I F I B E T R AY

THESE WORDS

Moral Injury in Medicine and Why

It’s So Hard for Clinicians to Put Patients First

Wendy Dean, M.D.

with
Simon Talbot, M.D.

s t e e r f o rt h p r e s s
lebanon, new hampshire
 Copyright © 2023 by Wendy Dean

All Rights Reserved

For information about permission to reproduce

selections from this book, write to:
Steerforth Press L.L.C., 31 Hanover Street, Suite 1
Lebanon, New Hampshire 03766

Cataloging-in-Publication Data is available from the Library of Congress

ISBN 978-1-58642-355-1

Printed in the United States of America

 I ntroducti on

What Beer and Modern Healthcare Have in Common

Dr. Mike Hilden answered the knock on his front door in the fall of
2012 to find two Federal Bureau of Investigation (FBI) agents waiting
to speak with him. The FBI hadn’t come to Carlisle, a quiet college
town of twenty thousand people in central Pennsylvania, for drug
dealers or old-school racketeers. They were talking to doctors, nurses,
and administrators at the local hospital, tipped off by whistleblow-
ers who leveled fraud allegations at Health Management Associates
(HMA), the fourth-largest hospital corporation in the United States,
and the owner of Carlisle Regional Medical Center.
Dr. Hilden had been a hospitalist at Carlisle Regional for more
than a decade, since before the board of the nonprofit community
hospital sold out to HMA. Now it was one of seventy-one hospitals
in a nationwide for-profit enterprise that was being accused of coerc-
ing physicians to forsake their medical judgment — to hospitalize
patients who didn’t meet insurance criteria, to order more tests than
their conditions required, and to keep them in the hospital longer
than necessary — to increase profits.
Carlisle, established by Scots Irish in the mid-eighteenth century,
had an early history fraught with conflict. The Carlisle Barracks, now
home to the United States Army War College, served as supply head-
quarters in the Revolutionary War. George Washington reviewed
troops there before sending them west to put down the Whiskey
Rebellion, and downtown buildings still bear the scars of a three-day
occupation by Robert E. Lee during the Civil War. But since stopping
the northward advance of the Confederate army, the town had been a
2 Introduction

quiet place. Unfortunately, though the community didn’t know it yet,

the fight in healthcare over profits, patients, and physician autonomy,
waged by ever-larger corporations, was coming to them.
A key figure in the FBI investigation was someone few people in
Carlisle had ever heard of: HMA board chairman William Schoen. Just
a few months earlier, at the company’s annual shareholders’ meeting
at a Ritz-Carlton resort in Naples, Florida, Schoen defended himself
against a few shareholders agitating for his ouster. The disgruntled
shareholders claimed that HMA failed to hold its executives to the
same standards as competing corporations and that its insufficient
attention to compliance with federal regulations put the corporation
at risk.
Under Schoen, HMA’s only criterion for executive bonuses was
a single financial measure: EBITDA (earnings before interest, taxes,
depreciation, and amortization), a measure that isn’t one of the gener-
ally accepted accounting principles used by publicly traded companies
in financial statements. Moreover, most large, publicly traded health-
care corporations also included at least one quality indicator, such
as readmission rates, hospital-acquired infections, or patient satisfac-
tion, in bonus calculations.1 Charlie Munger, vice president of Warren
Buffett’s Berkshire Hathaway, in his 2020 address to the Daily Journal
shareholders meeting, referred to EBITDA as “bullshit earnings,” a
measure so manipulable it deserves little credence.2 Shareholders were
concerned that HMA executives were manipulating the numbers to
line their own pockets rather than creating real value for investors,
while a weak board, whose members were handpicked by Schoen and
secure in their tenure, was doing nothing about it.
During his time as chief executive officer and board chairman,
Schoen had grown the organization from a small regional player to
a Fortune 500 company with national reach and billions in revenue.
His responsibility was to his shareholders, not to clinicians, and not
to patients, who were both free to go elsewhere if they didn’t like the
conditions at his hospitals. Schoen believed that his compensation,
 What Beer and Modern Healthcare Have in Common 3

and that of his senior team, was hardly out of line with their success,
or with their peers in the industry.
At the meeting, HMA’s vice president of financial relations at the
time, John Merriwether, denied the critics’ contentions: “To imply
that we don’t take quality as seriously as we should, that’s not fair. If
you don’t provide good quality care, you won’t have good financial
performance.”3 But HMA specifically targeted markets where it knew
there was little or no competition, so patients at HMA hospitals could
not vote with their feet or their healthcare dollars. The Center for
American Progress found that rural emergency rooms in hospitals like
those HMA acquired were, on average, twenty-two miles from the
next nearest emergency room,4 a distance that could mean the differ-
ence between life and death.
Ultimately, the shareholders weren’t swayed by the critics. Schoen,
the board, and the compensation structure all remained unchanged.
But the Health Care Fraud Prevention and Enforcement Action Team,
a joint effort by the US Department of Justice and the US secretary
of health and human services, was just getting started with HMA.
Between 2009 and 2011, whistleblowers filed eight lawsuits against the
corporation, alleging fraud. Agents from the FBI and Department of
Justice spent two years talking with hundreds of employees across at
least eight states, and by the time the investigation was over, HMA
agreed to pay a $260 million settlement for forcing doctors, under
threat of losing their jobs, to provide unnecessary care against their
best judgment and training. Dr. Hilden was vindicated, but he and
his partners, like so many other physicians in the grip of increasingly
corporatized healthcare, were looking for new jobs — ones where
they could practice medicine as they had been trained to do, not as
corporate growth plans told them they must.

William Schoen grew up during the Great Depression in Arcadia,

Florida. Even as a child, he was resourceful: selling flower seeds at
eight years old; hawking newspapers at the racetrack at thirteen; and
4 Introduction

dropping out of high school to start a scrap metal business. During the
Korean War, he enlisted in the marines. Unhappy serving on the front
lines, he vowed to finish his education when he got home. He even-
tually earned a master’s degree in business administration, studying
lean management principles and how economies of scale benefit the
bottom line, and upon graduation went straight into the turbulent,
low-margin world of glassmaking as a marketing manager for Anchor
Hocking.5 In less than a decade, he became president and CEO of
Pierce Glass, where his ambition caught the eye of Robert Lear, CEO
of the holding company that owned Pierce.6 When family-run brewer
F&M Schaefer Corporation recruited Lear to turn around their falter-
ing beer business in 1972, Lear jumped at the chance but knew he
couldn’t do it alone. He started planning how to bring Schoen on at
Schaefer.
Businesses usually succeed in one of three ways: through better qual-
ity, lower cost, or less competition. Until the mid-twentieth century,
most beer was locally brewed, and companies balanced quality and
cost to appeal to local tastes. By the 1960s, however, companies like
Anheuser-Busch, Schlitz, Pabst, and Miller had built industrial brew-
eries, churning out beer at one-quarter the cost of local breweries, in
strategic locations along the new interstate highway system, which
enabled them to ship their cheap, bland brew around the country.7
Brothers Frederick and Maximilian Schaefer, immigrants from
Germany, founded F&M Schaefer Brewing in New York City in 1846.
The company survived the Civil War, Prohibition, and the privations
of two world wars, but by the late 1960s, it was struggling. An attempt
to expand Schaefer’s regional market into Ohio had failed. Brewing
was consolidating, with companies leveraging economies of scale
to compete on cost. Schaefer’s breweries in Albany, Brooklyn, and
Baltimore were aging and inefficient. To compete with the big brands,
then CEO Rudolph Schaefer II, grandson of Maximilian, decided
to build a new brewery. To fund the project, he needed cash,8 so in
1968 he took the company public, raising $106 million in capital. In
 What Beer and Modern Healthcare Have in Common 5

taking the company public, F&M Schaefer Brewing was split into
two business entities: F&M Schaefer Corporation, the parent holding
company, and Schaefer Brewing Company, the production subsidi-
ary. Schaefer immediately spent $60 million building a modern brew-
ery near major transportation hubs in Fogelsville, Pennsylvania, just
outside the former steel powerhouse of Allentown, where land was
cheap and labor was plentiful, with so many steel workers recently
laid off.
During the four years of construction, from 1968 to 1972, the
company continued to lose market share to the national brands.9
When the new brewery finally started sending out beer, customers
complained they could taste a difference. Sales flagged and debts
mounted. Something had to change.
Enter Robert Lear. Just a year after he was brought in, Lear lured
Schoen away from Pierce Glass to oversee the production subsidiary,
Schaefer Brewing, displacing Rudie Schaefer III. Rudie had been with
the company for sixteen years, working his way up the ranks as an
expert in production, and was being groomed to take over from his
father.10 But Lear and Schoen dismissed Rudie’s expertise. Their goal
wasn’t quality, it was survival as a profitable company. Lear was confi-
dent that Schoen’s “record of making his own way, overcoming prob-
lems, and meeting formidable challenges” would make up for his lack
of experience in the beer industry.11 But Rudie couldn’t bear to watch
his family name associated with a shoddy product. In 1976, after three
years of working with men who didn’t value his expertise, Rudie told
his father the work was “untenable” and left. The younger Schaefer
never returned to brewing.12
When the Fogelsville brewery opened in 1972, Rudie Schaefer had
closed the Albany facility, and three hundred people lost their jobs.
Still plagued by falling market share in 1976, Schoen needed to cut
expenses further. He again increased production in Fogelsville, then
shuttered the Brooklyn plant, putting another 850 employees on the
street.
6 Introduction

Schaefer had tried competing first with better quality, then with
lower cost, both unsuccessfully. So Schoen looked to the third strat-
egy: less competition. With the bigger brands dominating most of
the mainland US market, he set his sights on the island of Puerto
Rico, where beer consumption per capita had doubled in the 1960s,
but competition from local breweries was limited. By 1977, Schaefer
held 70 percent of the beer market in Puerto Rico, and its Baltimore
brewery was shipping 1.3 million barrels of beer to the island every
year, amounting to a third of Schaefer’s entire business.13
Then in 1978, after years of rumors it would happen, legislators
in Puerto Rico imposed a five-cent-per-can excise tax on imports
from large breweries, which undercut Schaefer’s price advantage in
that market. A third of Schaefer’s business evaporated overnight, and
Schoen needed to cut overhead sharply, so he closed the Baltimore
brewery and put three hundred more workers on the street.14 Spooked,
and out of ideas for how to recover, Schoen started eyeing the exits.
On Thursday, May 14, 1981, after barely eight years at the company,
Schoen completed the sale of Schaefer to Stroh Brewing, which
wanted the Fogelsville brewery to expand production of its own
beer. He walked away with, as the Tampa Bay Times put it, “a pile of
money” from his time as CEO, but the deal he struck was less a wind-
fall for shareholders than a way to save face and avoid bankruptcy. In
less than a decade, William Schoen, who knew nothing about the beer
industry, took a family business that had been around for a century
and a half and sold it for parts. Schaefer beer was no more.

Schoen had been semi-retired and working as a consultant for less

than two years when twenty-eight-year-old Kent Dauten asked him
to join the board of directors of Naples, Florida–based HMA, which
at the time owned twelve hospitals. Dauten had joined First Chicago
Venture Capital in Chicago two years earlier, after graduating from
Harvard with an MBA, and HMA was his first investment for the
firm. He’d gambled on the founder, Joseph Greene, who had deep
 What Beer and Modern Healthcare Have in Common 7

experience in healthcare, but his business principles were unorthodox,

and HMA had been losing money on its urban hospitals. Dauten
had heard rumors about a guy in Naples who managed a tough turn-
around in a low-margin industry and made a king’s ransom in the
process. How different could brewing be from healthcare? Balance
sheets were balance sheets.
Greene, formerly the president of hospital operations at Humana,
founded HMA in 1977; he ran the company as a family business, with
his brother and son in leadership roles. An evangelical Christian, he
applied biblical principles to his business practices, going so far as to
develop a “Ministry Plan” for how the corporation would serve not
only its patients but also its employees and its vendors.15 For exam-
ple, he insisted that every bill be paid within twenty-four hours, to
avoid using money owed to someone else — “borrowing from Peter
to pay Paul.” More traditional accounting practices delayed payment
until nearly the due date to let the capital work by accruing interest.16
Greene’s practices cut into profit margins and frustrated shareholders,
like Dauten’s investment bank, who started agitating for change.
Within months of Schoen joining the board in 1983, his fellow
board members elected him president and chief operating officer of
the company. He brought in $7 million in outside investments to
shore up the company’s financial position, and in 1985, the board
elevated him to co-CEO with Greene. Fed up with constant conflict
with Schoen, Greene stepped down just months later.17 Once again,
someone with deep industry expertise was out of the picture in one of
Schoen’s ventures, and he had free rein to run a company in a sector
he knew nothing about.
Schoen even admitted as much. “I came from the beer business
with no preconceived idea other than that monopoly was good.”18 His
first move as CEO was to sell off ten of the company’s twelve hospi-
tals, mostly in competitive urban markets. Those hospitals may have
aligned with Joseph Greene’s Christian intent to help the needy, but
they had a poor payer mix (few patients with private insurance, too
8 Introduction

many uninsured) and were dragging HMA’s balance sheet into the
red. They had to go.
Then he started rebuilding, buying up ailing community hospitals
in rural areas where population growth guaranteed strong demand
and a lack of competition meant HMA would own the market. These
small hospitals typically operated at low margins, if they made any
profit; after all, they existed to serve their communities. But Schoen
was confident that he could turn them into moneymakers for HMA.
The Tampa Bay Times described the HMA formula as “simple, but
capital-intensive.”

Improve patient-grabbing basics such as obstetrics and the

emergency room. Add more sophisticated services to keep
residents from taking their business to the nearest big city.
And recruit more specialists and sub-specialists.
At the same time, HMA squeezes cost out of its hospitals
by volume purchasing and by hooking up hospitals to a
computerized information system that tracks everything
from lab use to patient billing. HMA also cuts labor costs by
relying heavily on flextime. In other words, its hospitals send
nurses home when the patient count is low and load them
up with overtime during peak winter months.19

At the start of Schoen’s tenure, most healthcare executives were

nervous about how impending changes to Medicare reimburse-
ment would affect profitability. Instead of paying hospitals accord-
ing to the care they rendered, which can encourage overtreatment,
Medicare would soon begin reimbursing at a fixed rate according to
the patient’s diagnosis, known as diagnosis-related group payments.
More-experienced healthcare executives knew that these fixed rates
were calculated based on careful estimates of what it cost hospitals
to treat various conditions, but Schoen was unfazed. Provided that
HMA cut costs below the Medicare rate, kept more of its beds full,
 What Beer and Modern Healthcare Have in Common 9

or some combination of the two, Schoen saw fixed prices as guar-

anteed profit.20 He controlled large parts of each hospital’s overhead
with group purchasing; installed software to direct and monitor
patient care; established goals for admissions, testing, and revenue;
then told local hospital leadership they’d lose their jobs if they didn’t
keep up.
Meanwhile, HMA invested in superficial improvements, like
updating lobbies and offering senior citizen discounts in the cafeteria,
designed to increase patient satisfaction. As Andrea Robbins wrote
in The Atlantic in 2015: “Many hospitals seem to be highly focused
on pixie-dusted sleight of hand because they believe they can trick
patients into thinking they got better care . . . the smoke and mirrors
serve to distract from the real problem.”21 By 2012, HMA had acquired
seventy-one hospitals in fourteen states and was one of the most prof-
itable healthcare companies in the country.
Schoen’s relentless focus on profit also had consequences for
doctors at HMA hospitals. HMA pressured all its physicians to
increase revenue, but the problem was particularly acute in emer-
gency rooms. Shifts previously staffed by two physicians were now
covered by just one. When a patient entered an emergency room at an
HMA hospital, nurses entered their information into the computer,
which automatically ordered extensive batteries of tests, called proto-
cols, under the emergency physician’s name, before the physician had
even seen the patient. Physicians are taught that all testing should
occur in a stepwise fashion, based on a differential diagnosis of the
most likely conditions. Testing confirms or refutes that differential;
it doesn’t substitute for it. Besides the risk of harm inherent in any
test — from benign anxiety to permanent impairment — overtesting
inflicts financial harm from excessive copays. Many of the tests auto-
matically ordered in HMA emergency rooms were unnecessary once
the physician saw the patient, but it was too late to stop them. The
company also set targets for hospital admissions and strong-armed
doctors to meet them.
10 Introduction

If doctors at HMA hospitals had complained — to an adminis-

trator, supervisor, or colleague — about the difficulty of caring for
patients under such conditions, they might have been dismissed as
burned out. In other words, they just didn’t have what it took to hack
this job.
But the deep distress these doctors felt was something that went
beyond burnout. Doctors were being pressured to practice in ways
that went against their conscience and their training, and patient care
was suffering. If they spoke up about what was happening, they might
lose their jobs. Schoen fired the CEO of one local hospital in 2009 for
telling his physicians to “do what you think is best for the patient,”
rather than meeting the targets HMA set.22 And if they lost their jobs,
where else in their rural communities could they find work without
uprooting their families?
Sadly, doctors were right to worry about patient harm. Understaffing
likely contributed to at least two deaths in Mike Hilden’s hospital
in Pennsylvania in 2011.23 From 2009 through 2011, former HMA
staff across the country, including physicians, administrators, and
executives, filed eight separate whistleblower lawsuits alleging years
of Medicare fraud throughout the HMA healthcare system. In
December 2013, the Department of Justice had sufficient evidence
to join the suits and moved them to Washington, DC, for litigation.
The FBI agents who showed up on Mike Hilden’s doorstep were part
of the investigation, as were US attorneys in seven states, the Health
and Human Services Office of the Inspector General, and the Defense
Health Agency Program Integrity.24 In July 2013, the CEO of HMA,
Gary Newsome, abruptly resigned.
In mid-August 2013, Glenview Capital Management, a $6 billion
hedge fund in New York City, initiated the process to oust the board.
Glenview argued that HMA was not maximizing shareholder value,
and the board was not taking sufficient corrective action. The major-
ity of shareholders agreed.25 William Schoen was out, along with the
rest of the board.
 What Beer and Modern Healthcare Have in Common 11

Just before his ouster, Schoen negotiated a $7.6 billion buyout of

HMA by Community Health Systems, which was finalized in 2014,26
in which he walked away with a severance deal of $1 million per year,
use of a private jet, and a treasure chest of tens of millions in stock
options amassed during his thirty-year career.27 After the merger,
Wayne Smith, the new chairman and CEO, said, “We look forward
to effectively integrating this acquisition and generating significant
value for our shareholders.”28
William Schoen seems like a remarkable character, worthy of a
book of his own. But the sobering fact is that he was in the vanguard
of thousands of executives who moved into healthcare as other sectors
consolidated and offshored. Schoen’s ilk extracted massive profits for
themselves and their associates by manipulating the mission of health-
care, exploiting the altruism of their workforce, and taking advantage
of patients at their most defenseless and vulnerable time.

I grew up in western Massachusetts, where I spent my childhood on

the go — climbing trees, playing pickup sports, riding horses, and
mucking stalls to pay for lessons. My father was a self-employed trav-
eling salesman, peddling fasteners and cable to manufacturers like
General Electric, Sikorsky, and Raytheon. My mother was his secre-
tary and bookkeeper, as her mother had been for her father’s plumb-
ing business. Though I did clerical and cleaning tasks for the business,
my father made it clear from the very beginning that I had no future
there; my brother, six years older, was being groomed to take over.
Shut out of the family business, I declared at nine years old I would
be a doctor, much to my parents’ disbelief.
In high school, I shadowed a local pediatrician and volunteered at
the community hospital; in college, I discovered the Journal of Bone and
Joint Surgery and read every issue cover-to-cover. Drawn to the physics
of orthopedics and the immediate gratification of “cutting to cure,” I
shadowed a local orthopedic surgeon the summer after my freshman
year. By the time I graduated from medical school at the University
12 Introduction

of Massachusetts in 1991, my goal had shifted to plastic surgery, and I

began a five-year general surgery residency at Dartmouth Hitchcock
Medical Center in Hanover, New Hampshire, to qualify for a three-
year plastic surgery fellowship. Three years in, I realized that no matter
how much I loved it, or how good I was at it, surgery was not right for
me. Surgeons excel through repetition, honing their craft by doing the
same procedures time after time, whereas I thrive on novelty. More
than that, when I realized the reconstructive practice I’d planned was
so poorly reimbursed that breast augmentation, tummy tucks, and
face-lifts would need to subsidize it, I reconsidered. I left for work in
rural emergency rooms to catch my breath, pay my bills, and decide
what was next, including whether I could even stay in medicine.
The one thing I was absolutely sure about that year was the man
I first met in the summer of 1993 when he started his neurosurgery
internship. Initially skeptical that anyone could be as smart, compe-
tent, and kind as my neurosurgery friends said this guy was, when we
started dating in the early winter, I soon realized that Shervin was all
they promised, and more. After a whirlwind courtship, he proposed
just weeks before I resigned my residency, and we married the next fall.
Emergency medicine offered the variety I craved — earaches,
intentional poisoning, terrible car wrecks, chain-saw accidents, self-­
castration, falls, strokes, heart attacks, and plenty of animal bites. By
the end of my first year, I realized two things: I still wanted to be
a doctor, and my satisfaction came from forming relationships with
patients, knowing who they were, not just how they were suffering,
and bearing witness to the course of their illness. The emergency room
was not a place for that.
The psychiatry patients who presented in crisis drew me. The rela-
tionship with the patient was the primary tool for both diagnosis and
treatment, and the biological underpinnings of the disorders were just
beginning to emerge. The field would evolve rapidly, probably for my
whole career, which would keep me engaged. Finally, an outpatient
psychiatry practice does not require any special equipment, facilities,
 What Beer and Modern Healthcare Have in Common 13

or assistants. If I couldn’t find a job that suited me, I could rent an

office, hang out my shingle, and practice exactly as I was trained to do.
In the fall of 1996, I returned to residency at Dartmouth, this
time in psychiatry. I chose Dartmouth, in part, for its strong repu-
tation of training excellent psychotherapists. In the 1990s, managed
care, which was wreaking havoc in general medicine, was particu-
larly destructive to mental health care, slashing reimbursement by 54
percent as opposed to the 11.5 percent cut to general medical services.29
Revenue in Dartmouth’s psychiatry program faced a crisis because,
like all other psychiatry programs, revenue had fallen precipitously,
but the hospital, strained by cuts across the board, had decreed that
every department had to at least cover its costs.
In response, the department hired Dr. Leighton Huey as vice chair
to turn the department around the year before I arrived. Huey had
a reputation for being unapologetic about pursuing his vision of the
future: psychiatrists with “a sense of fiscal realities and . . . the implica-
tions of health care reform and managed care.”30 Psychiatrists should
manage medication (the biology) and leave therapy (the psychosocial
aspects of treatment) to other clinicians. He was also an advocate of
hustle culture. If we wanted to gain the respect of surgeons, he said,
we had to work as hard as they did.
The pace of my psychiatry residency turned out to be very similar
to my surgical residency, although the call nights were fewer and
easier. By the time I was in my next-to-last year, I ran from a morning
of caring for psychiatry inpatients and supervising junior residents
to a medication management clinic with as many as twenty outpa-
tients in the afternoon. Most days I returned to the hospital — a
quarter mile away — multiple times to do psychiatric assessments
of patients admitted for medical or surgical conditions. Training in
psychotherapy was sharply curtailed, but I refused to give up on what
I viewed as an essential part of training, so I added extra hours every
week to learn psychotherapy from clinicians in private practice in the
community.
14 Introduction

Six months before I finished residency, and shortly after giving

birth to my first child, I started looking for employment at a large
hospital that offered opportunities for career advancement. I would
be supporting our family while Shervin, who had recently resigned
his neurosurgery residency, stayed home and cared for our son. After
interviewing for several jobs, I was offered the position of director of
the Emergency Psychiatry Service at Rhode Island Hospital, part of
Lifespan, the state’s first health system, established in 1994. Before
accepting, I did my due diligence and confirmed the position was as
advertised, so we moved to Providence.
But as many of my friends found in their first jobs, the position
was not what I expected. The service was under-resourced — just
me, a very competent nurse practitioner, and an administrative assis-
tant unqualified to help with insurance prior authorizations, the most
time-intensive part of my job. For every thirty minutes I spent with a
patient, I spent ninety minutes or more trying to convince insurance
companies to pay for a hospital admission my training and expertise
deemed necessary, and another hour calling hospital after hospital
looking for one that would accept the admission. The reimbursement
cuts in mental health care over the previous decade had hit Rhode
Island as hard as everywhere else, and competition among organi-
zations to bring in well-insured patients, while avoiding the under-
insured, was cutthroat. The pressure to avoid admitting uninsured
patients, which would have meant a financial loss for the hospital,
sometimes bordered on unethical to me, though my bosses dismissed
my concerns. When I learned, after several months, that there was no
opportunity for advancement because of a quirk in how they’d funded
the position, I was done.
As the sole earner for my young family paying off two sets of
student loans, I was in no position to be an activist. But I was not
willing to compromise my ethics or the standard of care I had been
trained to provide. Shervin supported my objection, even if it meant
making personal sacrifices to do it. After less than a year in that job
 What Beer and Modern Healthcare Have in Common 15

I decided that navigating the politics and financial imperatives of a

big hospital that were tangled in the politics of a notoriously corrupt
city, all of which interfered with my ability to care for patients, was
not for me.
Shervin and I decided to move back to Hanover, New Hampshire.
He would return to a radiology residency at Dartmouth the follow-
ing year, and the area had enough demand to keep another private-­
practice psychiatrist busy. The community highly valued mental
health care and was wealthy enough that patients could afford the
higher costs of seeing clinicians outside their insurance network. I still
had enough connections with colleagues in the area that my practice
filled quickly. The trade-off for autonomy and latitude, though, was
shouldering all the financial risk and responsibility of the practice,
while being on call for my patients every day, all year long. But the
freedom to practice with integrity was a profound relief. For the four
years of Shervin’s residency, my practice supported our family.
In 2006, Shervin finished his training and we moved to Carlisle,
Pennsylvania, for his first job as a radiologist. I opened another solo
practice but soon learned that insurance plans were not as gener-
ous, the area was less affluent, and patients were more reluctant to
seek out-of-network care. Insurance paid one rate for psychotherapy,
whether a social worker, psychologist, or psychiatrist provided it. But
my malpractice costs were ten times higher because I could be held
responsible for other clinicians’ care.31 If I agreed to take insurance
and accept their payment for psychotherapy, I would struggle to keep
the practice viable. The best way to ensure a viable practice was to
give up doing psychotherapy, accept insurance, and only see patients
for medication management. Stubbornly hoping to create the niche
I’d found in New Hampshire, I tried to do psychotherapy half the
time and medication management the other half, but after five years
of struggling, I closed the practice. I still loved the work I did with
patients, but I couldn’t justify the liability while only breaking even,
and I couldn’t make more money without compromising my care.
16 Introduction

When I closed my practice in 2011, I took a job with the US Army,

managing research funding for regenerative medicine and hand and
face transplants. As part of our oversight, my office held monthly
conference calls with physicians in various specialties at many differ-
ent healthcare systems across the country. I also saw many of them
several times each year at conferences. These colleagues were at the
top of their fields, doctors deeply committed to the practice of medi-
cine and who genuinely enjoyed caring for patients. But in unguarded
moments, over dinner or drinks, many confessed to being increas-
ingly unhappy in their jobs. They signed up for hard work and long
hours, but lately the pace had accelerated dramatically: They were
seeing more patients, in less time, with fewer support staff, and they
were required to use technology that interfered with rather than facil-
itated care. In our conversations, many of these doctors were speaking
frankly about their frustrations for the first time.
For years, hospitals had been surveying their staff about their
levels of fatigue, frustration, or disengagement, using tools like the
Maslach Burnout Inventory. The consistency of findings across dispa-
rate organizations led to a 2018 report by Harvard University and the
Massachusetts Medical Society, which declared physician burnout a
“public health crisis.”32 Ostensibly, the goal of the inventory was to
better understand the phenomenon of workplace distress; in practice,
it was often used to identify outliers with high scores — in the burn-
out range — and manage the risk they represented to the organiza-
tion, since burnout is associated with lower quality of care and lower
productivity.33 Employers encouraged these physicians to seek out
programs — meditation, mindfulness, yoga, or others — that would
help them build resilience and learn to take better care of themselves,
though there was no data proving these programs were effective at
relieving the distress.34 If doctors didn’t follow recommendations, they
could be labeled as difficult or impaired (a term usually reserved for
those with substance use disorders) by their burnout, which could put
their medical license in jeopardy.35
 What Beer and Modern Healthcare Have in Common 17

While the doctors I spoke to were admittedly exhausted, they

were adamant that their personal mental health was not the issue.
Something had gone terribly wrong with our healthcare system, and
it was causing them profound distress. If it wasn’t burnout, though,
what was it?
The question nagged at me for months until one spring day in
2016, I was weeding the garden when I heard a guest on public radio
describe how service members returning from Iraq and Afghanistan
were not responding to PTSD treatments known to be effective.
Through deeper interviews and consulting research on Vietnam veter-
ans, the researcher realized these veterans were not experiencing anxi-
ety and avoidance caused by fear but rather shame and guilt associated
with perceived immoral conduct. To help them, clinicians needed a
better description of the nature of the traumatic experience that was
causing the veterans’ distress. What they came up with was moral
injury: “perpetrating, bearing witness to, or failing to prevent acts that
transgress deeply held moral beliefs and expectations.”36 As doctors,
we know what our patients deserve but often cannot provide it
because the business of medicine gets in the way. There in the garden,
I asked myself: Could it be that doctors are also suffering from a kind
of moral injury, caught in a conflict between the profit motive of our
employers and our oaths to heal?
In his 1994 book Achilles in Vietnam, Dr. Jonathan Shay describes
moral injury slightly differently, as “betrayal of what is right by some-
one who holds legitimate authority in a high stakes situation.”37 In
healthcare, the stakes aren’t always life and death, but for each patient,
their health is always a high-stakes situation. In the first half of the
twentieth century, most doctors worked in solo practices with mini-
mal administrative support. Hospitals were locally owned and oper-
ated by the communities they served, guided by experts in healthcare
— physicians. When doctors started banding together to form group
practices, beginning in the 1970s, they hired administrators to keep
operations running smoothly. But as healthcare systems corporatized
18 Introduction

and consolidated over the past forty years, most executives have come
to see themselves as responsible not to physicians or to patients but
rather to shareholders, who have one goal: maximizing profit.
Today, MBAs like Schoen control most of our healthcare systems.
But there is one consistent face of medicine for patients: their physi-
cian. Bearing the weight of responsibility and liability for these profit-­
generating systems is breaking them.

For months after hearing about moral injury, I thought of little else.
Giving up clinical medicine had been a personal loss, but now I under-
stood the problem was not with me but with our healthcare system. I
wanted other doctors in distress to know they were not alone, and for
them to stop blaming themselves for their frustrations with clinical
medicine.
In the fall of 2016, I shared my thoughts about this with my
friend Dr. Simon Talbot, an academic plastic surgeon whom I’d
gotten to know through his work in hand transplants and with
whom I’d done other disruptive work. Over the next year and a
half, we researched, revised, and refined the idea. Eventually we
drafted an article about why moral injury, not burnout, was the
source of widespread distress among physicians, which we submit-
ted to journals like the New England Journal of Medicine and the
Journal of the American Medical Association. For six months, we
received only rejections, until finally Pat Skerrett, the editor at a
new medical spinoff of the Boston Globe, STAT News, accepted the
article. Since the day it was published, the response has been over-
whelmingly positive. The article has been downloaded more than
300,000 times, and scores of clinicians — doctors, nurses, physical
therapists, social workers — have reached out directly, telling us
what a relief it was to have language to accurately characterize their
experience, and telling their stories of peril. It became clear that
patients and the public needed to hear those stories, and there was
a growing appetite for change.
 What Beer and Modern Healthcare Have in Common 19

Before I started writing this book, I expected that physicians would

be eager to share their experiences, but when I started doing inter-
views, it was surprisingly hard to find people willing to go on the
record, even when I promised them anonymity. This is partly because
physicians fear retaliation for speaking publicly about their distress
but also because naming this problem would mean feeling obligated
to confront it, something most doctors can’t fathom doing when they
are already working upward of eighty hours a week. I don’t blame
them for staying quiet; if I were still practicing in corporate health-
care, I probably would not have gone on the record, either.
It was, perhaps unsurprisingly, even harder to find administrators
who wanted to talk to me. If they publicly admit that systems chal-
lenges are at the heart of distress in their workforce, they are assuming
responsibility for issues they do not have the training, or the time, to
address. Because identifying clinicians and administrators to feature
in this book was so challenging, I am even more grateful for the people
who did come forward, both those whose stories I tell in specific chap-
ters and those who contributed background and perspective.
Even once people committed to participating, getting to know
them well enough for them to tell their stories faithfully was a chal-
lenge. Most doctors have learned to hide their own pain; if they let
themselves feel the extent of their distress, their patients might suffer.
Usually, I’d talk to someone once, often for hours. Both of us would
think I had the whole story. But it was only when I went back for
clarification that I would get the real story — of anger, shame, disap-
pointment, grief, fear, and the risk of being destroyed.
Some of the clinicians in this book are people I know from
Carlisle; others I met through word of mouth, through friends of
friends, or after reading news stories or journal articles that intrigued
me. Medicine as a field, and particularly in leadership positions, is still
dominated by white men, and although I talked to many doctors from
underrepresented backgrounds, who confirmed their experiences of
distress, most declined to be featured in the book; unless someone is
20 Introduction

in a position of power or has nothing to lose, speaking out is often

too dangerous.38 For the same reason, I agreed to anonymize three
of the doctors in this book. And, of course, the names of all patients
and family members, except my own, are anonymized to protect their
privacy.
Every one of the generous physicians who told me the stories of
distress and triumph that follow did it for only one reason: to make
medicine better.