Interview by Janina Levin
In July 2024, a man known for making nature videos on a YouTube channel named Goobie and Doobie posted a video with the headline: I Was an MIT Educated Neurosurgeon Now I’m Unemployed and Alone in the Mountains How Did I Get Here? This highly personal video explains why he quit operating on people’s backs and necks at thirty-eight years old, without a plan about what to do afterwards other than to spend time in nature with his dog Doobie and heal his troubled soul. (After he posted the video, viewers started calling him “Dr. Goobie,” as he did not reveal his real name, Jonathan Choi, until October).
Beyond the personal reasons, Dr. Goobie details what he calls the “moral injury” of working for nine years at a hospital, performing surgeries that did not always help patients. Although this was profitable work, both for him and for the hospital, he compares it to putting new dry wall into a house with a leaky roof—a temporary fix for a more serious underlying problem. Part cry of the soul and part indictment of a medical system that has the wrong priorities, the video has over thirteen million views to date.
On the other side of the spectrum, a now retired emergency physician, Dr. Drew Remignanti, refused to quit medicine in the 1980s even after suffering some initial symptoms of burnout and experiencing a severe a stroke (coincidentally also at thirty-eight years old). He recently published The Healing Connection, an honest and hopeful book arguing that the future of medicine should involve a partnership between medical professionals and their patients. These two highly skilled medical practitioners sacrificed much to maintain high standards in patient care, and the difference between them may depend on the difference between physicians experiencing burnout versus moral injury.
The term moral injury is relatively new in the context of medicine.1 Doctors express suffering from moral injury when they cannot provide their patients with the high quality healthcare they believe all patients deserve, experiencing feelings of meaninglessness and remorse because they have violated their core beliefs.2 We have known for many decades that conflicts of interest between hospitals, insurers, and healthcare systems undermine and fragment patient care, but now more doctors are speaking out about their role in perpetuating this broken system. Although physician burnout has received a lot of attention (researchers recognized the problem in the 1980s), some physicians claim that moral injury is distinct from burnout and should be addressed as a separate issue.3 With many doctors-in-training questioning whether to stay on track and finish medical school, as well as more working doctors quitting after the pandemic, moral injury in doctors deserves greater visibility and discussion.4
In February, I reviewed Dr. Remignanti’s book, which touches on moral injury in a chapter on physician burnout. In a recent interview, I asked him to elaborate on the topic. We discussed how moral injury is distinct from burnout, how the medical system can respond to the problem, and why empowering patients might be part of the solution.
Doctors Simon G. Talbot and Wendy Dean argue that moral injury is distinct from physician burnout. Do you agree?
I think they are distinctly different. Burnout is the psychological and emotional fatigue you feel in trying to do the right thing within any profession.5 You beat yourself against things that you don’t think are right, and you become emotionally, spiritually, and psychologically exhausted by that process. It’s a very real issue.
Moral injury is when you find yourself in a system where you’re not allowed to object to doing things that are diametrically in conflict with your moral code. Talbot and Dean compare it to the type of decisions that soldiers make in war, when you have to kill individuals and that goes against your moral code. They call it “death by a thousand cuts” because any one of these incessant betrayals might heal, but over time, they can lead to bad healthcare decisions and therefore to moral injury. That, I think, is a better analogy for what’s going on in healthcare today. I may know exactly what’s right for you as a patient but the pressures brought to bear upon me by the system I work in—whether it’s my department administrator, the hospital administrator, or just the general consensus within healthcare— are saying no, you can’t do that for this patient. So I decide to go along with that guidance because I want to protect my job, knowing I’m making a bad decision under pressure.
Would you consider doctors’ justifying treatment to insurance companies a moral injury?
That’s more in the category of burnout because you can stick to your guns in that situation. You don’t have to make a compromised decision. You can continue the argument. Jennifer Lycette, an oncologist, points out that sometimes she’s talking to a non-medical person that is trained to tell her “No, you can’t do that because it’s not hitting this box and that box.” So being told what to do by people who know less than you do and know next to nothing about the patients themselves, that’s horrible. But it’s not moral injury because you’re not making a bad decision. You’re advocating for your patients. But it’s burnout because you’re banging your head against the wall. An unrelenting wall.
So in this case doctors can argue for the case. Once it reaches the stage of moral injury, then you cannot do anything about it all.
Yes. I have the advantage of being a very stubborn individual, by nature and by choice. So it’s hard to convince me to do what I do not want to do, especially when it comes to something that will be a detriment to a patient. It wears you down, but you make peace with it one way or another. Or leave the system, like the neurosurgeon we talked about.
Do you know how the medical system currently handles moral injury?
I think it’s being ignored. But I see two approaches, one is individual and one is societal. My optimism is with the societal. We can course correct if we can get enough people to have at least a glimmer of an understanding of the compromises we’re asking physicians to make in regard to patient care. If we all start beating on the same drum, saying Hey, things have gone astray here! We are compromising good healthcare decision-making, we have more ability to get through the system. I wrote my book to provoke that society-wide conversation.
But patients are relatively protected from knowing how much of the care that their doctors think they need is being prevented by the system itself. You have to take our word for it that we’re trying to do our best by you. So I’m hoping patients begin to see that. The fact that patients outnumber healthcare workers may help. In partnership, our greater numbers may succeed in effecting change.
Individually, those of us who work in healthcare can say, “Look, these are my moral principles. I’m going to do what I believe is right.” The risk you run is that you’re seen as a squeaky wheel, and it’s easy to throw out the squeaky wheel and replace it. You lose your job, which compromises your professional goals and your family. You may have to move. These are pretty powerful disincentives to speak up.
I appreciate that you stuck it out until retirement in emergency medicine. You tell that story in your book.
Oddly, the fact that I was knocked out of the practice of emergency medicine for five years by my stroke was almost a benefit, because I got a chance to catch my breath and reassess what I had been doing. I not only made the decision to re-enter medicine a second time, I made the decision to specifically re-enter emergency medicine, because I could have retrained for a different type of medicine. At that point, my identity was as an emergency physician, and I wanted to end that identity on my own time. It goes back to my being, both inherently and by choice, a stubborn individual.
But it seems as if you’re the exception, right?
I think every physician practicing medicine wonders what could I do other than medicine? Because it’s difficult. The straightforward cases are easier. You think your shoulder is dislocated. I look at it, and without even an X-ray, I could tell it’s more than likely dislocated. The X-ray confirms the expected dislocation. I then pop your shoulder back in place with your cooperation. You feel tremendously better. I feel good about having delivered that service to you. But many patients don’t realize that most of medicine is not so straightforward. There’s tons of uncertainty involved in healthcare. Having to deal with the stress and strain of making the right decisions for patients every moment of every day that you’re at work is stressful.
Since publishing the book, I came across this concerning statistic: 61% of medical students today don’t intend on actually seeing patients. They want to go into healthcare administration, which could be a good thing if they bring the right principles to this work. Even so, we can make practicing medicine less stressful and more effective. But I’ve always loved the challenge. Practicing medicine is an endless challenge. I think a lot of us that go into it like the challenge of it.
Which points in your analysis do you think will matter in the long term? And which parts of your solution might be solidified?
If you had said to my generation during medical training—“Now the business people will lecture you about why you will need to make quicker decisions, and spend less time talking to, evaluating, and caring about your patients”—we would have said, “What are you talking about?” Medical students today are aware of that reality much earlier, which is why they may be saying, “I want don’t want to put myself in that compromised position right from the get go. Maybe healthcare is not for me.”
But I’m hoping that we’ll see that the beginning of the twenty-first century was when we decided to abandon the passive, patient role in this equation and create a true patient-physician partnership. I think it is the only way out of burnout, moral injury, and more doctors leaving the profession.
And this can happen overnight. A patient could literally decide—if they’re reading my book or listening to me talk—this crazy guy, Drew, said I should become more knowledgeable about more engaged in the my own healthcare. And so that’s what I want to do with you, Dr. X. Then they’ll have to pause and walk across the room and help us up off the floor, because some of us are passing out ready to hear that.
Thank you so much for sharing your insights and expertise with our readers.
Janina Levin is BMJ’s Medical Humanities blog content editor, a trained medical editor, and a literary critic working in the areas of narrative empathy and men and masculinities. She also teaches writing at Saint Joseph’s University.
References
[1] Sneha Mantri et al., “Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP,” Journal of Religion and Health 59 (2020): 2324. https://doi.org/10.1007/s10943-020-01065-w
[2] Mantri et al., “Identifying Moral Injury in Healthcare Professionals,” 2324.
[3] Drew Remignanti, The Healing Connection: A Partnership for Your Health (Something or Other Publishing, 2023), 179; Simon G. Talbot and Wendy Dean, “Physicians Aren’t ‘Burning Out.’ They’re Suffering from Moral Injury,” STAT, July 26, 2018, https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
[4] Samantha E. Smith et al., “Foundation Year 2 Doctors’ Reasons for Leaving UK Medicine: An In-depth Analysis of Decision-making Using Semistructured Interviews,” BMJ Open 8, no. 3 (2018): e019456. doi:10.1136/bmjopen-2017-019456
[5] Remignanti, The Healing Connection, 179.