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  • Writer's pictureRebekah Bernard

Does corporate healthcare contribute to physician moral injury?

One of the biggest issues in medicine today is physician burnout, with almost 50% of all physicians reporting making active plans to leave the practice of medicine. We are joined by an expert on the subject of physician wellness, psychiatrist Wendy Dean. Dr. Dean and her co-author have singlehandedly changed the dialogue away from ‘burnout’ and towards the concept of ‘moral injury.’ We asked Dr. Dean for her perspective on the impact of corporatization and the replacement of physicians by nonphysician practitioners on physician morale and burnout.


Rebekah Bernard MD 0:07

Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard. And I'm joined as usual by my co-host and the co-author of our book, 'Patients at risk: the rise of the nurse practitioner and physician assistant in healthcare,' Dr. Niran Al-Agba.

Niran Al-Agba MD 0:26

Good evening.

Rebekah Bernard MD 0:27

One of the biggest issues in medicine today is physician burnout, with almost 50% of all physicians reporting making active plans to leave the practice of medicine. Today we are speaking with an expert on the subject of physician wellness, a psychiatrist who single-handedly changed the dialogue away from burnout and towards the concept of moral injury. Dr. Wendy Dean, welcome to the show.

Wendy Dean MD 0:50

Thank you so much. It's really a pleasure to be here. And I just I just want to put in that I didn't do it all by myself. My co-author is fantastic - Simon Talbott.

Rebekah Bernard MD 1:00

Well, thank you for that. Yes, I did see you had a co-author. So thank you, Dr. Talbot, as well. Dr. Dean, I want to tell you that it's such an incredible privilege for me to be talking with you because you know, I kind of feel starstruck in a way because you really have you and your co-author have really been so instrumental in changing the way that we view this issue of physician wellness and the problems that we face in the healthcare system. So maybe we can start out by having you talk about your background, and the whole idea of moral injury as it pertains to physicians.

Wendy Dean MD 1:32

So I realized in retrospect, of course, I didn't understand it at the time. But I realized that from the time I was in residency, and I actually started my residency as a surgery resident, did that for three years, then decided that living a life where the OR ran my schedule was just not going to work. For me, I loved the work, I loved the patients, I loved the disease processes, but it just was not going to work. So I went to the emergency room for a while and did kind of - had a - it was a place where I could see all of medicine. And what I figured out was that psychiatry was probably the place that I was going to be less inclined to be bored because there was so little known about, really what was going on the brain was still kind of a big black box. So I went back and did my psychiatry residency. But what I realized was, I was trying all along, from my residency, through my practice to figure out how to take good care of patients in a way that was sustainable for me. And eventually, in psychiatry, I mean, as everybody knows, it's been chronically underfunded. It's been, you know, that chronic underfunding has sort of systematically dismantled the infrastructure of mental healthcare, as we saw in COVID. And it became impossible where I was living, actually make a living, treating patients the way I thought was right for them. And so I went and did some research, funding oversight for the Department of Defense for the army, and worked there for about a decade.

Rebekah Bernard MD 3:04

Now, were you actually in the military, or you worked for them?

Wendy Dean MD 3:08

I never wore a uniform. I was a government civilian.

Niran Al-Agba MD 3:13

I love the way you said it, you know, find a way to practice medicine that works for you. And I think, to be honest, it's probably the best summarizing I've ever heard of what I think we're all missing, which is you have to be you. And I guess could you kind of take that further and sort of talk about the definition or how you define moral injury or what made you decide to talk about it in that way because I think words are so so important. When we describe things and many doctors now are finally on the what I'd say the moral injury train, right? That number one, they're on it. They've been on it for a long time. But as far as identifying that feeling, or identifying that kind of experience, I think moral injury really so much better describes it. So I'll just stop talking and let you talk.

Wendy Dean MD 3:59

So it was one of those things where I had talked to a whole bunch of colleagues across the country, because that was a great part of being in the DOJ is I got to see people all across the country, in civilian academic institutions, because they were the ones doing the research and the military folks. But you know, I got a broad swath of people. What they all said was, I'm challenged trying to take care of my patients. I still love what I do for work, but I don't love everything around it. And then when I would ask them, I would challenge them and say, Well, are you burnt out? They would say, No, not really. I know what my patients need, and I can't get it for them. And that's what's so hard because I know what's available and I can't get it for them. And so, people were being asked, they were taking an oath, whether it was spoken or unspoken, to put their patients first. And then they were being asked as soon as they went out into practice to compromise that by putting something else in front of their patients. So it's this idea of transgressing a deeply held moral belief, which is the essence of moral injury. And in healthcare that deeply held moral belief is the oath that we took to put our patients first.

Rebekah Bernard MD 5:15

First of all, Dr. Dean wrote a landmark article. And if you haven't read it, of course, I would encourage you, it's in stat news, it was published in July of 2018. And we'll include a link to that article in our show notes. But that was her landmark article with Dr. Talbot in which they discussed this whole idea of moral injury and physicians. And they wrote that they believe that 'burnout is itself a symptom of something larger, our broken healthcare system, and the increasingly complex web of highly conflicted allegiances to patients, to self, to employers. So this role conflict and its attendant moral injury may be driving the healthcare ecosystem to a tipping point, and causing the collapse of resilience.' Can you talk about what you've observed, as far as the medical-industrial complex, and what that's done to physicians and patients?

Wendy Dean MD 6:08

Oh, boy, there are so many things I could talk about. So what I feel like is, at its heart, at the essence of the problem is that we used to have a system where physicians and patients were in a one on one relationship with each other, I have a problem, I go to the physician, the physician diagnoses me, they, you know, they take care of me and I pay them. And as we have grown more and more into an industry and into corporations, there are more and more people who are between the patient and the clinician, and who have a say in what care that patient gets, whether it's the insurance company saying what drugs you can get, or what surgery you can get or what hoops you need to go through to get the surgery or the hospital saying how many nights they can stay in-house. All of those things are getting between the physician and the patient. And I think it's causing a breakdown.

Rebekah Bernard MD 7:07

I think you're 100%, right, and Niran and I actually have a chapter in our book where we go into all of this. And, of course, you know, our book is about the takeover of nonphysician practitioners. But a lot of that has to do with this medical-industrial complex, and just that there are so many barriers. And now we've had to add additional clinicians into the mix just to help doctors take care of all of these challenges. And one of the things that you talked about in that article, I loved it because it said most physicians enter medicine following a calling rather than a career path. We have the desire to help people. And I like how you said 'many approaches it with an almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health and a multitude of other challenges.' And you mentioned, 'each hurdle offers a lesson a lesson in endurance in the service of one's goal, which starting in the third year of medical school is sharply focused on ensuring the best care for one's patients.' And of course, they teach us that's the whole definition of professionalism is really putting yourself behind the patient's interest. So I think that's when you talk about moral injury and physicians. I think that's one of the reasons that doctors get so incensed when a clinician with a fraction of the training, who didn't go through any of those steps, just walks in and says I can do the same thing. Don't you think that that affects moral injury and physicians?

Wendy Dean MD 8:37

So I think it's bigger than that. And I think what we need to keep in mind is that we're so on our part, podcast, Moral Matters. There's an episode with Richard Lamont, who is the former dean of the School of strategic land power, what does that got to do with medicine? Professionalism. And what he talks about is how we are losing how the military lost its way with professionalism, which led eventually to this concept of My Lai, which is the massacre that happened in a Vietnamese village. And what the army learned in those lessons were critically important. And I think if we went back and read those things, it gave me chills when I read it, because it, you could just cross out the military, and you could put in health care, and it sounded very, very familiar. So we're really good at developing great clinicians. What we have been less good at is making sure that we keep the other three pillars going, the human development side, the social contact side, and ethics and morality side. And I think what we need to keep our eyes on is that when we lose those, we lose our profession. And when we lose the profession, we lose this sense of transforming people into this professional identity. So I was listening to another podcast by Yuval Levin on three takeaways. And what he was talking about was how we've lost the trust in large institutions has eroded in the US over the past 50 years. And the only exception to that is the military. And why has the military increased? Well, first of all, they started very low, because it was right after the Vietnam War. So you know, but the other part of it is that the military is known as a transformative experience. I would argue that medical, the transformative experience of going through medical school and residency is not the same as the military. But it is definitely a transformative experience. I don't think anybody who goes through that comes out the other side, the same person that they went in.

Niran Al-Agba MD 11:02

I think that answer is so spot-on, because my husband's an Army Special Forces, you know, veteran, and he talks about like living on bugs in the south in seer school and things. And I often say to him, You have no idea what I've been training. And he says, Well, you have no idea what I've been through it, I'm like, I did get to eat peanut butter that I took from the hospital, little packets when I was there. So okay, I wasn't eating bugs, that's fair. But it's so similar. And I think there's so many things we can use to relate. But you're right, we enter as a person, and we come out as a completely transformed, hopefully, human being, but a completely transformed identity. And I think that's such an important point, right?

Wendy Dean MD 11:44

And we learn, we learn to think differently, you know, one of my bosses, Joe Carvalho was a two-star General, and a physician. We had talks more than once about how, in this large corporation, the physicians thought differently, we learn to manipulate and transform and, you know, change the data, you know, acquire data at such an unbelievable speed, and then put it into a package that gives us a diagnosis or gives us a direction. And that's not something that's innate. Nobody comes in with that skill set.

Niran Al-Agba MD 12:33

Well, and I think, I guess my question would be, do you think that it's something in our training that could, you know, again, I think Special Forces, for example, are selected just in a similar way? Very few make it in very few make it through. It's, you know, it's this funnel, right. And is there more we can do when we are being trained? Or when we're training our young people to help with moral injury? Is it anticipation? I mean, could you talk a little more about that? And what can we do?

Wendy Dean MD 13:02

Yeah, so um, one of the things we need to do is we need to have each other's backs. And as we're, as we're driven to communicate through the EMR, because of meaningful use, as we are driven to be more productive, so we're too exhausted to go to the Medical Society dinners. And oh, by the way, our medical society dues are now paid for by the hospitals. So they're not working in our best interest anymore. So if we want to take them back, we need to start paying those dues. You know, we're being broken apart, we're being broken into these tiny little silos. And so one of the first things I would encourage people to do is to start reaching out and rebuilding community, the community of physicians. The other is that yes, we need to educate folks better about what to expect coming up in medicine, what does the landscape really look like? Where do you need to go when you have questions? What do you need to do to protect yourself? How do you manage yourself in a corporate environment? Because it's very difficult, different than a medical environment. And then, how are we training? How are we identifying and training our next set of leaders? Because that's part of the development and the maturation piece.

Niran Al-Agba MD 14:24

I love that. You know, just as aside, I'm an independent physician, like Rebekah, and we just recently finally had an independent orthopedist decide to go out on his own and of course, the plans were hashed out over dinners like with some of us that are independent doctors saying like this can be done, we will help you - we didn't even really need to help him too much. To be honest, he's very bright and very capable. But you know, even some of us who reached out to the newspaper like again, I think it's so important that we stopped tearing each other down and I think it's been interesting just for both Dr. Bernard and I even on Facebook, other places, you know, obviously people have very strong feelings about what we've done - writing the book, I'm sure they had strong feelings about your article and you took, you know, positives and negatives from that. And I think it's so important that we remember to if we want to critique the product, or we want to critique the opinion, I think that's so different than critiquing the person. And we forget that sometimes you know, it, no one who has this certain opinion is a bad doctor or a bad human being necessarily, you can disagree. And I think we need to stop sort of saying you must fit this one mold. We have this idea if we don't fit this mold we thought medicine was, we tear people down. So how do you work with people who are suffering, then moral injury or attacking each other? What advice do you have to sort of smooth the waters? I mean, you're at a psychiatry background, I admire y'all so much because it is extremely difficult.

Wendy Dean MD 15:52

I'll admit that it's been more than a decade since I practiced so that you know that psychiatrist hat is put on the shelf a long time ago. I feel like there are many levels that moral injury can happen on. So one of them - there are two mechanisms that I see. One is the transgression of deeply, deeply held moral beliefs, but the other is betrayal by legitimate authority in a high-stakes situation. So that could be the governors who didn't require mask mandates, the CEOs who kept elective surgeries running, knowing that they're going to run out of PPE. Right. So those are two different mechanisms. But then there are different levels. And so it depends on what level whether it's personal, whether it's sort of institutional, organizational, the organizational level, or whether it happens at a societal level, depending on which of those it is, determines the best way to help folks. So if you have an episode of personal moral injury, something has, has crossed your own personal beliefs, maybe your religious beliefs. That's something where you go and you get, you get mentorship. And you look to somebody who's more senior who has dealt with that issue and can help you manage through it. But if it's on an organizational level, like an organizational/professional level, which is more what we talk about, that's a situation where it's really about identifying what the challenges are in the system. And then finding your allies, finding the other stakeholders who believe as you do, and then learning how to speak up in ways that other people can listen. And making change one small step at a time.

Rebekah Bernard MD 17:43

Dr. Dean, do you think that there are times when physicians should just decide that enough is enough and walk away? You know, I'm thinking about the times that I've worked in these large organizations, and I always felt like, okay, I'm going to get in there. And I'm going to make that small incremental change, I'm going to be on the EHR committee task force, all these things, and then finally just realized that it may be that environment is just too toxic. And so for myself, and Niran, and we both own ourselves, and that's been for me just really eliminated my whole burnout issue, not that we don't still have challenges, but being my own boss has made a huge difference. Do you think that there's a place for that? Or do you think we should really just be trying to change the system?

Wendy Dean MD 18:27

I think we need to do both. And I think it depends on it depends on a lot of personal circumstances, which is the right answer. So it goes back to that finding what's right for you.

Niran Al-Agba MD 18:40

That's essentially what I was gonna ask, I am going to be the skeptic here. I'm not sure I believe the systems can be changed anymore. I've never even really been part of one ironically. But you know, I stepped down from active hospital staff when I was going to start having children, for example, and I've kind of never gone back and never looked back. But I love what you said about building consensus, and then figuring out who the stakeholders are, and then trying to be very deliberate about the change you're asking for. And I think there are people who have the gift to do that. I'm definitely not one of them. I just want to go in with a bulldozer and make the big change that I think is necessary and tell my patient what I think and me and my patient against the world. But that's not the right - like you said, what works for you. That's not - that doesn't work for me. There are probably people out there who are very skilled at this. It's an amazing gift. And I think you're right, if we can build consensus, then we can start to build up the system.

Wendy Dean MD 19:32

Yeah, I always think about it as the difference between a soccer tackle and a soccer lift. Right. You know, so...

Niran Al-Agba MD 19:40

I'm the tackle.

Wendy Dean MD 19:41

Yeah. And, and a lot of us as physicians are, right, because usually when we're faced with a crisis, we don't have time to think we don't have time to do the lift. And in the corporate environment, the lift is what's critical. So going in and just scooping that ball away.

Rebekah Bernard MD 19:57

That is such an interesting point, and I guess it is personality type. And what we do need are those physician leaders that have the finesse and the patience and diplomatic skills. And then with all the other physicians that want to tackle being having their back and solidarity. And that's really got to be the key. I think administrators and organizations really count on physicians being divided. You know, one of the reasons that Niran and I discovered that nurse practitioners have been so successful in gaining all of their increased rights is because they work together. I mean, they, they are united on this one issue, and they will not let anything else get in that way. Whereas physicians, you can hardly get us united on any one thing.

Wendy Dean MD 20:43

Correct. Yeah. And I think the other thing that we need to remember is a brand new soccer player doesn't know how to do that lift, we need to teach them, we need to coach them and encourage them and train them to be our leaders to be our voices

Rebekah Bernard MD 20:58

That is so important. So how do we get that going? I mean, do we look to organized medicine? How do we do this?

Wendy Dean MD 21:07

So that's a, that's the harder question, right? I think we need to - so what I hope is that physician groups, maybe physicians, either medical societies or professional societies, will start actively training people to take those roles, identify who has the interest and the aptitude, and not just wait for people to float to the top, because they're good researchers or good surgeons, because those skills are very different than the skills that you need in the corporate environment or in the boardroom. When those decisions come up. And when you walk into that unprepared, it's quite a shock.

Niran Al-Agba MD 21:49

I don't know if you're as aware about there's this sort of like massive growth in physician coaches. And Rebekah and I talk about this often, because to a certain extent, it sometimes feels like we have physicians, and I tell my patients all the time, you know, nobody wants to do this job anymore. So we've got all these very highly trained, skilled, brilliant people, you know, leaving medicine to be physician coaches, specifically to coach especially women physicians, but there are other kinds of coaches out there, you know, to coach on a variety of different things. But I think to a certain extent, they may be onto something. I mean, it's not my bag, I like my patients, and I like kids. But again, I think there's an element of when you go to your professional societies, you're afraid about confidentiality, and you're afraid of this obligation on behalf of the society to maybe share or not be as confidential, because that's what I hear from people that they want to see a counselor or psychiatrist off the books, they'll drive to another state. And I'm not even talking about depression. I'm talking about just like counseling, just like I'm burned out.

Wendy Dean MD 22:48

Yeah. So yeah, really different things. And that's why identifying the source of your distress is important. Is it depression? Is it anxiety? Is it relationship issues at home? Is it something else? Or is it the toxic environment that you're working in every day? If it's the toxic environment, that's where I think it's really important to identify a mentor to identify a sponsor, to, to look for people who can help you understand how to swim in that system, how to swim in that environment that is toxic, or that is challenging. I think the coaching world is fine. With caveats. If you're talking to another physician who left practice, because they didn't like the practice, and they wanted to get out, then maybe, you know, maybe that coaching won't be in the direction you want it to be in. If it's somebody who has been an executive in the past, who can understand what that mindset is and how to move you to it or through it. That's a different situation. I also think we have to be so much better in not outsourcing all that. We need to mentor our own. We need to commit to bringing the next generation up, and not just teaching them the technical skills, but teaching them how to think like a physician, how to be a patient advocate, not only in the exam room but also in the boardroom.

Rebekah Bernard MD 24:25

Gosh, you're so right. And as I listen to you, I just think I hope everyone out there listening decides to make a commitment to reach out to someone that's in training or just starting their career. And just let them know that you're available to help them and see them through because they probably would be afraid to just come up to you and say 'Hey, will you be my mentor?' I would imagine so we need to be as the more senior physicians reach out to newer doctors and just give each other a hand I think that's so critical.

Wendy Dean MD 24:54

Well, I think it's a you know, it's a matter - I see it as not just a matter of reaching one individual person, it's a, it's a mindset across the younger generation. This is how you conduct yourself in this situation. Let me show you right seat- left seat.

Niran Al-Agba MD 25:13

I would encourage everyone who's listening because I think you're exactly right. Try to reach out and even work with if there's a local residency program or things like that to support. Because I often joke that I adopt residents here and there and I do I have them for dinner, and I have them in the clinic, and I really kind of fight for them to have certain experiences. I think it's so so important that residents do get to experience all kinds of no matter what their specialty is, you know, even general surgeons, right. There's private general surgeons, and there's employed general surgeons, and there's, you know, all sorts of different kinds of places to work and grow. And I just think it's so so important that we managed to stay connected, even if we're not academic physicians, with training, because I do think there's that element of who's coming up behind me. And I learned something too. I learned something every day when I'm working with the residents. They're faster up to date than I am. They have it on their phones and all this fancy stuff. But it's cute. They'll say to me, 'oh, that's what a growth chart looks like.' And I'm like, 'oh, wow, yeah, here's my ruler and my pen.' I had that today. And he said, 'Well, the computer just does it.' And I said, 'Okay, well, this is how we used to do it.' And so again, there's this exchange, I guess that's what I'm looking for. And there's a lot of satisfaction I find from that exchange. And I hope the trainees feel the same way. But we've gotten away from that. So I mean, how can we get more of that or get that back? I guess, is probably the question.

Wendy Dean MD 26:38

Yeah. So I think the way to get it back, is to start asking for your, for the systems in medicine, rather than for physicians to be answerable to those systems, that those systems facilitate the physician or the clinician-patient relationship. So, you know, it's not about 'what does the CFO want to hear from me as a clinician?' What do I owe to risk management for safety or for anybody else, but turning it on its head and saying, 'how is the CFO asking making my life my job easier with my patients?' What can you streamline out of the EMR? For example, what is your hospital doing to fight prior authorization? What is your hospital doing basically, to break down barriers, not explain to you why they're there.

Rebekah Bernard MD 27:35

And you know, one of the things you talked about in your article is this idea of learned helplessness in which we basically stop doing those kinds of things, because we just feel like we're pushing against the wall, and what's the point, but you're so right, we can't give up. We can't just, you know, say, Well, this is what it is, and I'm just gonna suffer and be miserable. Either you do something different like you walk away, or you make a concerted effort to make the system better. And although that's hard and get support and get help, you know, we've talked about how physicians are impacted by moral injury. But I want to take a few minutes to talk about how really patients are the ones that are harmed by this because when doctors and nurses and clinical people are not in a good mental headspace, they can't take good care of patients. And Dr. Dean had a really difficult situation with her husband. And she wrote about it in an article published in January of 2020. And can you explain a little bit about what happened with your husband?

Wendy Dean MD 28:33

So we live in a relatively rural area, and we're two hours from the academic center and a big Academic Center, and he had a, he has a congenital condition that decompensated pretty quickly. And at our local hospital, we couldn't really get their attention and help them understand the urgency of what we saw as two physicians. And we watched him decline over the period of four days to the point where he couldn't lie down because he couldn't breathe. And he could instead up because his liver was down to his pelvis. And it was, it was a tricky situation. And the only way I could, you know, I couldn't figure out was like, these people are not our advocate, I don't understand what's going on. And the only way I could think about it in retrospect was to say their hands were tied. Right? If they transferred him out, they were sending him outside of the system, they were increasing their leakage that was going to be held against them. And so they kept him until the very last minute when they said, Oh, the next step is ECMO, and we can't do that. And then they transferred him out. And by the way, he's fine.

Rebekah Bernard MD 29:51

Yeah, so just to kind of summarize what had happened from your article, you have run into so many challenges. I mean, in the very beginning, Before he was admitted to the hospital, he was trying to call doctors he was trying to get a callback. Nobody was calling back. He finally you finally got into the hospital. And basically, anytime you would challenge or question the clinicians, you were just met by, you know, stoic faces and just really didn't seem like a lot of empathy. So, fortunately, you're able to finally get him transferred. And then what was so interesting was when you got to the second hospital, things were completely different. They took really good care of him. And what you notice that you wrote about, as far as what was the difference you wrote here at that small hospital, the first one, 'the specialist treating my husband had recently transitioned from private practice to being employees of a health system. The system had bound the physician so tightly with scheduling control, data, metrics, policies, and punishments, that they too could barely breathe. They had almost no control over their patient interactions'. And I love how you say 'they were bound so tightly, in fact, that they stopped struggling because it was futile. It was about being shackled, straight, jacketed, and hamstrung. They knew what patients needed, but did not have the latitude or the autonomy to get it. They looked beaten, distanced, as if they had given up disengaged, stopped empathizing depersonalized, they felt as if they couldn't accomplish anything, so why bother even trying?' I mean, it just really, it hits the truth of what is happening in organizations all over the place.

Niran Al-Agba MD 31:28

That to me is the outcome of moral injury. Like that is the epitome your description is sort of the outcome of repetitive moral injury. On top, I mean, I guess maybe you'd start out even saying maybe they're a little burnt out, but that moral injury is a disaster.

Wendy Dean MD 31:43

I mean, when you think about it, when you look at what the symptoms of burnout are, right? When you go into work every day, knowing that you're not going to be able to make it, you know, knowing you're going to have to fight the system, it's exhausting. When you go in knowing that, you're not going to be able to change it, it makes you feel very ineffective. And then when you do that often enough, and you watch your patients suffer long enough, you depersonalized you separate yourself from your patients because you can't bear to feel their pain much longer. Those are the three symptoms of burnout. So I would argue that and what we've seen in talking to all kinds of clinicians is that unrecognized, on attended moral injury is probably the highway to burnout.

Rebekah Bernard MD 32:30

Wow, I think you're so right. And I also really appreciate how you wrote about this, not in a way to say these were bad doctors, these were bad nurses because that's what we usually hear 'Oh, they're just terrible people,' you identified that there was a core defect that turned compassionate, caring people into this terrible situation that can really harm patients. The other thing that you wrote about in a in a private message that I thought was really interesting, where there was a doctor who was sharing a story about how her child was in the emergency room, and a physician assistant came to evaluate the child. And the mom said, I'm not comfortable with that, I'd like it to be the physician please to come. And the physician assistant didn't like that. And actually, the attending physician didn't like it either. And so the mom of the child was, you know, basically had a negative experience. And you wrote to her, you said, this is the new double bind, don't say anything, and pray for no big misses, advocate for yourself or the patient and get labeled difficult confrontational, which also gets bad care. So if you choose number one, where you don't say anything, and something happens, why didn't you speak up, you need to be a powerful patient advocate. And then you mentioned that you yourself, are on the no-fly list at a hospital because you made such a fuss over your husband's care because you were advocating for him. And then the CMO later, you know, had some words to say about you actually thought said it was actually your fault, while your husband didn't get the best care that he should have gotten.

Wendy Dean MD 33:56

Correct. And I've shared that story with other people, and they've had the same experience. So it is a very difficult, it's a tightrope that patients and families now have to walk. They're supposed to be powerful advocates. And yet, if they make the staff uncomfortable, then they become the problem.

Rebekah Bernard MD 34:18

And that's kind of the case that happened with Dr. Susan Moore, the physician who was African American who - same thing, she advocated for herself, and she made people feel uncomfortable, but it doesn't necessarily come from just you know, a disparity issue. This happens to people across all spectrums.

Niran Al-Agba MD 34:40

And I think the hardest part you know, because you're scared, you have a loved one, you need the care done and yet, it's like you have no avenue to get that care

Wendy Dean MD 34:53

I also need to be empathic with the people who are in that situation, right? Because every physician now is running on a Jetson treadmill. And all it takes is one minor misstep and they are on their face, right? This is like they don't have any slack in the system, right anywhere ever. And so one patient that makes their life harder can ruin their whole day.

Rebekah Bernard MD 35:21

That's so true. It's I think it is all about empathy, but also changing the system. And you've really taken the first step and just changing the terminology. And I think that's so critical. I want to thank you so much for your work and for coming on our podcast to discuss this really important topic. If you'd like to learn more about these issues, we encourage you to check out our book, it's called 'Patients at risk the rise of the nurse practitioner and physician assistant in healthcare.' It's available at and Barnes and Your physician and you'd like to join us in this and we are providing a lot of mentorship to young physicians. So if you're interested in taking on that kind of role, please join our organization physicians for patient please subscribe to our podcast and our YouTube channel. It's called patients at risk. Thank you so much, and we'll see you on the next podcast.

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