't know about that. It's like a little too much. Why do you think it's so polarized? .
Wendy Dean: So I, I think some people hear me say, think, they hear me say it's not burnout.
Like burnout doesn't exist. It's all moral injury, and I absolutely do not believe that. So I think it's, there is burnout, but that doesn't cover the entire spectrum of distress that people feel. That is, that is the, the sort of resource Ms. . I have too many administrative tasks. I have too many, too much in my inbox.
I have too many calls to make. I have, I'm working too many hours because we're short staffed, right? But then there's this other piece, which is the relational disruption of healthcare where, you know, moral injury. The definition is there are two that are in wide use. One is betrayal by a legitimate authority in a high stake situation.
So when someone says to you, this is how I expect you to provide care, when you know that it's not, that, that isn't what your training dictates because it, it's better for the organization or it's better for them, that's where we get into the challenge of moral injury, right? So I don't think we should stop doing the things that we're doing to try to.
The administrative tasks, the overwork, those kinds of things. But we also need to make sure that we are addressing the relational issues in moral injury.
Janae Sharp: So I have an uncle who is a veteran from Vietnam. When I started hearing about moral injury and ptsd, it was in, in the framework of his experiences in Vietnam, right.
And he had some stories that are horrific. You know, like his leader's doing horrible things. He's like, you could feel it. So, and when we've talked before, it's been with people who are also like experts in P T S D and as you know, working with Veterans Affairs, like there are some really horrible stories.
What is it about healthcare that's different than that and what is it that's similar?
Wendy Dean: So the moral injury that we see in the military, tends to be more often single egregious events in healthcare. I think it's more like the death by a thousand cuts, where it's just every day I go into work and I know that I'm not gonna be able to get my patients the care they need.
That is exhausting, right? So that's one of the differences. I also think. in the military if you, and this kind of means that we need to go back and think about what are, what is our covenant with society as a profession? Mm-hmm. in the military, it's to protect and part of, unfortunately, part of that protection sometimes requires that you go to lengths of lethal.
So there's a, there is inherent in that commitment to joining that profession that you may eventually have to do something morally injurious, right? In healthcare, that isn't our covenant. Our covenant is to heal. And so I sort of think that if we ever have, if the, the flag of moral injury goes up, That's a signal that we should be looking at our systems and saying, what's happening here?
Because this should not be an event in healthcare.
Janae Sharp: Why do you think when, when you say that to people like in healthcare, who gives the most pushback?
Wendy Dean: I think people push back the most when they're not really clear on what it means. Because we've actually, we've done research with a group in the UK.
That shows that even executives experienced moral injury throughout the pandemic. About 40% of executives were experiencing moral injury. And what I've heard repeatedly is people will say, oh, I didn't really understand until you put it into their framework. So, you know, the one, that one definition betrayal by legitimate authority in a high stake situation.
And there's another that. Perpetrating bearing, bearing witness to, or learning about acts that transgress deeply held moral beliefs. And we believe that there's, that they're not two separate definitions, that they're linked, that you experience a betrayal and then you have a moment when you can choose.
And it's not, and I wanna be clear, it's not always a voluntary choice. Sometimes it's a forced choice where you can either stand up, speak out, push back and say, this is not okay. or you can acquiesce to that betrayal and transgress your own moral beliefs and expectations.
Janae Sharp: I like that, that it's not always a choice.
Wendy Dean: It is, it is not. I mean, you know, there are plenty of us who are primary earners, who have huge student debt, who can't practice a specialty anywhere, but where you're practicing, right? You don't have a choice to leave. , but it doesn't mean that you aren't in that moment aware that you could either speak, speak up, but for these constraints, and instead you have to acquiesce.
Janae Sharp: Right. I've, I had a friend once who said that to me in the context of like having kids since you know, the other parent passed away. They're like, do you really have the luxury of morals right now? Mm-hmm. . And I was like, okay, first of all, that was pretty harsh. Yeah. They're a math guy. Right. And I was just like, okay, rude, first of all, and second of all, good point.
Do you get, have you ever told someone that? Like what do you tell physicians?
Wendy Dean: I feel like, , it's always important to empathize with people's position where, where they are and I can't dictate for, my morals are not theirs.
My position is not, is not theirs. So what I feel, it's a very healthy answer. Right?
Janae Sharp: That's a, you can tell, she's like, I'm a psychiatrist. Your feelings matter.
Wendy Dean: I feel like what is important is to help people understand what their options are and to help them understand what's possible. Now, what's possible, in the future.
Janae Sharp: What are the options like for a physician that I could give you a story like? Yeah. I have a friend who called me a few weeks ago and she was having trouble. She had like she was pregnant, she lost the baby. She almost died. She's a physician. She's having difficulty with the, going back to work because she had to take leave for depression.
And the weight of all of it was so, so heavy. But also what do you, what do you tell people on that individual level? Like what are the possibilities that people, do you think they see them or don't see them like, or, you know? So first, I think that's a slightly different situation. Slightly different. I mean, that's legit.
Literally the worst.
Wendy Dean: That's literal, that's legitimately grieving. Right, right. That is a, that is a terrible place to be in.
Janae Sharp: I'm glad we did though, because now I want, I wanna talk about the difference between grieving and moral injury because so many people now have lost a colleague or you know, have lost something.
Wendy Dean: Well, so I think, I think one of the things that we really wanna make sure that we do is to stick with the definitions of moral injury. So betrayal by legitimate authority in a high stake situation that cause you to transgress your deeply held moral beliefs and expectations. Right? So those are the setting conditions for moral injury.
So if you come into a room, you know, I've, I've heard this story when, when someone came into the room, a vegan and someone was a colleague was eating tuna fish, that person said, that's a moral injury. And I just wanna be clear that those kind of situations aren't necessarily right. That may be, it may offend you, but it's not a moral.
Right, right. So I, I just wanna make sure that we keep those definitions very clear so that we don't have creep.
Janae Sharp: That's hard too, because it is very hard. That's hard. Like, because the language is the same a lot of the times, the different difference between like grief or like workforce issues versus moral injury.
to me it's a continuum of horrible. Mm-hmm. , you know, and on the continuum of horrible. Like, it's important to be able to have those definitions, but I'm not always clear on where they are. And I'm also not always clear on which solution works. And I feel like you might have more insight about that both from your background and experience.
Wendy Dean: Yeah. So I, I think the thing to keep in mind with moral injury is that betrayal is really important. But it is also, it's also that point where you're asked to d to betray your oath, right? This is this. I am being asked to practice in a way that I didn't expect that I would be that does not align with my commitment to my profession, to my training as a physician.
And that betrayal is the relational rupture. And so, if you think about it that way, . What we need to do in order to repair moral injury is to do relational repair and rebuild trust with our workforce, to rebuild trust between the workforce and the administration to rebuild trust between patients and clinicians.
Janae Sharp: Have you seen that happen successfully?
Wendy Dean: It is hard. It is hard to find places that are doing it well. All right. It. hard. It's easier to find places that are doing it well in bits and pieces, but globally it's very hard to find places that are doing it well. And I will say , there's a funny story. We went into an organization that we thought was doing it well, and we went in with a specific intent of getting their story so that we could use it as an.
and we walked into the room with the CEO and the, and the president and they said, oh, we are so glad you're here. We've got a problem. I thought, okay, well we're gonna pivot then. How was it? Did it go well? The pivot? It did. Yeah. And, and that's, so what we notice are when leadership is open to feedback, particularly from their workforce, It tends the transformation, the repair tends to go better.
It is sometimes very hard to remain open to that feedback. Yes. Because when people have been through what they've been through in the last three years, the emotions are pretty intense.
Janae Sharp: Yeah. It's hard to be open to feedback when you're already drowning. Right. I wanna ask you, where you think your place is in healthcare?
Like what do you see as your Like It's a small question. It's a small question. It's a very small question. So she won an award last night. And we, we ask hundreds of people in healthcare who are, who are involved in mental health and some of the other people in the same category, which was healthy healthcare.
They were like surgeon general, giant position. Or like a health system that was doing quite well. And you won. And she didn't just like win a little bit. It was like these people are kind of tied down here and Wendy Dean is like winning by far. Why, I mean, maybe this is an opportunity for you to brag because I think it was important, especially since some of the judges were like, oh, this giant organization is naturally gonna be the person who wins.
And you see that a lot in healthcare where people trust authority a lot. And I was like, you guys don't realize that like the people involved in mental health, they're not gonna have the same voting rules that you have in healthcare. Have, has that been something that surprised you or like, does it surprise you that you have such a powerful voice?
Like, why did you win?
Wendy Dean: Because it's not about me. , right? That's that's the secret of our organization. It's not about me, it's not about Simon. It's about giving voice to clinicians who feel voiceless. And that's what I hear most of the time is I can't say these things, but you can. And it's why we are an independent organization.
It's why I have not affiliated with anyone, because I don't want to have that voice silenced and I wanna be able to get the emails from clinicians who say, , here's what's happening in my organization. I can anonymize it and I can put it forward, and I can collate it and aggregate it and say, here's what we're hearing on the front lines.
Janae Sharp: Do you think, what's something that has happened that's been the most gratifying for you then? Like, how do you measure your success?
Wendy Dean: I don't spend a lot of time. Thinking about my success. I like that. I like that. I mean, I really, I don't, because that's not what the work is about. The work is, you know, what I feel like is success is people are thinking about it.
They're looking for ways to change, and clinicians who are struggling and suffering feel like they're being heard finally. Right. So, you know, I guess the fact that the language is out there in healthcare now, , it feels really important, but every time somebody says, at least once a week, I will get a call or an email and somebody says, I found this, and it feels finally, I've been looking for this exact language to explain my experience for the last three decades and my, my response every single time, and it surprised me.
You know, six years later, five years later, when somebody says that to me, my immediate. Response is, I'm so grateful that you have that language and I am simultaneously heartbroken that you need it. Yeah. And so my real success will be when I work myself out of a job. Right. Like that will be success for me.
Janae Sharp: That is a great measure of success when you're like done with the work. Yeah. Tell us a little bit about, you're writing a book, right? Didn't you just write a book? I, yeah, I wrote a book. It's about to come out. I'm about to hold it in my hand. The publisher says, really? Yes.
So tell us about it and then we're gonna have que if everyone has, can think of one hard question.
That'd be great. That'd be great. She's like, we can ask hard questions. I'm like, Hmm. Okay. I'm gonna ask the audience to help. Okay. So tell us about your book while everyone thinks about their hard question.
Wendy Dean: So, I, I never, I, like, I never, writing a book was so not on my bucket list. . It just, it was one of those where I was, this is also a great story.
We were having dinner with Simon and I were having dinner with Sam Shem who wrote The House of God, and Sam was like, oh, you guys need to write a book. And we were like, oh no. He was like, nah, it's not that hard. You really need to write a book. And so, we thought about it for a while and realized, you know what?
That's the best way to. to get the message out. We want it to not just be for clinicians, but also for patients to understand why is your experience of healthcare so hard? It's not that your clinicians don't wanna do better. They do. They're dying to do better, almost literally. And so this is a book about, it's narrative nonfiction because everybody learns better with stories.
It's easier to read and digest stories, but it follows. There are 10 stories of 10 clinicians, physicians in particular who faced moral injury, why healthcare was in the situation that it was in. So it goes into the background of why they were in that particular situation, sometimes going back to 1900. And then it also talks about who's been successful getting out of it.
Mm-hmm. , who's faced it down. . And the, the goal of it is to get physicians and patients speaking together and asking for change. I like that. Like having people speak together. Correct. All right. You ready for questions? Ready? I'm ready. And then, yeah, I'm looking. Does anyone have a question? Oh, look, there's a question.
Audience Member: Yeah, I just wanted to thank you for your work because I, myself, as a physician who started off in general surgery, did not have that language to understand because it wasn't about the hours.
I had a pretty horrific story in which we had a patient who was sexually assaulted and needed surgical care and at the time, , I needed to go to the emergency room. That is the only place where they had sexually sane nurses, which sounds to me insane. Like you have to go to someone and say, I need to find someone sane to evaluate you for sexual assault.
But she needed to go to the cer, to the or, and if we went to the or, then she wouldn't have been able to make the claim. And so that's the kind of dilemma that you're in. I can't send her back to the emergency room. She can't make the claim. I need to get her to the or. So that's only one of like many, many stories and I'm sure like a lot of people have that.
But I think that residency is a key time when people are faced with this impossible goal. Right. You have, as you were speaking, I was thinking about the fact that residency is the first time that. , A lot of doctors are given this impossible workload. They have little voice and the stakes are so high against them and they're forced into this kind of hero complex.
And I think in the pandemic we see that a lot as well as, because a lot of the attendings were not coming in. They were afraid of covid. The residents were frontline, the residents were getting sick, and their careers, their future, their ability to practice medicine is at. So what is the role? So, I'm getting to my question, , sorry.
What is the role of your work in addressing the residency training and should residents be unionized? Should they be protected? Should they have maybe even hazard pay in regards to moral injury or anything like that?
Wendy Dean: So, I, I'm not gonna pre pretend to say that hazard pay is gonna be a solution.
What I do think is that we all need to be better. , he helping residents, learners of all kinds. Everyone on our team have a voice, and I think we don't do a great job right now of teaching residents how to speak back, how to speak up in a way that others can hear and that is safe for them. We also need to make sure that their attendings are willing to be protected.
right? So if a resident speaks up, they are incredibly vulnerable, right? And if they don't speak up, they're also vulnerable. So we need to put in place some better mechanisms for teaching attendings what their role is, what their influence influences, and then helping residents understand how to have that voice.
I mean, I, I, I spend a fair amount of time now. talking people through that who are attendings who have been out for 10 years and are saying, what do I do with this situation?
Audience Member: Dr. Dean, so far great conversation. I'm curious, as your book comes out, what your hopes are, what, what would be your top three hopes as far as a demonstration of clinicians and patients coming together and actually changing something?
Wendy Dean: So, . We're planning an event in a town out in the Midwest in June that is a conversa, a community-wide conversation including law enforcement, the National Guard, healthcare and the community to say, how do we think differently about what we want in this community?
And I think that's, That's it. That's what I want. I want everyone in the healthcare community to be speaking together about how we want it to be different. That includes patients, clinicians, administrators. This isn't a problem we can solve by ourselves and it's not gonna get better with individual solutions.
It's going to get better as a community. And so, in particular, I, I would love to walk into a meeting one day where there are patients, clinicians, And administrators, and I can't tell the difference between them because they each are equally empowered and they each feel equally safe to speak up. And they're each, each of them is being listened to equally.
Janae Sharp: So I have a follow up question for that. Mm-hmm. , some people say like, you know, they're doing this wellbeing program. They want us to tell, they want us to tell 'em how we're doing, but why would I tell my employer that?
why a conversation?
Wendy Dean: I'm not sure I follow it.
Janae Sharp: Why do you say the conversation is the goal? What I feel like you might be defining conversation is differently than, than how a lot of people take it.
Wendy Dean: So I'm, yeah. So I'm not defining this as we're gonna have a conversation about my mental health, right? I think that is necessary and insufficient and that is not going to change the situation with moral injury.
We absolutely need to make sure that it's available for clinicians, but that will not change the dysfunction of our systems. Right. So that is the conversation that I'm talking about having the conversation about the system. Correct. And then how do we want this system to be different so that it's easier for all of us and it's more healing for everyone, and then they actually do it well.
Yeah. They have to follow through. Yeah. That's ideal. Yeah. Mm-hmm. , I feel that's, It's ideal. It's ideal. Well, what, and what a lot of organizations don't realize is when you have those conversations, people get their hopes up. They invest a lot of energy and effort into, into giving you the information you need to make the change.
And if you don't follow through, that in itself can feel like a betrayals.
Janae Sharp: That's a great point. Like the, in terms of building trust, like if you just ask people how they're doing and they're like, horrible, and then you're like, good. Good to know. Bye. Like that can be pretty right. Demoralizing.
Wendy Dean: Or if you asked how do you think things should change and then you don't follow through and say, okay, here's how we're planning to make that change, or here's why we can't right now.
We will keep this on the burner for six months or a year from now.
Janae Sharp: Well, thank you. Thank you for your work and thank you for coming and for sharing. For sharing that. Like I appreciate it and I'm glad you're in this space. Thank you. It's a pleasure. Yes.