Moral Injury Starts in Medical School

I have received feedback about my content and ideas being relevant to a variety of fields/industries – and I love it! I hope for as many people as possible to find value in my work. I do however, want to explain why I am so driven to write specifically about med student/physician well being. I’ve seen how the practice of medicine has turned into a healthcare system. A broken system. And I’m in it, I’m part of it. I realize this now. It’s a broken system and I can’t passively tip-toe over the pieces for the rest of my career, let alone for the rest of my life. But I didn’t decide to start doing this for myself. I started doing this because I see what’s happening to my colleges and physician teachers. Before medical school, I didn’t know any physician personally, so when I entered medical school I was overjoyed to find myself surrounded by some of the most compassionate and dedicated people I had ever met. The majority of student and current physicians that I know are genuinely good people, which is why it kills me to read articles like this one. Please, take the time to read this article and understand the importance of advocating for physicians. They take care of us, and we need to start taking care of them too.

It starts with unrealistic expectations. In my first two years of medical school I was taught the best practices, the gold standards, the “right” way to practice medicine. I figured out (with great frustration) how to complete a 14 minute patient encounter and a 9 minute SOAP note. Although I typically scored well with these practice patients, I rarely satisfied myself. Sometimes it was a question I forgot to ask or test I didn’t have time to do. Mostly it was the feeling of being so rushed that I didn’t actually get to know the patient’s story beyond their medically relevant history. We’d get a point for “rapport building” but we learned early on that we had to prioritize the aspects of the encounter that would get us the most points. “Oh I skip that test because it takes too long” (and is only worth a point or two) was a common phrase among my classmates. On the wards and in the clinic points turn into dollars… now checking the boxes becomes necessary to appease the insurance providers to make sure someone gets paid. And in the real world, no one is paid for rapport.

Another difference between school and the real world – patients don’t come in with just one complaint. Some bring a laundry list, and from my experience as both a student and a patient, no one is happy when a patient confesses all of their (sometimes very personal) problems, and then gets rushed out door with only a fraction of their needs addressed. The frustration for the patient is obvious, but I the moral injury that this inflicts on the physician needs to be understood as well. I think many students/physicians agree that we want to take the best possible care of every single patient, and this includes addressing all of their concerns. It feels like a moral obligation because as a patient I understand the inconvenience of going to the doctor. Having to take time off from work, and paying for multiple visits isn’t always possible. And when patients get admitted to the hospital  for a preventable condition we blame them, wondering how they went so long without taking them of themselves… But when physicians get penalized for not seeing four+ patients an hour, nobody wins (except those making the big bucks). Either the physician gets in trouble with the employer for taking to long, or with the patient for not taking long enough. Or with the next patient who is now late to be seen. What is a good doctor supposed to do?

Medical school doesn’t teach you what to do when insurance denials, prior authorizations or weekend closures prevent optimal care and endanger your patient. They have no solutions for an excessive patient load. School emphasizes the necessity timeliness and of the important aspects of care that must be completed, but they turn a blind eye to the fact that sometimes we will have no control, and we can’t complete everything. They teach how to provide optimal care. And don’t think that I would ever blame the school for this, they teach us all the “right answers” because they have to in order for us to pass the test. But the real world isn’t multiple choice, sometimes there are multiple right answers, and other time there are none. Sometimes the right answer on the test is the wrong answer in real life.

We know the importance of what we do, the gravity of our role is instilled in us with every wrong answer that reminds us we’re not ready – that we could have killed that patient it wasn’t just a test question. Eventually we start getting the answers right. We start knowing what to do. We figure out what would be best for our patients. This is what makes the inflicted moral injury so painful. No-one teaches us how to deal with the barriers that prevent us from doing what we’re taught, what we spend countless sleepless nights learning. Making sacrifice after sacrifice just to be prevented from doing what we’re taught – providing the best possible care to each and every patient. Nobody teaches us how to cope with the pain we feel when we feel like we let our patients down (even if it’s out of our control). Does anyone have an idea of what’s happening to their future physicians? Does anyone realize that the pain from moral injury starts in medical school? Is everyone oblivious to the fact that so many physicians are suffering because they simply cannot practice medicine the way they were taught, the way that is best for the patient?

By no means is it a fix all, but I will continue to share these points originally written by Elliott Martin, MD Psychiatry. I agree that implementing the below policies would be a good place to start.

  • Dismantle the state boards of registration in medicine and any and all “maintenance of certification”
  • Make prior authorizations for hospitalizations, procedures, and/or medications of any kind flat-out illegal
  • Eliminate “value-based” incentives
  • Criminalize online reviews of physicians
  • Decrease documentation requirements
  • Provide national amnesty for all medical school loans
  • Pay more (My opinion is to add additional compensation for additional time spent with patients.)h

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Kailee Marin

Aloha! My name is Kailee Marin, I'm a DO student in California. I was 15 years old when I decided to go to medical school. I spent three years in Hawaii getting my bachelors, then I came straight to CA to pursue my dream. These three years have been a rollercoaster - the best and worst of my life. I've spent med school listening to, and participating in the complaining of my classmates. I've come to realized that it's all the same. It comes down to the common barriers that current and future doctors face - and it starts in medical school. Moral injury being disguised as burnout so that institutions can pretend they care... But moral injury can't be fixed by wellness Wednesdays, or fitness Fridays. I have realized, to heal moral injury, you have to treat the underlying cause. And there are so. many. causes. So I guess I have a lot to talk about! As an aspiring psychiatrist, I feel compelled to advocate for mental health. This includes the mental health of my colleagues, my future patients, and myself. 

  2 comments for “Moral Injury Starts in Medical School

  1. May 20, 2019 at 8:43 pm

    If you want to be free of third-party (including government) red tape (prior auths, “value” incentives, etc.), you have to declare independence and not take their money. Whose bread I eat, his song I must sing. See As for amnesty for loans, where does the money come from? From those who honored their contracts and paid what they owed? From families struggling to pay their mortgage or rent?

  2. Sir Lance-a-lot
    May 19, 2019 at 8:56 am

    “… when I entered medical school I was overjoyed to find myself surrounded by some of the most compassionate and dedicated people I had ever met.”


    I clearly remember my first day at one of the more “touchy-feely” medical schools: There was a little reception for he new students (no alcohol!), and I realized, as I talked to one after another, and listened to other conversations, that I was standing in the middle of the biggest group of self-centered egotistical assholes I’d ever seen in one place.

    I was overwhelmed by a feeling of dread, which I now know was premonitory, made a mental calculation balancing all the work I’d done and all the money I’d spent to get there, and all the people who were proud of me, with the personal cost of immersion in this swamp of narcissism, came up with the wrong answer, and decided to stay and stick it out.

    Since that time, I have met almost no doctors I have actually liked (a few I could tolerate working with), and literally hundreds of self-important nincompoops I couldn’t bear to be in a small room with. Fortunately, I get along with the nurses, nurses’ aides, and ambulance crews, so I still have someone to talk to all day at work (when the bosses aren’t watching me and telling me I talk too much, anyway).

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