Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their long standing, deeply held commitment to healing.
Moral injury is a form of trauma that can occur in any workplace. It is often a result of someone witnessing or participating in a behavior that goes against their beliefs or values. This can cause an employee to feel isolated and be less motivated and engaged at work — and it can have a lasting negative impact on an organization.
Moral injury and burnout often go hand-in-hand.
In this enlightening conversation between our SHE RECOVERS podcast host, Dr. Tiffany Wynn, and our guest, Dr. Wendy Dean, we learn the definition of moral injury, how and why it manifests, how the systems we live and operate under play into this experience, and how we can recover from it.
ABOUT DR. WENDY DEAN:
Dr. Dean left clinical medicine when generating revenue crowded out the patient-centered priorities of her practice. Her focus since has been on finding innovative ways to make medicine better for both patients and physicians through technology, ethics, and systems change.
Dr. Dean practiced for fifteen years as an emergency room physician and then as a psychiatrist. After leaving clinical practice, she spent eight years in leadership positions, overseeing medical research funding for the U.S. Army, and as a senior executive at a large nonprofit, in Washington D.C., supporting novel strategies to restore form, function, and appearance to ill and injured service members. She turned her full attention to addressing moral injury in 2019.
Dr. Dean is a regular contributor to Medscape’s Business of Medicine, blogs on Psychology Today, and continues to work in innovative fields with NASA, the American Society of Reconstructive Transplantation, and the Transplant Ethics and Policy Working Group at New York University Langone Medical Center.
Visit her website here: https://wendydeanmd.com/
Listen to her podcast here: https://www.fixmoralinjury.org/
EPISODE RESOURCES
SHE RECOVERS Support For Healthcare & Allied Professionals Support Group & Gatherings
The Healing Power of Stories : A Symposium For Recovery Professionals
SHE RECOVERS in Chicago
SHE RECOVERS® Foundation is a 501(c)(3) non-profit public charity and a global grassroots movement serving more than 325,000 women and non-binary individuals in or seeking recovery from life challenges including mental health issues, trauma and substance use. SHE RECOVERS is dedicated to redefining recovery, inspiring hope, ending stigma and empowering women to increase their recovery capital, heal themselves and help other women to do the same.
If you found this conversation helpful please consider making a donation to our lifeline organization or sharing it with others who may benefit. We would love to also receive your rating and review of the SHE RECOVERS Podcast on your favorite platform.
Visit sherecovers.org to donate today.
LAND ACKNOWLEDGEMENT
SHE RECOVERS® Foundation Headquarters is located on the traditional, ancestral and unceded territory of the Tewa people—O’gah’poh geh Owingeh (White Shell Water Place)—now present day Santa Fe, New Mexico.
Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their long standing, deeply held commitment to healing.
Moral injury is a form of trauma that can occur in any workplace. It is often a result of someone witnessing or participating in a behavior that goes against their beliefs or values. This can cause an employee to feel isolated and be less motivated and engaged at work — and it can have a lasting negative impact on an organization.
Moral injury and burnout often go hand-in-hand.
In this enlightening conversation between our SHE RECOVERS podcast host, Dr. Tiffany Wynn, and our guest, Dr. Wendy Dean, we learn the definition of moral injury, how and why it manifests, how the systems we live and operate under play into this experience, and how we can recover from it.
ABOUT DR. WENDY DEAN:
Dr. Dean left clinical medicine when generating revenue crowded out the patient-centered priorities of her practice. Her focus since has been on finding innovative ways to make medicine better for both patients and physicians through technology, ethics, and systems change.
Dr. Dean practiced for fifteen years as an emergency room physician and then as a psychiatrist. After leaving clinical practice, she spent eight years in leadership positions, overseeing medical research funding for the U.S. Army, and as a senior executive at a large nonprofit, in Washington D.C., supporting novel strategies to restore form, function, and appearance to ill and injured service members. She turned her full attention to addressing moral injury in 2019.
Dr. Dean is a regular contributor to Medscape’s Business of Medicine, blogs on Psychology Today, and continues to work in innovative fields with NASA, the American Society of Reconstructive Transplantation, and the Transplant Ethics and Policy Working Group at New York University Langone Medical Center.
Visit her website here: https://wendydeanmd.com/
Listen to her podcast here: https://www.fixmoralinjury.org/
EPISODE RESOURCES
SHE RECOVERS Support For Healthcare & Allied Professionals Support Group & Gatherings
The Healing Power of Stories : A Symposium For Recovery Professionals
SHE RECOVERS in Chicago
SHE RECOVERS® Foundation is a 501(c)(3) non-profit public charity and a global grassroots movement serving more than 325,000 women and non-binary individuals in or seeking recovery from life challenges including mental health issues, trauma and substance use. SHE RECOVERS is dedicated to redefining recovery, inspiring hope, ending stigma and empowering women to increase their recovery capital, heal themselves and help other women to do the same.
If you found this conversation helpful please consider making a donation to our lifeline organization or sharing it with others who may benefit. We would love to also receive your rating and review of the SHE RECOVERS Podcast on your favorite platform.
Visit sherecovers.org to donate today.
LAND ACKNOWLEDGEMENT
SHE RECOVERS® Foundation Headquarters is located on the traditional, ancestral and unceded territory of the Tewa people—O’gah’poh geh Owingeh (White Shell Water Place)—now present day Santa Fe, New Mexico.
SHE RECOVERS Introduction:
Welcome to the SHE RECOVERS Podcast. This podcast is recorded on the traditional, ancestral and unseated territory of the Tewa people. I am Lisa Wall of Mission Programs and Community Care here at SHE RECOVERS, and I am honored to share a little bit of our HERtory with you today.
The SHE RECOVERS story began in 2011 as a passion project initiated by a recovering duo - a mother, Dawn Nickel, and her daughter, Taryn Strong, who both desired to normalize what it meant to be a woman in recovery and inspire those seeking healing from substance use
disorders and trauma to find and follow individualized pathways and patchworks of recovery.
Today, SHE RECOVERS Foundation is a 501 (c)(3) nonprofit, public charity and a global grassroots movement serving more than 325,000 women and nonbinary individuals in or seeking recovery from a myriad of life challenges, including trauma, mental health issues, and substance use.
Our mission is to redefine recovery, inspire hope, end stigma, and empower women to increase their recovery capital, heal themselves, and help other women to do the same. There is no greater source of inspiration or influence than a woman in recovery and our story is proof.
SHE RECOVERS believes that we are all recovering from something. And here on the podcast, we examine the healing power of connection and intentional living, as well as what happens in our lives when we put down our past stories and pick up our soul's true purpose.
We know that if you're tuning in today, you too envision a world where all women in or seeking recovery are celebrated, supported and deemed essential to help healthy communities. A world where no one has to recover alone. We believe the following guest story will inspire you to write a new chapter in your recovery story. I hope you find connection, support, and empowerment in this week's episode. It is an honor to share it with you.
Wendy’s Introduction:
Welcome back to the SHE RECOVERS Podcast. We're happy to have you back today, and we're very excited about this conversation between our podcast host, Dr. Tiffany, and Dr. Wendy Dean, who specializes in the topic of moral injury. Dr. Dean is the author of If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First, as well as the host of the Moral Matters podcast. They dive into what exactly moral injury is, how it presents in the healthcare field, and how people can recover from it. We're so excited for you to listen.
Dr. Tiffany Wynn:
Today, Dr. Wendy Dean is our guest. And Dr. Dean left clinical medicine when generating revenue crowded out the patient centered priorities of her practice. Her focus since has been on finding innovative ways to make medicine better for both parties and physicians. Through technology, ethics, and systems change.
Dr. Dean practiced for 15 years as an emergency room physician and then as a psychiatrist. After leaving clinical practice, she spent eight years in leadership positions, overseeing medical research funding for the US Army, and as a senior executive at a large nonprofit in Washington, DC supporting novel strategies to restore form, function, and appearance to ill and injured service members. She turned her full attention to addressing moral injury in 2019. Dr. Dean is a regular contributor to Medscape's Business Medicine, Business of Medicine, blogs on Psychology Today, and continues to work in innovative fields with NASA, the American Society of Reconstructive Transplantation, and the Transplant Ethics and Policy Working Group at New York University Langone Medical Center.
So welcome, Dr. Dean. Your new book, If I Betray These Words, looks really good, and I want to talk with you about that today. I've been enjoying your podcast, and I think what would be a great place to start, if you don't mind, is if you tell me and the people who listen to this podcast every week a little bit about how you the human being, Wendy Dean, ended up really being a champion for the conversation around moral injury as opposed to burnout, and really getting honest about what's happening in our fields of medicine and health across all domains of health.
Wendy Dean, MD:
Ah, that's an interesting story, and it's not one that I did intentionally. So I like to say that I didn't volunteer for this. I got conscripted. And in part, it's because I had this experience as a family member, watching my mother and my husband getting care and seeing that the folks who are taking care of her were struggling with their own challenges. It was getting in the way of their providing the kind of care that they wanted to provide.
And as I thought about that, and as I thought about how I used to think that when I struggled in health care, I could compartmentalize it and put it away and my patients didn't experience it. And in fact, being on the other side of it, I realized, oh, hang on, it really does impact patients, so what are we going to be able to do with that? What is behind that and what do we do with that?
And I ended up asking all of the clinicians that I was working with across the country with this research funding oversight with the army what their experience was and was it burnout? And most of them would say to me, I love my patients this, I love what I do for work, I love the medicine that I practice. What I don't love is everything that goes around it.
Dr. Tiffany Wynn:
Yeah.
Wendy Dean, MD:
And so, I would say to them, oh, so are you burned out? And they would also say, almost 201. Well, I guess so. It doesn't really land right with me, but I guess so because I don't have better language for it.
Dr. Tiffany Wynn:
It's interesting how systems want us to think that it's a particular thing, when in reality, it's the system that's making us sick. It's not an internal issue of burnout. And I shared this with you in our email thread that I've been in behavioral health for 20 years, and I have found myself at different points thinking, I don't know if I can do this anymore. And it had nothing to do with the people in front of me. It had everything to do with the pressure of billing, the churn, how quickly the system needed us to move. And I wonder, can you define for us what moral injury is? Because I think this is a pretty new concept for a lot of people who do this kind of work.
Wendy Dean, MD:
Sure. And then I'd love if we talked about the relationship with burnout.
So moral injury was initially defined in the context of soldiers coming back from combat particularly in the Vietnam War. So Jonathan Shea originally defined it as betrayal by a legitimate authority in a high stakes situation. And it was a condition that required all three of those things. Betrayal, a legitimate authority, and high stakes situation.
Brett Litz and William Nash expanded on that concept about a decade and a half later, and they said it's perpetrating bearing witness to or learning about acts that transgress deeply held moral beliefs or expectations.
And in healthcare, those deeply held beliefs and expectations are the oaths that we took to put our patients first, whether explicit or implicit.
So we tend to think about those two definitions not as separate things, but as connected to each other as sort of a stimulus and response. So you perceive a betrayal, and it may not be an egregious one. It may be that somebody is just subtly undermining what you're doing as a clinician. But you perceive that betrayal and you have two choices. You can push back and stand up and have less of a risk of moral injury, or you can acquiesce to that betrayal and transgress your deeply held moral beliefs and put yourself at greater risk for moral injury.
Now, I want to be crystal clear here that I'm not saying that we have a free choice to do those things because sometimes we have bills to pay, mortgages to pay, kids to feed, and we can't uproot everything and move to a new city and get a new job. So sometimes the decision is, I need to keep my job and acquiesce. But there is a moment when you can go down one of those two paths.
Dr. Tiffany Wynn:
Yeah. And SHE RECOVERS is all about believing that all people have the opportunity to heal from something.
And do you think that there well, I have two questions after you shared those things. One is, do you think that we can heal from moral injury? And the second question is, how is this different from secondary trauma?
Because what I'm hearing really leans into traumatic experience, especially by systems, which is deeply influenced by social determinants of health and other socio political things.
So, I'm sorry I threw two questions at you, but I'd like to hear from you on both things.
Wendy Dean, MD:
Okay. What was the first one?
Dr. Tiffany Wynn:
Can we heal from these injuries, these moral injuries that we sort of get pigeonholed into because of the kind of culture we live in? Moral injury happens, so can we heal from it? That's my first question. And the second question is for you, Dr. Dean, how do you see this as being different than secondary trauma or trauma perpetrated by a system or institution tuition?
Wendy Dean, MD:
So I think regarding the first one, absolutely we can heal from it. And I want to be clear that typically what we talk about is not the individual betrayal of my personal beliefs, but in the context of a professional role. Right, so the betrayal of that oath that I took as a healthcare, as a clinician, to put my patients first, it may align with my religious beliefs or my other personal beliefs, but what we really talk about is because this is a work environment, in the context of that professional role, I do think we can heal from it. But the first thing we need to do is acknowledge that it exists and for everybody to know that we all face these moral dilemmas, these moral experiences. And part two is what we need to do is be prepared for those and understand how it could impact us and understand that we have that ability to stand up and speak out and reduce our risk. And that then means that we prepare ourselves to do that in a safe way, which I acknowledge is also quite challenging in our corporatized healthcare system.
Dr. Tiffany Wynn:
It is.
Wendy Dean, MD:
Right? That's the answer to the first question. To the second question. Some of the evidence that we're seeing coming out of the UK shows that they are distinct entities that burnout and moral injury and second victim syndrome or experiences are separate entities. They can influence each other, but they aren't the same thing. Nor is it the same as depression.
Dr. Tiffany Wynn:
I'm so excited to deconstruct all these with you. Do you have personal experience that led you to the construct of moral injury and feeling like it was too big to solve or feeling like you had to speak out? Do you have a story there?
Wendy Dean, MD:
I spent the early part of my career, which I only realized in retrospect I spent the early part of my career trying to find a model of care that would allow me to treat patients the way I believed that they deserved and that was best for them and in a way that was sustainable for me.
So I was a psychiatrist, and typically psychiatrists are in a role of being a prescriber. The way I trained my experience of patient care was that sometimes that was the right thing to do, and sometimes it was better for the patient, more efficacious. It led to a quicker outcome for the prescriber to also be the therapist…
Dr. Tiffany Wynn:
That's right.
Wendy Dean, MD:
To be doing both together. But the challenge as a psychiatrist is you don't get paid that way. Right. So you have the overhead of a psychiatrist and you don't get paid at the rate of a psychiatrist. So it just ended up being an economic model that did not work.
And I had a choice to make. Either I would acquiesce and become the prescriber, or I would push back. And what I did was I pushed back and tried to find you know, tried every permutation I could think of to find a place and a way where I could practice in that way, and ultimately, I couldn't.
And I ended up deciding that I would rather find another way to use my MD than to give care that I didn't believe in 100%.
Dr. Tiffany Wynn:
That's powerful. And I'm not sure many of us in the field, in behavioral health in particular, and probably in medicine, I don't work in medical. I work in behavioral health, although I think they're the same a lot of the time. I don't know that many of us can actually say, I choose what's right. I choose to stand by what my soul is calling me to do, which is care about human beings instead of pushing forward with this model that's leading me to fatigue. And you raised a question or or a concept around the difference between moral injury and burnout, and you said you wanted to explore that a little further. Would you like to take a few minutes and do that now?
Wendy Dean, MD:
Sure. And by the way, I'm lucky to have a husband who enjoys his job.
Dr. Tiffany Wynn:
Yeah.
Wendy Dean, MD:
I recognized that I had the luxury of making that choice and taking a couple of months to decide where I was going next. So I'm going to be perfectly upfront.
Dr. Tiffany Wynn:
What a gift, yeah. What a privilege, right. To be partnered…
Wendy Dean, MD:
Correct.
Dr. Tiffany Wynn:
…and partnered with someone who likes what they do and makes enough money that we can pause and figure it out. That's a big deal…
Wendy Dean, MD:
And we also made life choices so that we could do that. Anyway, a lot of people will hear when we're talking about moral injury that it's not about burnout, it's about moral injury. And that is not the way I look at it.
Dr. Tiffany Wynn:
Okay.
Wendy Dean, MD:
The way I look at it is that the two are separate entities. And by the way, there's plenty of distress to go around. Nobody needs a corner on that market.
Dr. Tiffany Wynn:
Thank you very much. Yes.
Wendy Dean, MD:
Right. So let's say yes, and let's bring more people into this place of healing. So, burnout. I recognize that there's a lot of conversation about it being systems issues and yes, it yes, it is systems issues. There is administrative burden that could be reduced. There are issues with the EHR that take too much time and could be streamlined. There are regulations that need to go away. Yes, 100%. There are systems issues that lead to burnout that are just they simply lead to demand. Demand resource mismatch. I think of those as the operational issues that need to be addressed that lead to burnout. Demand resource mismatch.
On the moral injury side, where we're talking about a betrayal that, by the way, is often unintentional, I don't think anybody sets out any day to betray the people who work for them. I think they too have forced choices and they're trying to do their level best, but sometimes there are constraints outside of their control as well. But in the end, there is this perception that I am being undermined or I'm not free to do my job as I was trained to do, that sets up a relational challenge in healthcare. So we have the operational side, which is that we don't have systems that are working smoothly, and then we have the relational side, which is we don't have a trustworthy system in which to work.
Dr. Tiffany Wynn:
That is powerful.
Wendy Dean, MD:
Yeah. And so we need to do both. It's yes and...
Dr. Tiffany Wynn:
Yes, it is yes and…And why do you think it's so hard for us in this culture, in this community, in this time, to peel back the layers on this? Why don't more people know about this?
Wendy Dean, MD:
If you look at my previous job working with the army was doing research, funding oversight, developing innovative technologies. So I learned a lot about product development. And when you look at adoption of new ideas or new technology, it takes about a generation.
When you look at Burnout, it started in the mid 70s. We really started to talk about it in earnest in the late 90s, early 2000s. So, moral injury has been accelerated by the pandemic, which I have very mixed feelings about, but it is not unexpected that it's taking a little bit of time for that uptake to happen and for people to learn about it.
So we spent the first two to three years of the work that we were doing entirely about raising awareness and educating people about what this new concept is. And we're now, in the last year and a half or two years, starting to look at what the solutions might be. But that is a very expected trajectory.
We're also building the research, the data that we need to back up these concepts. But it's been five years. It's only been five years, which is not a long time.
Dr. Tiffany Wynn:
It's not a long time. That's like baby construct emergence. That's the very beginning.
Wendy Dean, MD:
Right.
Dr. Tiffany Wynn:
And so I have so many questions about your military experience.
Wendy Dean, MD:
And by the way, I didn't wear the uniform. I was a civilian.
Dr. Tiffany Wynn:
I don't love that we are in our third opioid crisis as a country, and then we had the public health emergency with COVID overlaid on top of that. But can you talk about how those two things have connected and danced around together? And I suppose it's not just the opioid crisis, but also the amphetamine crisis that then tags onto the back of all opiate crisis. Right.
Wendy Dean, MD:
Yeah. So I'm not going to pretend to be an expert in that. There are people who are so much more well informed about that. And honestly, I read a brilliant book, the Least of Us by Sam Quinones, his follow on to his initial book. And I would direct anyone to that book, along with a very long laundry list of other books. I think there's something about a sense of disempowerment and hopelessness that's driving that pandemic that feels familiar to what I talk about with moral injury.
But I'm sure that I can't talk really intelligently about how the similarities and connections between the two.
Dr. Tiffany Wynn:
It is it possible, though, that the multiple issues, societal, cultural issues, just taking the opioid crisis and COVID, because you've mentioned COVID and how that impacted everyone and specifically the issue of moral injury, are they compounded and do they make it harder on providers? I think the answer is yes, but can you tell us a little bit?
Wendy Dean, MD:
You mean COVID and moral injury? Oh, for sure.
Dr. Tiffany Wynn:
Thank you.
Wendy Dean, MD:
Yes. So we're clear that this did not start with COVID but I think what happened during the pandemic is that all of the things that were everyday annoyances before the chronic short staffing, the just in time supply chains, the making sure that every square foot of space made the right ROI, all of those things were annoyances every day. And then when the pandemic hit, those annoyances became potentially catastrophic, right? When you don't have enough staff to take care of critically ill patients, when you have a just in time supply chain that oh, by the way, if you ask any logistician, those just-in-time supply chains reliably fail in a crisis.
So whoops we've allowed health care, right? We've allowed healthcare to rely on just in time supply chains. Maybe that wasn't a great idea.
Dr. Tiffany Wynn:
Right? It seems like the standard operating procedure for how these system works. It was designed to fail in the worst possible moment.
Wendy Dean, MD:
It was designed based on systems that are not crisis based. So if you think about it, a lot of the management principles come from somewhere like a car manufacturer. Car manufacturers don't typically have crises, right? So they're not asking this system to consistently function and function at a very high level through a crisis in healthcare. We've been asking it to do that for way too long. We've been running it way too hot. And the only reason it's surviving is because of what Danielle Ofrey described in her New York Times opinion piece in 2018 as the altruism and the goodwill of the healthcare workforce, because doctors and nurses and every other clinician, and frankly, most people in healthcare will not let the patients suffer as a result of systems issues. We'll take that on ourselves instead.
Dr. Tiffany Wynn:
And so I think I heard you say in one of your podcasts that looking at clinicians in the field during the time of COVID they actually found more purpose and their hearts came forward. But that didn't mean they didn't experience significant moral injury during that time, right?
Wendy Dean, MD:
Right. So about 25% felt like this was what I went into this field for. This is my moment to serve and bring it. Now, I do have purpose. I had purpose before, but this is the peak of what I came here to do.
It doesn't mean that they didn't struggle, that, you know, I talked to one ER physician the other day who herself was faced with deciding who got a ventilator.
Dr. Tiffany Wynn:
That's right.
Wendy Dean, MD:
And two, two years later, she left the field because she said, I can't come to rights with this and my hospital just wants to get back to business as usual and I have healing to do and I can't do that with the situation that we're in.
Dr. Tiffany Wynn:
And how do we help these folks recover? Part of SHE RECOVERS is really getting into some of these bigger things. And I personally think we're going to see the psychological and economic effects and the moral injury effects of COVID for decades and the restructuring of the brain as a result of this long standing issue.
How do we help people move from the injury to what's next for them?
Wendy Dean, MD:
I think one of the best parts, one of the reasons that people really resonate with moral injury is because it says to them, this isn't about you. It's not a deficit, it's not a vulnerability in you, it's not a deficit in you. You are tough enough.
And by the way, we know that clinicians, physicians in particular, but I would extend this to nurses and everybody else who works in healthcare are significantly more resilient than the average employed population. So asking them to be more resilient individually may be like bringing coals to Newcastle, right? Maybe we don't need to do more of that.
Dr. Tiffany Wynn:
We shouldn't do.
Wendy Dean, MD:
So that's the first thing, and I can't tell you how healing it is, at least from what I've seen, for people to have language for this to actually say, oh, that thing that I have never been able to name, I can now name. It makes me feel less alone, especially when other people name it as well. And to know that it's not about me is really a huge relief.
So I will say that my co-founder, Simon Talbot, and I had this a-ha moment when we were talking at one point years ago and a couple of years before we wrote our article. And we realized that a psychiatrist and a plastic surgeon, who are sort of arguably at the opposite ends of the spectrum of health care, had had the same experience of being a physician in medicine. And we were like, oh hang on, if that's true for both of us, maybe it's not about us,
Dr. Tiffany Wynn:
Right. That's revolutionary. When we find out we are not terminally unique in our suffering and there is actually a large community of people that we can relate to, that reflection and that witnessing and that shared lived experience can change everything.
Wendy Dean, MD:
Right? And what was interesting was, when we brought this language, we were just kind of playing around with the idea. And we brought the language to one of the in-person meetings that we had had with this research funding, and we shared it with a few people, and it was instantaneous. They were like, oh, that's it. That's it.
Dr. Tiffany Wynn:
And it must have been this really powerful moment for you and Dr. Talbot to know to just know that your work right now is critically important to this entire…not just this workforce, I think in some of your writing, you talk about how moral injury impacts veterans. And you've said that today it can impact doctors and first responders, EMS folks. Who else is at risk? And I wonder if this other category might not have the same protective factors or resiliency that the other folks that you've already talked about have.
Wendy Dean, MD:
Yeah. So we have heard from veterinarians, teachers, public defenders - I heard from someone who worked for the massive consulting agency McKinsey who said he left, didn't know why, didn't have the language, and in retrospect, when he read my piece, said that's what it was. It's moral injury.
Dr. Tiffany Wynn:
Yeah. I was in state government at the time that COVID hit, and my job was to make sure that all the substance use and mental health services stayed open and functional. And I can't speak for other states, I can speak for this state of New Mexico to say they did a really good job and they worked really closely by taking care of provider agencies and every individual staff person. However, those large scale systems can ask us to do things that aren't that great for us. And so I think that's part of the reason I ended up leaving. And I didn't have words for it until I read your work and listened to your podcasts with Dr. Talbot. And I just want to express gratitude because I wondered, why am I not good at this? What's wrong with me? What's going on with my heart? What's going on with my brain? Why isn't my brain doing the right thing? Turns out maybe my brain was doing the right thing, but the system couldn't allow me to keep doing what the right thing was.
Wendy Dean, MD:
Right. And I think there are some times when systems themselves have constraints that we don't acknowledge openly, that we don't have conversations about. And that's also one of the paths to healing, is to be able for all of us to say, you know what? We need to talk openly about these challenges that we're facing within the system. It may be that there's not enough funding. So let's have a conversation with that as a society. Let's have a conversation about that as a society and wrestle with that and wrestle it to the ground. And then we all know this is what we've decided and this is how it will go.
And unfortunately, it may not be a choice that you want to live with or work with, which allows you then to make the choice of, I'm going to look elsewhere and / or I'm going to make the active choice to stay because I don't have another choice and I'm going to find another way to be okay with it or to try to change it from within.
Dr. Tiffany Wynn:
Do you think that moral injury or not, do you think, how would you describe how moral injury impacts communities of color and more impoverished communities?
Wendy Dean, MD:
So I want to be careful about how we define moral injury. If we go back to the definition again, it's a betrayal by legitimate authority in a high stakes situation. So there are situations where that would occur. But I want to be careful about not making blanket statements about a population that suffers from moral injury.
Right. What we do know is that those who are disempowered. Have a higher risk of moral injury, of experiencing moral injury. And it doesn't matter whether you're a woman or you're a person of color or if you feel relatively disempowered, you're at higher risk.
Dr. Tiffany Wynn:
So being part of a minority group or identifying in an oppressed class could increase the likelihood that you would have moral injury. That's a question I'm asking.
Wendy Dean, MD:
Correct. Okay. It could. And that gets complicated. It gets complicated by the fact that if you have experienced betrayals in the past, you may be more likely to have a betrayal schema. And so you're going to see betrayal where it may or may not exist.
And I'm not saying that we should dismiss someone's experience, but we need to be very careful about the definitions. I'm a little bit worried that moral injury is going to become a new buzzword and we're going to start using it as burnout has become colloquialized.
Dr. Tiffany Wynn:
I hope not. I hope that we can tailor the conversation and empower the conversation in the right way. I have to ask, too, is…ell, maybe I don't have to ask, but I'm going to ask because I'm nosy and this is how my brain works. How is moral injury different than, or the same as, somebody saying I won't talk about abortion because it's against my value set, or I will talk about it because it's within my value set. I'm curious how this construct touches or does not connect to some of that controversial stuff that's out in our world right now.
Wendy Dean, MD:
Right. So I think we need to go back again. I'm going to keep returning to the definitions.
Dr. Tiffany Wynn:
Good.
Wendy Dean, MD:
And it's betrayal in a high stakes situation, right. And yes, abortion can be a high stake situation, but the thought of abortion is not a high stakes situation. And also moral injury implies that you've experienced this condition or these challenges to the extent that. You, you almost wonder if you can continue to be the good person you thought of yourself as. So there's a bit of disorientation that happens with it.
So, for example, I have had people say to me, if I continue to work in this health system, I don't know if I can still think of myself as the doctor I hoped I would be, because I feel like I'm complicit in delivering care that's not what I would hope it would be.
Dr. Tiffany Wynn:
What you're talking about is so big, and I feel like there's so many tentacles attached to it.
Could you share a little bit about your military experience as a civilian person within that system? How did this play out? And I have to say, I'm a child of a 100% disabled military veteran, and I'm not sure that we got good care. However, my partner's family has had excellent care, and I wonder in that system, can we get it right? Because the VA, the military system, it's incredibly complex, and it gets a lot of things right. So can you speak to moral injury in that particular system a little bit?
Wendy Dean, MD:
I wish I could. I did not work as a clinician when I worked for the army. So I was working in research funding oversight.
Dr. Tiffany Wynn:
Okay.
Wendy Dean, MD:
I was working on product development to restore form, function, and appearance to folks who were catastrophically wounded in battle. So I was looking at regenerative medicine techniques and hand and face transplants.
Dr. Tiffany Wynn:
Wow.
Wendy Dean, MD:
So it put me in contact with some of the military healthcare facilities. But I didn't actually practice in them and don't have the expertise to speak to what their challenges are or how well they're doing or not.
Dr. Tiffany Wynn:
Okay. That's okay. I'm so curious. This is the part that gets me in trouble, is that I love to be curious.
Wendy Dean, MD:
I have had physicians from each of those systems say to me, you know, I struggle with certain aspects of it. They don't have the same challenges with, for example, private payer health care, health insurance. Right. So they don't have those struggles. And in the military, especially, the patient doesn't want typically. Right. Because the whole point of medicine in the military is to put that wounded service member back into a position of being ready to go into conflict. A ready medical force. Right. And a medically ready force. The purpose of medicine in the military is slightly different and may act against the same level of moral injury. But that's speculation.
Dr. Tiffany Wynn:
Yeah, well, I appreciate your speculation. I would love to have another conversation with you just about that.
I know SHE RECOVERS has support for healthcare and allied professionals - there's a community, a support group, and we really focus on storytelling and we're going to be doing that in Chicago this fall. Are you aware of any other supports for folks in healthcare settings who are experiencing moral injury or other…what's the word? Injury?
Wendy Dean, MD:
Distress.
Dr. Tiffany Wynn:
Yeah, distress. That might need community.
Wendy Dean, MD:
So there are a lot of healthcare systems that are putting in place peer support and true peer support, meaning, like licensees. There are some that are completely informal and are ad hoc, meaning when an event happens, you can reach out at the moment and get a peer. You're not buddied up in perpetuity. They're not all addressing specifically moral injury. They're addressing all of the challenges and hopefully with mentorship that helps folks learn how to speak up in a safe way in that environment, if that makes sense.
Dr. Tiffany Wynn:
I think it does. And I feel like everyone needs to meet you. I feel like if you're a doctor, you should know Dr. Dean and Dr. Talbot. And I know that folks can connect with you on LinkedIn through Moral Injury of Healthcare and the same on Facebook. And, I know your podcast is fixmoralinjury.org/podcast.
Wendy Dean, MD:
So, the podcast is called Moral Matters.
Dr. Tiffany Wynn:
Moral Matters. Thank you.
Wendy Dean, MD:
And if you go on Twitter, we're @fixmoralinjury. Okay. And then our website is fixmoralindury.org.
Dr. Tiffany Wynn:
And I've been really grateful for your YouTube videos as well. The difference between burnout and moral injury, I think that's really critical. Could you tell our listeners a little bit more about your book and where they can get it so that we don't miss an opportunity for folks to learn more about this and support healthcare workers in all of our communities?
Wendy Dean, MD:
Yeah. So by the way, a book was never on my bucket list.
Dr. Tiffany Wynn:
I don't think anybody decides they want to write a book. I don’t think they do.
Wendy Dean, MD:
Oh, boy. Yeah, there are some folks who really want to. And I was really clear that no, I'm good.
And the reason we wrote it I wrote it with Simon. And the reason we wrote it is because we really feel like it's important not just for clinicians to have and to see themselves in this book, but for our patients to understand, because there's this veil, there's a curtain that's up, and clinicians are on one side and patients are on the other. It's really hard to get a window into that world. My parents never even understood what I did right. So, it's really hard, unless you've been through it, to understand what it's like and to understand then how betraying your oath might be such a might be such a blow.
And so I wrote it as narrative nonfiction, which means it's told in stories. It has a history of how we got here woven through it, but the point was to tell it as a story, because that's how we learn best, and that's how we remember best. And so it's stories of ten different clinicians how their moral injury looked like, why they were set up in that way. You know, sort of quote unquote set up. Why the healthcare system was the way it was and caused that particular kind of moral injury, or that was that driver of moral injury. And then what they did with it. And some of them stood up and pushed back, and some of them didn't have that option.
Dr. Tiffany Wynn:
Yeah. Yeah, I think the storytelling is the most powerful thing. And I'm really glad you wrote the book because I think people witnessing these ten stories is how we begin the deep healing.
Every single person has a doctor. Every single person knows a nurse. Every single person has to deal with EMS at one time or another. Every single person deals with a psychiatrist or knows someone who's dealing with a psychiatrist. It turns out all these people are just humans. These are just human beings with hearts and souls who happen to have gone to school for a really long time. And we don't end up in these positions without our hearts or without being driven by purpose.
What is something that you would like everybody to know about moral injury, about you, about what to do next? How do we take people into hope around this?
Wendy Dean, MD:
I couldn't do this work if I wasn't optimistic about being able to change it. The other thing is that a lot of clinicians, although they may be distressed, although they may be struggling, they are also almost every one of them said, I love my patients. I love the medicine I practice. This was the only thing I could imagine doing. And I just want to get back to being able to be a really good doctor. That's what I want to do. And so I think if we all acknowledge what's happening, how it's happening, and then work together towards better, I think there's the possibility for change.
I will also say that I have spoken to a lot of executives who feel the same. They went into healthcare specifically because they didn't want to be in medicine. They didn't want to be in nursing, but they wanted to be part of healing. And so they're driven to do this as well by sort of that calling, and they experience their own moral injury.
Dr. Tiffany Wynn:
Yeah. My heart goes out to all the folks at any level in these systems, and two things are coming up for me.
One is Ram Dass’ book, How can I help? which talks about the dismantling of the hierarchy in medical and medical modeled systems, where we're all just actually humans who need to tell each other our stories so that we can help each other be well or be better.
And the other thing that is coming into mind is something I say all the time, which is more love, not less. Like, your doctors, our nurses, all these people in these systems, they need more love from all of us. We need to play nice with these folks. And I think it's a misguided idea to think that they're somehow superheroes who are not experiencing the same distress that we're all experiencing out here in the non medical field world.
Wendy Dean, MD:
So I think I struggle with calling clinicians healthcare heroes. I think what they do every day is heroic. But when we call them heroes, we take away their ability to be human. We take away their ability to be vulnerable. And I think that doesn't give them the opportunity to feel and to feel and to heal and to connect with their patients in that very human way.
Dr. Tiffany Wynn:
Thank you so much, because I think I did exactly the thing I didn't want to do, which is non humanize. The people who are doing this work, who are absolutely humans. So thank you for that check in. And is there anything else you want our listeners to know? Is there anything you want SHE RECOVERS to do in response to this new information? It's new information for me, and I read a lot, so I'm going to assume there are a lot of our listeners who don't know much about moral injury.
Wendy Dean, MD:
Yeah. So what I'd really love people to do is be respectful of how hard health care is right now and also to do the human thing in return. And just check in or just acknowledge if you've been waiting for an hour in the waiting room, your clinician is probably not happy about that either. And to just acknowledge, seems like you've had a bad day, or seems like it's been a tough day. They have no idea how far that can go.
Dr. Tiffany Wynn:
I really appreciate that. Just a little bit of compassion, a little bit of gentleness, and a little bit of humanity. Nobody likes stuff to not work very well, including the people who are delivering said stuff. Right?
Wendy Dean, MD:
Right.
Dr. Tiffany Wynn:
Okay. Well, Dr. Dean. Anything else?
Wendy Dean, MD:
No. Thank you so much for your interest in this, I really appreciate it.
Dr. Tiffany Wynn:
Oh,. Thank you so much. Thank you for being here with SHE RECOVERS. Thank you for letting me get to know you. And I would love to see you in Chicago at our conference if you have time in the fall to join us in September. All right, well, thank you so much.
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