Review of If I Betray These Words by Wendy Dean with Simon Talbot

This is a book about physician burnout [1]. Drs. Dean and Talbot prefer the term “moral injury” to “burnout” when discussing the affliction which affects so many physicians today. Since I represent a classic case of burnout, I was eager to read this book.

As I read each chapter, I wanted to engage the author in conversation. My mind was filled with anecdotes from my own practice. I had arguments and comments that I longed to share with her. This, I think, is the main value of the book. It is a fantastic stimulus for dialogue about a topic that is crucial to healthcare in our world today.

Most of us enter medical school feeling a calling to serve others, to comfort and heal those who are sick. We think of medicine as a noble calling, a moral life. We expect to make sacrifices that include grueling hours of training and interrupted family life. The personal price, we believe, will be more than balanced by the satisfaction of grateful patients restored to health. Unselfish humanitarianism is the core of our role as physicians.

On the other hand, the modern American healthcare system operates, to an overwhelming extent, as a business. Success is measured in dollars. Healthcare is no longer mission-driven with humanitarian goals. Rather, it has become an industry, focused primarily on revenue.

Moral injury occurs when a physician, sworn to healing patients, is forced to deny them optimum care. By performing inferior care or denying care for business reasons, including financial ones, physicians are required to violate the very principles that are at the ethical core of our self-image. Moral injury stems from systemic issues and is not synonymous with burnout, which reflects more individual symptoms, but moral injury and burnout are related.

Each chapter of this book is the story of a physician who has experienced moral injury in the practice of medicine and how she or he responded to the challenge. This, of course, is the time-honored way in which clinicians learn medicine, by case study.

The first chapter is brilliantly written. It provides a wonderful insight about the basic moral mindset of physicians and how that mindset enables them to endure emotionally and physically demanding training. This foundation is particularly valuable to non-physician readers, who can gain an understanding of the kind of people who choose medicine as a profession and what it takes to become a doctor.

Subsequent chapters describe real situations in which idealistic doctors enter the real world of medical practice. Each case study illustrates how practice in the real world of healthcare can contribute to moral injury. Principles which drive successful businesses conflict with desires to help individual patients. Physicians spend enormous time on documentation and paperwork. Pressures to produce revenue mean cramming more patients into busy schedules and selecting patients with good insurance over those whose care is less lucrative. Staffing is determined by measures of business efficiency. If a hospital needs three physicians in-house to provide safe coverage for patients but can cut costs by providing only one, hospital management chooses to ignore the opinions of the physicians, minimize costs, and accept certain risks, like the occasional in-house death. Physicians, driven to provide patient care, are often overruled by business executives. Issues of patient welfare and community service are secondary to corporate profit. Promises to physicians are broken when business conditions change. Healthcare stakeholders, which include not only physicians, other healthcare providers, and employees, but also patients and communities, are less important than healthcare shareholders, which include corporate stockholders and executives.

In each case study, we see how the physician responds to the challenges of modern healthcare. Some flee, looking for better employment, more favorable practice settings, new locations. Some change specialties, seeking professional satisfaction, improved lifestyle, better compensation. Others surrender in despair, including my own friend and colleague who took his own life. His story is found in Chapter 6.

The book is not perfect. The Introduction is long and tedious, perhaps better skipped lest the reader lose interest before getting started on the good part. Individual chapters can be very similar to one another and seem repetitive. Long, detailed discussions of corporate maneuvering and changes in management can distract the reader.

The proposals for solutions and improvement to the healthcare system that the author puts forth include education, public policy changes, enlightened leadership, and personal courage. These seem like the usual approaches to societal problems. Still, they get the reader thinking.

The book should be read not only by physicians, but also by other healthcare professionals and, perhaps more importantly, by people involved with the management of healthcare organizations. Healthcare executives are not bad people; they need to understand that physicians have different moral values. There are discussions that need to happen. This book provides an excellent stimulus for those discussions.