Actual People
Welcome to Actual People, an unfiltered exploration of individual and societal shifts in a world undergoing tremendous change.
I open up about my own experiences in order to dive into social and cultural phenomena, positive developments, and collective pain.
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Actual People
S2E14 - Moral Injury in Healthcare and the Entire Nation
Chauncey Zalkin sits down with Dr. Jennie Byrne, a psychiatrist working with clinicians who sees a painful trend in healthcare but first Chauncey explores why she thinks the wound has spread to the entire nation and why it's time to exile virtue signaling and embrace anger signaling. Like immediately.
Written, directed, and executive produced by Chauncey Zalkin. Intro/Outro sound engineered by Eric Aaron. Photography by Alonza Mitchell with Design Consulting by Paper + Screen.
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I have to be honest. I am struggling to come up with a way to express my feelings in any sort of concise, succinct way but today's episode is extremely relevant. This episode has been weighing on my mind, and I hadn't edited it yet but I thought it was really important right now because It is about moral injury. Moral injury is the psychological impact of doing, witnessing, or failing to prevent something that goes against one's values. I am talking to Dr. Jenny Byrne. She's a psychiatrist. She works with clinicians, suffering from moral injury in the healthcare industry, a widespread crisis in healthcare. This term is usually used in the context of healthcare or the military where the stakes are really high but they are under the authority of somebody else, like the healthcare system, or the orders in the military having them do things that they don't feel are ethically sound or go along with their values.
Usually it's used in those contexts, But I feel that we,as a nation, and maybe the world, we're in the process of experiencing a moral injury that feels unstoppable.
And so I thought this would be a really good time to talk about moral injury and the impact on all of us and what we're feeling.
So, before I get into it, I wanted to say I had two other ideas that have been circling around in my mind that I wanted to give you as food for thought in regards to what might have gone so wrong at this point. I think about something that my dear friend Danny said to me years ago, how people do not like to be told what to do. They don't like to be scolded past the age of five. Maybe we've been too alienating in our approach to inclusion. It's really important to be representative, but maybe we've over intellectualized the inclusion conversation making it inaccessiblEverybody wants to be seen and be heard, people they want to have a sense of belonging and a reason to be here that fits into community.
I think everybody feels marginalized, except for billionaires. What we have seen is a shift from the basic tenets of human decency and human rights and we're being swept along like, Hey, wait, wait for me. What's going on? This is I did not sign up for this. This is not what I believe. But we are inside of it. This is how the Third Reich started with Hitler in Nazi Germany. Just little pinpricks sometimes you really do need to break protocol and I think we're at that place. We have been very polite and well mannered and subdued in our delivery in our communication about our grievances and about the administration stomping all over human rights. Scolding has not worked.
I feel we have moved from virtue signaling, performing virtue and performing equality to a period of very necessary anger signaling. We need to embrace the language of fisticuffs, I was gonna say. We need to embrace the language of primordial anger and strength that the alt right has embraced and made very potent.
I thought about this the other day because I wore this t-shirt that says MAGA is a fascist cult.
I don't really wear t-shirts that say anything in general, but I went to a little brewery a couple weeks ago, and there was a guy sitting wearing a MAGA hat, a black on black Elon Musk style, dark MAGA hat. If he hadn't been wearing the hat, I wouldn't have known he was MAGA. I realized they are the dominant force in American culture right now.
So I just angrily got on line and ordered this MAGA is a fascist cult t-shirt. I thought, well, you know what? It's time for me to start wearing these things so I wore it as a social experiment and the first time I wore it, both times to grocery stores, this is a grocery store story, the first time I wore it, I went to Trader Joe's, but I had to run in and run out. I saw people looking at me, but nothing happened. Then I went to a Harris Teeter and I wore the T-shirt again and in this case, I was wearing a sweatshirt, but it got really hot in the middle of the day so I had the T shirt on underneath it. And I went into the store and these two women were sitting down. I think they worked there. One of them said, nice shirt. And I said, Oh, thank you. I was hoping somebody would notice. And then this guy came up to me, and he started talking, I was gonna be a liberal for Halloween, he was smiling, and he seemed friendly, and I'm like, I'm very confused, are you telling me that you're liberal. He said, hell no, I'm not liberal. I used to be, but Joe Biden, he's the fascist. You should stop listening to Rachel Maddow and CNN. I was dumbfounded, I didn't know what to say. Where do I even begin to unpack that? What do I even begin to say? I went outside. I went to my car. He was outside by the time I got out there and he was talking to two other men and he was like, girl…, t-shirt…
I knew he was talking about me and I got in the car and I said to myself, my work here is done. I thought if I'm wearing this t-shirt and he sees somebody else wearing something similar and then somebody else these little different connect-the-dots like we have with MAGA they might get the idea. They might start to question. If we start to see all kinds of people taking a page of the rule book of MAGA, I think we might get somewhere but right now we are enduring this horrible pain of a moral injury.
From the perspective of ethics, what's going on in this country is morally bankrupt and deeply painful. The confusion of it is overwhelming, but deep down we are feeling this deep pain of this unraveling of all of the values that we hold dear and that we cherish
so this idea of disruption or shaking things up in Washington, we didn't mean to destroy everything. All love, empathy, and care. The reason behind government is to take care of the people and to make sure people are healthy and that we have peace and that there's justice and those kinds of things.
We didn't mean throw that out the window. This idea of disruption has been co opted but I think it's time for us to co opt the idea of anger signaling showing our righteous anger in more clear ways that are not so academically intellectually explainy and here's the other thing even using the selfish rationale of wanting to live on a planet that's sustainable making sure there is enough opportunity to sustain an economy from which you will benefit All of that is crumbling, crumbling, crumbling.
All of logic and reason is crumbling alongside ethics. I've been reading this book, and I'm on my last chapter. I read it one chapter at a time and put it down. It's called The Rigor of Angels, and it compares the work of Borges, the literary genius, Heisenberg, the German theoretical physicist, and Kant, the German philosopher.
And one of the ideas that really struck me is this idea that if there were no objects, no gases or particles, meteors or planets in outer space, then outer space would be nothing. It would be nothing. It would be nowhere. It would be, there would be nothing to speak about when something is nothing at all and holds nothing at all then it doesn't exist. And I was thinking about this and I was thinking about Einstein's theory of relativity and quantum physics and Yung's collective unconscious.
The book is, the book is about uncertainty.
I was thinking about connectedness as the only thing that makes anything exist if we disconnect completely from all the ways that we are unified by our shared space physically, but also our shared experience and memories, our connection to nature, the world, to traditions, to our families and our friends, if we disconnect from all of it, we are truly adrift.
But at the same time, all of these pleas for unity, reason, logic, love, they're, they're not working. They've not worked. It's like when a loved one is in an abusive relationship, which I think a lot of our loved ones are in an abusive relationship, you can't reach them anymore., let's think about the terms liberal, you know, liberal and conservative. Liberal used to mean Free, liberty, freedom of choice, as long as you're not hurting anyone, then we don't mess with people, it's liberal thinking. And then you have the word progressive, and that means taking on new ideas, having the courage to take on new ideas that will serve humanity.
Isn't that what Tesla was supposed to be about? It was a progressive idea, right? Green energy, that's a progressive idea. And then you have conservative. And if you think about the word conservative along the lines of conservation, you think about preserving things, things that are sacred, like our values, like our ethics, like our morals, I think you can hold the idea of being liberal, progressive and free and conservative in your head at the same time, you want to preserve what is sacred. You want to preserve tradition. You want to preserve connections and family. And you want to progress in a way that takes away the harms and sins of our past and move towards a more unified, joyful, peaceful, harmonious future? That should be the common goal. So there really isn't this divide. It's completely manufactured.
I mean, we know this. It's completely manufactured. And so very rich people get richer. And I also don't understand the motive behind that. I don't understand why the rich want to get even richer and push other people away. Because if there aren't consumers that can afford the goods that the very rich are producing and distributing, then there's no economy. If they have no customers to serve, they're also going to lose money. I mean, even economically, we are all connected. I'm not talking about trickle down economics, but I'm saying that producer, consumer, we all are both, if huge sections of society are not doing well, it's going to impact the very rich as well. What are they going to do with us? These are the things that keep me up at night.
Anyway, despite digging into the terms conservative, liberal, and progressive, we are semantically very far away. Since language is a living, vibrant, dynamic thing, we have to accept that we are embracing two different ideologies, but have the same end of wanting to stay alive and have peace... what we're doing, this anti intellectualism, is It's really just anti thinking, anti mind, anti humanity. And one of the best things about being alive is the life of the mind and being able to think and be conscious and to explore and to question. People have the right to thrive. You should question norms. You should question authority. You should question assumptions. But never question basic human rights.
I'm going to end this with a story before we get on to the interview. You know what? I've recorded that story before, so I'm going to actually just let that story tell itself.
My mother was in another grocery store in a Publix in South Carolina, she didn't have any kind of t-shirt on but she's a liberal, okay? So she's in the grocery store and my mom is many things, she doesn't always understand social cues. Sometimes it's really rewarding to watch her in action. And sometimes it's really embarrassing
It depends. This is a story she told me. She was in the grocery store, and there was a guy with a grocery cart filled with carrots. She just went up to this guy and I bet he was not giving off the vibes of I'm open to a conversation at all. And I've seen her do this where someone's like not having it, but she just plows ahead.
And she said, I bet someone in this grocery store asks you why you have all those carrots. It just begs the question, what are they for? He didn't say anything. She said, okay, I'll bite. What are all those carrots for in your grocery cart?
And he said the deer like them. And she said, oh my god, are you a hunter? So you're buying all these carrots and the deer are gonna eat the carrots and then you're gonna kill the deer? She said this several different ways to me, so you're feeding them and killing them, feeding them and killing them.
She thinks it's a joke that she's sharing with this man who's giving her no simpatico energy whatsoever. And he looks her dead in the eye and he says, no, but I shoot liberals. And her reaction was to burst into laughter, probably nervous laughter. I was like, you just threatened her life. She said, I just went into another aisle. I just was laughing. I couldn't stop laughing. I can see that scene.
My mom has blonde hair and wears stone and sterling silver kind of jewelry. She's not super hippie. She's more woodsy preppy, like L. L. Bean ish, but she looks liberal. She has a no war sticker on the back of her car and she lives near Parris Island where the Marines train just to give you a sense of her. One time she drove me into Parris Island. There was a birthday party in Parris Island with a sticker on the back of her car. These people are going off to war and yes, no war, war's terrible, but she has a sticker. Of all the things that she believes in, it's a sticker that I think she just bought the letters in black, and she put them on the back of her car. So she has a no war sticker in a military town.
That's just to tell you a little bit about her, inside of her house on her fridge, she has a sticker that says no farms, no food, . Why didn't she put that sticker on the car and leave the no war? I mean, it's just so on the nose. Too pointed for this crowd. I don't even know why she lives in the Deep South.
She just loves it there. , I couldn't stand it. I was there for four years from Brooklyn because I got a divorce and it was too much with twin toddlers. And I I needed some sort of help. So I was there for a couple of years that's a story for another day. Sunday, the whole town shuts down.
Everyone's in church. They don't even have a movie theater. It's a beautiful town on the water. It's been in the notebook and, Forrest Gump the Big Chill was also filmed there. The Big Chill house is in the neighborhood my mom lives in. Very beautiful town. Picturesque. Gorgeous. I mean, really. But, not friendly. Not a friendly town. Not an un racist town. This town is the first place I heard somebody make the argument that the civil war was about states rights. I didn't know this is what they were taught in schools. A 19 year old in college looked me in the eye and told me that the North had it wrong, that the civil war was not about slavery and it wasn't racist, it was about state rights.
I didn't know what to do with it. But now we live in a world rewriting history. We live in an alternate reality, an upside down world as a lot of people are calling it so yes, I think we've moved on from virtue signaling, which I think was a mistake. the East Coast elite accusation came from this kind of scolding but now we're in an era of anger signaling. People who want to fight for sanity, reason, morality, ethics, justice, equity, diversity, inclusion… a lot of people I speak to on this podcast have sustained moral injury in their professions.
Behind closed doors, which is where I sit and I've also sat as a psychiatrist taking care of other clinicians from my vantage point, it's way worse than anybody knows because people tell me behind closed doors what they won't tell other people. This isn't just I'm tired. I need a vacation. This is deeper.
Welcome to Actual People, a podcast hosted by me, Chauncey Zalkin, dedicated to meaningful conversations about the evolving landscape of our lives and the power of our own creativity and imagination to make magic.
I was talking to a friend of mine and what I think your premises came up organically about, the moral wound. We were talking about people not being able to do what they really want to be doing. I think in you talking about it, we're going to get to understand a little bit more about one sector of the economy and how it's being impacted by all kinds of hidden factors and obvious factors.
Tell me a little bit about the premise of what the moral wound is and how you got to that idea and why it became so compelling for you.
I'm a physician, I work in healthcare. I work with a lot of physicians who are on the ground doing traditional work. I work with a lot of clinicians who do leadership work. I work with executives, CEOs, I work with investors. I kept hearing from different angles the same thing, which is something's wrong with our clinicians. So the clinicians say I'm done. I'm tired. I'm fed up. Don't want to do this anymore. I want to leave medicine and I just, I don't know. I just can't take it anymore. Right. Then I hear from the clinical leaders like, Oh my gosh, our teams are so burned out and I don't know how to fix it. I'm trying to be a good leader and I don't know what to do.
And I'm getting to the point where I'm getting fed up because I'm feeling I don't know. Hopeless. And I am thinking about leaving my career. These are the leaders. And then I talked to the business people, the CEOs and so forth. And they're like, we don't understand what's going on. Why is it so hard to get a clinician?
Why is it so hard to retain them? Why are they so unhappy? Why don't they want to do what we are asking them to do? what's going on? this is just a big mess. And then I hear from the investors We can't rely on clinicians let's just find someone with a high school degree and train them to do this thing because it's so hard to work with clinicians these days
Define what a clinician is in this context.
I would define a clinician as somebody who is licensed by some sort of clinical entity. A physician has a license, a nurse. Physical therapist, a pharmacist, a coach for example, does not need to be licensed. You can be a coach, anybody can be a coach. you don't need a license. So anything that requires a license of some kind is a clinician.
So advanced schooling and specialized training.
Yes.
So, because it really tripped me up when you said, Oh, let's replace him with some high school student because I'm thinking doctor. Yeah. How many years do people have to be in medical school? I don't want to get it wrong. I think it's eight years. How long are people in medical school? Four
years of medical school, and then at least three years of residency to have a specialty. It's theoretically possible to do four years of medical school in one year of internship, but nobody really does that anymore. That used to be like 50, 60 years ago. Sometimes people would just do that and not worry about the rest.
Okay. So, but they want to replace. It's also sounds like for legality and safety purposes.
I mean, obviously there's a there's a range, a spectrum of how much you need to be schooled in order to be a clinician if you're
okay, so I have to stop the podcast for a second. I'm re listening to this. And it's really funny to me. I decided not to edit out the hesitation in my voice, but you can tell I'm really struggling.
We live in such an upside down world that I'm stuttering trying to wrap my head around the fact that people who have extremely necessary schooling to become a specialist, that these people could be replaced with high school students or unqualified professionals.
Does this sound familiar to you? Here I am and I think it's probably the beginning or middle of, it's the middle of 2024 when I recorded this episode and I can hear the struggle in my voice and the confusion and I wanted to keep it in the edit and bottle it because it's that level of confusion. You can tell I'm short circuiting a little bit while she's talking because I know I'm pointing out the obvious. And I can tell by the look on her face that she knows it's obvious. And also her expression is reflecting that frustration she feels about what she is contending with and why she wrote this book. Which is about the moral wound that clinicians, qualified, highly educated professionals are facing in this upside down world. So this was just a couple years after Dr. Fauci was questioned and later pardoned in advance of potentially being arrested for disagreeing with Donald Trump the CDC was also questioned by people who had really gone down the rabbit hole of QAnon, which we don't hear a lot about lately, if you think about it. Because now we have a second Trump presidency. No need for dark Channels to talk about conspiracy theories. Now they have become mainstream. So I'm in the middle of contending with something that has gone terribly wrong and I'm not in the healthcare field, not yet. And so I'm listening to this kind of for the first time, but I already had the inklings of the unhappiness and the Loss of identity, in the medical field that we were feeling in other fields as well. But it was, hard to wrap my head around. That this knowledge attained through rigor and empirical evidence deep longitudinal studies of it. Our body of knowledge that became these building blocks of modern civilization and understanding of our world was starting to to unravel these. Institutions had become suspect. Expertise and education in and of itself is frowned upon. This is where we are right now this is when it's starting to really coalesce into this dangerous, scary situation we're finding ourselves in right now. This was already being talked about, but more, it was more like parlor talk. It was more theoretical that people were not believing science. When I moved here in 2019, people had signs on their yards that said science is real but it was just this fringe that thought science might not be real. But now we are placing people into the administration that have no expertise, it has crescendoed to this apex where the people who are running this country are all completely unqualified and really dangerous loose cannons and expertise has been relegated to this non player character video game idea . Expertise is too difficult to understand too difficult to wrap your head around expertise. So just forget it. Forget the expertise. Let's just do digestible. Let's just do easy to digest and toss out expertise. It's just too complicated for our monkey minds to comprehend, for our algorithm driven no attention span brains we have been stripped of critical thinking to the point where We just don't have time for that. We need the meme. We need the shortcut. We need the, you know, Republican hairstyle. I don't know.
Now back to the episode.
Right. The point of a license is that it's codified and monitored in some way. There's a board that says, yes, you meet the criteria. Yes, you can have a license. And then typically there's some ongoing obligation to renew your license through continuing education no malpractice, things like that.
Rigor, oversight, training, lots of things, deep expertise that has checks and balances to it. You can't just go out and say, I play one on TV. Okay. So these people are leaving the business and. Yes. Can you explain the problem, pinpoint why people are burnt out? They're burnt out from what?
How is it different from 20 years ago?
Well, that's, so that's where I got interested, right? Because people talk about burnout and they've been saying burnout, burnout, burnout, everybody's burned out. And I'm like, I don't think it's just burnout. You know, when a medical student says they're ready to leave medicine, I don't think they're burned out or resident. These are people who are young, full of energy. It's not …most people talk about burnouts. It's like energy depletion model where you just need to take vacations and take care of yourself and my premise is it's way more than that. Not every time there is just pure burnout, but often it's something much deeper than that.
And somebody who has chosen to go into clinical patient care has already sacrificed a lot, has already been very resilient, has already done all these things. So when they're all saying like, I'm ready to go, I don't think that's just burnout because you've already persevered to get to this point.
It sounds like it's from different. areas are there any numbers in your research that, you know, gosh,
yeah.
Percentages of people who are burned.
It's like 60, 70, 80% of physicians say they're burned out.
So would anybody called this an attrition crisis in the healthcare industry?
Yeah. So I don't know if they're calling it a crisis yet but I guess my point is behind closed doors, which is where I sit and I've also sat as a psychiatrist taking care of other clinicians from my vantage point, it's way worse than anybody knows because people tell me behind closed doors what they won't tell other people. So that's why I got kind of passionate about the topic because this isn't just I'm tired. I need a vacation. This is deeper.
Okay, go on. I want to hear more.
So then I started talking to people and researching and I talked to a colleague of mine here in North Carolina. whose name is Dr. Warren Kinghorn. He is really interesting because his career is at the intersection of three things.
He is a psychiatrist, he works with veterans in the military, and he has a degree from the Divinity School. And he told me about moral injury, which is a concept that comes from the military, because they were seeing people come back from deployment and really struggling, but it wasn't really PTSD. They were trying to understand what's going on. The military did research and came up with this definition of moral injury, which has three key components. The first component is that you do something, witness something, are part of something that goes against your values, whether it's your personal values or your professional values and ethics.
The second thing is that it is either ordered or condoned by somebody superior to you. And the 3rd is that the stakes are high. If you frame that in terms of. Health care, people that work in health care, obviously the stakes are high for someone like me, a physician every time I talk to someone, stakes are high. I take a huge responsibility. That's part of my ethics code. I have that responsibility. So the stakes are almost always high. Most physicians and others they're now part of hospital groups or they're bought by a company. the mom and pop family doc working out of the back office of their house, that model is very rare. It still exists, but it's rare. So most people are working for these organizations where they do have a superior. And so when the superior is telling them, do this, do this, do this, the stakes are high and then it goes against your values in some way, that's when the injuries are happening.
Can you shed some light through a couple anecdotes?Sure.
Still keeping privacy, but, you know
Obviously. Of course.
So the first one that you hear about the most often, if you talk to somebody, a clinician, doctor, nurse, is the system prevents me from doing what I know is right for this patient.
That can happen for a lot of different reasons. The most commonly cited one is time. I have 10 minutes with this patient. I have to be documenting the whole thing, I cannot create the relationship and the time I need to talk to them to explain to them what's going on to come up with the plan. Most people say time that's one of the first things they say, I don't have enough time. And as a patient, that sucks I go to the doctor and they have 10 minutes for me. It doesn't feel good to me. I see that they're trying but they're trying to get their stuff in their computer and talk to me and it doesn't feel good to me either.
So the human connection, the healing part of the relationship is lost most of the time.
And also you might not be getting enough Input to make a clear diagnosis or recommendation I was living in Barcelona, my doctor took a watch and he took it off his wrist and he, Face it towards me. And he said, this is how long you have. And you can tell me one problem. And I was so upset.
Yeah, it doesn't feel good. Human beings aren't fixed. They're healed and healing involves a human connection. We have all been tricked or coerced or, or led to believe that it's a factory floor and that the patients are little widgets moving along conveyor belt and the doctors and nurses are frantically trying to go faster and faster to do things to that little widget the patients feel like nobody cares. Clinicians don't feel like they're connecting with anyone. They don't feel like they're healing anybody. Moral injury can be death by 1000 cuts.
It can be one paper cut a thousand times a day, times 20 years, or it can be one big event. And some of the big events that can happen aren't necessarily related to operations. I give an example in the book about something that happened to me that was really painful when I was taking care of patients with substance use disorders 15 years ago when it was still very stigmatized. People weren't talking about opioid epidemic and the treatments buprenorphine. I was kind of early on to treat these folks because I felt like I had a moral duty to do so. And I had a. colleague who mentored me and I felt like I was doing a good job. Anyway a pharmacist complained to the medical board about me without ever talking to me, which triggered an investigation because they always have to investigate, which triggered 18 months of being investigated, having a lawyer, not being able to talk to them directly, having my stuff go out to an anonymous reviewer. Ultimately nothing bad happened to me, but they said, well, we need you to go take a class on how to prescribe opioids. The great irony of which I don't prescribe opioids. I help people who are addicted to opioids by prescribing a different medication. So
what was the complaint
Uh the patient had been addicted to many things, including ambien, and he was going there to ask for ambient early, and they I said, No, I said, You cannot get it early, but the pharmacist went back and saw that they had a history of early ambient prescriptions. Now, this is somebody who was addicted to Ambien, Valium, Oxycodone, Heroin, Cocaine, Alcohol, and I had managed to peel off the Cocaine, I had managed to peel off the Opioid, you know, we were peeling the layers one at a time. But instead of talking to me, they reported me. And so anyway, it ended with me having to go to Ohio for a week and take a special class. When I sat down the first day of the class, the presenter showed slide decks of jails and said, this is where we send doctors who prescribe medicines they shouldn't. It was basically like that. It was a scare tactic.
You were scared straight for doctors?
Yeah.
But you had not prescribed opioids and you had not prescribed Ambien early. You had done the opposite, but he just misunderstood because of his history and you were The
investigation, the person they sent my charts out for review, I don't know who it was, I don't know if they treated substance use. I don't know who they were. No. And, and my lawyer advised me, do not appeal this because every time people appeal, it ends badly for them. And I trusted him. He was good. My husband's an attorney. He's like, yeah, listen to your attorney.
Yeah. So I did.
I didn't appeal it.
I went through it. There was no sanction, nothing bad happened to me, but that 18 months the wound that that left on me is deep and it's still there. Even writing about it was extremely painful and scary.
And the reason I'm telling this story is because that that is not burnout, that is moral injury, that is where my values have been transgressed. Every time I tell this story, the other person says like that happened to me and I've never told anyone.
So that's a different kind of injury that is not just I don't have time to do my job. We never talk about the injuries that we do to one another and it's awful. There's a lot of shame and guilt and people try to be stoic and perfect.
And we are human. You know, doctors are human. We're expected to literally have a 0 percent failure rate, literally, which, as we know, is not possible. And then if we do we're not supposed to talk about it. So it's hard.
Obviously this is where people come at a point where they are the most vulnerable and they really need help. And people come into the field not easily either. it's a noble profession. It's a lot of work to get a degree and a lot of sacrifice and commitment and you have to endure some burnout in that process. So that sounds like a powder keg you also spoke to me about people not getting paid what they used to get paid. we were raised, you go through your career and you get paid commensurately with your years and your expertise. And we are now in this economic crisis that no one's really talking about that affects all kinds of professions. You and I were in chief together and this is, you community women in the c suite there were so many women who were looking for work who had been laid off or in transition not because they wanted to be in transition or were at a job feeling like they were not being valued in their role. This is part of a larger thing and I think this is an interesting entree into it because the medical profession we all as a society feel is very sacred.
Right. It's kind of the last bastion of trust. It's still there. It's just kind of buried under all this. So the money part is really, I think, interesting it's all about expectations. , you said that I was remembering, I don't know if you were a kid, you played the game of life. Did you ever play that game with the little cars?
I don't remember the rules of the game.
Do you remember how you would choose a career path go this path and make this much money. You're a doctor and you get this much money. Do you remember that?
No, but now I want to play it. I don't remember that.
So it's all about that expectation. You go through school. Okay. So what are your expectations? I'm a Gen X. So, you know, I was looking at boomers and saying, what is their life like, what can I expect?
Okay. You know, I'll put in time. It'll be a lot of work but when I get out, I'll make a good salary. I will be able to send my kids to school comfortably. I'll have the choice of having a one income household. I will be treated with great respect at home by my family, by my community. people will call me doctor. I will have a trusted place in the community. I will go to my office and people will ... Be kind and respectful, right? Because this is what you would look at and you'd see the doctors and that's kind of how they were treated, right? When you were, when I was a kid, that's how we treated our doctors.
Oh, and also, in a very retrograde way, the cliche the the mother would be like Oh, he's a doctor. Like, Oh, we should go on a date with him. He's a doctor. I mean, that's right. Yeah, no, seriously. Oh, a doctor? You want to marry a doctor or a lawyer?
Exactly. Maybe you're not going to make as much money as the guy that runs the factory
actually, it was more
esteemed. In movies the CEO was kind of a shyster, you know, the businessman nine to five, but the doctor and the lawyer were the respected pillars of the community, and also who you go to with your secrets almost like a priest
comparable to a priest in a lot of ways, and for people who were not religious, that was probably the closest they had to a priest. So this is the mental model or the image you have of what it's like to be a doctor as a kid. Okay. So flash forward to today. What's it really like to be a doctor? I'll tell you it ain't like that. Now we carry debt. Back then all the boomers either had a GI bill or money.
So nobody had debt. The average doctor now comes out with 300 to 500,000 in debt
plus extended training. So I mentioned earlier that back then you might do four years of med school and then about a year of internship. Well, now it's extended. Most residencies are at least three to four years and then people are doing fellowships. So now your training is like a decade after college decades.
So you're not in the job force until you're in your thirties. So you've not worked. Remember, you have no income.
You're not making money when you're a resident. Even any? Really? I didn't know that.
You're making like 17, 000 a year.
You are?
Maybe 30, 000. So how do you afford to live? I lived in New York City on 30, 000 a year.
Yeah, you don't. You take debt.
So this is You take out loans to live and get through that, because you think it will pay off in the end, because you will be a doctor, and you will have Exactly. But
then you get out on the other end, and what you see is that the different specialties have a wide range of salaries.
So a primary care doctor might make as little as 100, 000 a year. And I say that, and I get a reaction, oh, well that's a lot of money compared to the average American. And I say it is, but this is considered to be the highest amount of education and specialty and expertise that one could possibly accumulate.
So, when you put it in perspective 100,000 is extremely low.
And the investment of time and money if it's an equation. If you just do the numbers. Yeah.
Great. And so a psychiatrist who's kind of a low paid specialist, when I came out, people were offering me like 150, 000 a year as a specialist. Now that's gone up for psychiatry because it's more in demand, but it's not millions of dollars, you know, it might be 200 a year, maybe 300 a year now for a psychiatrist, which is one of the most in demand specialties we have, by the way, now you get up into like surgeons and, you know, net and then they're making more money, but it's not 10 million, it's still not maybe what you imagine. So anyway, the financial picture. So no job until you're in your thirties, right? 300, 000 to 500, 000 in debt, most people by then, if they're going to get married or have a kid, maybe they've got a kid on the way I had a kid when I graduated residency, you have a family responsibility, you know, so it's a pretty dismal financial picture, but you're still like, Okay, it'll be okay, because it's worth it
it will be alright
and so you kind of keep chugging along and what i think if happening now is you're hitting this respect issue as a woman physician, um, I am continually astounded by some of the expectations on me that would never be on a male colleague who is a
physician, like what,
cooking, cleaning, staying at home with kids, leaving my career to be a stay at home mom for five Don't you want to stay home when they're a baby? And don't you want to cook dinner? And don't you want to take? And I'm like, no, I don't. I don't want to do any of those things, actually., but that's just me. Everybody is different and some people might want to do that, but nobody would ever say to a male doctor can you imagine? Oh, don't you want to leave for five years and stay home with your kids? nobody would ever say that to them. No one would ever say to them, Oh, well you're going to leave early so you can go make dinner, right? Nobody would ever say to a male doctor any of these things because it's ridiculous.
I was wondering what the pressure was at work if you felt like there was a higher expectation on women in the workplace.
I think there is an expectation out of kindness that you are not available because you're doing everything at home. So you don't get promoted. You don't get sent to conferences.
You don't get asked to do projects. You don't get asked to sit on committees. I think there's actually this leaning out where people are trying to be kind and not ask you to do things.
I don't know if it's always kind. Sometimes I feel like It's condescending, but
I give it the benefit of the doubt. So anyway, the respect issue, and this isn't just for women. Men also the politicization around the pandemic led to a real meltdown of trust between different people, between different political groups, between the CDC and the doc, like it was just such a hot mess that the trust erosion really just exploded.
And then when you have a revolving door of doctors and nurses and you don't get to know your doctor, you lose trust. This erosion of trust has now led to an erosion of respect as well when you go into the room with the patient, you don't know, they may be very respectful and thankful, or they may yell at you, you don't really know.
I have to say my,
my kid's pediatrician, I really liked her, but she just closed her practice, almost unceremoniously we were given a little notice, but she didn't reach out to individual patients. She was great in the room with them, but, I think that she just couldn't make her practice run.
They often didn't have someone at the front desk, or she would, have different hours, shorter hours. I noticed her business dwindling. I didn't know what was happening.
It's the business of medicine is not easy. It's doable, but you really need to have it operate like a business and the people that unfortunately now are very focused on the business are also very operations minded and so again, that leads to that conveyor belt. And so, I'm a patient, if I've been waiting for 45 minutes, sitting in a little room with a five year old, who's fussing at me, I'm going to be mad
when
that person comes in the room, I'm probably not going to be as kind and respectful as I, I'm not going to yell at them, but I'm.
But you're not going to be in a great mood? I really hate rooming. You can tell they actually call it rooming patients. I really hate it. This idea that you put them in the tiny little progression of rooms and you just sit there and wait, they call that rooming.
Can you believe it?
What are they doing? Yeah. What is that about? I hate it. It's the factory floor.
It's the conveyor belt. It's the model of like, the most efficiency that you can gain as a conveyor belt model. It comes from the Ford factory in the 1910s. All of this comes from that. All of it.
It's a conveyor belt. It's industrialization of medicine.
The industrialization of medicine and people believing that that is more efficient. I do not believe that. I've worked in the industry long enough and designed enough clinical models to know that it doesn't have to be that way.
But getting back to the respect I had a grandfather that was a doctor who died when I was little. He was the only doctor in my family and the stories are always, you know, they called him Dr. B. Oh, Dr. B, Dr. B this, Dr. B that, Dr. B would come home and the children would be bathed and clothed and come in quietly and they couldn't talk to him. He had his dinner and his frosty beer and his TV show on. This whole ceremony of Dr. B is home. Oh, nice. Can you imagine? Like, where's the frosty beer? Yeah, the lazy boy
recliner.
Yeah. It's just different now. I think it has a lot to do with the respect in the community, the way doctors used to be treated. it's more about that than the money, but then when your bank account is crashed and you can't pay for college and you're like, how did this happen? I'm a doctor how can I not have any money? This is ridiculous. Then it just compounds, I still don't think doctors and clinicians are driven by money primarily because they're smart enough they could have done something else to make more money. But I do think the money just makes it so painful. And people are so ashamed and embarrassed to talk about it, right? I'm a doctor and then I'm complaining I don't have money. Like, that is like, I shouldn't do that, right? Like
money to go on vacations or to not have to worry.
Literally paying credit card. I mean, like it's bad and people just don't want to talk about it because it's so embarrassing.
I mean, I think it's embarrassing for me to talk about it.
We talked about moral injury as it relates to respect and community and society and financial freedom or the lack thereof, how has shortcuts to healing caused moral injury.
What does that healing process look like? How has it changed? Great. I believe that the human connection piece is actually the key. The technology is there to help support. The complexity of medicine, has exploded as with everything else. No way you can keep it all in your mind. No way you can keep it on your little black bag. Like my grandfather used to do, so we are reliant on tools to help us make our clinical decisions, but healing is when you as a human connect with another human, you understand them, you have empathy for them, and you also have the understanding of the different ways that they could heal, and then you make recommendations, you offer guidance, and you bear witness with them along the road.
That's what healing is. It's not just a medicine or a fix. Back in the days when medicine was more about you have a broken bone, let's fix it. Very reactive episodic care you could get away with more of that kind of industrial thinking, but now, when we're thinking about longitudinal care, chronic diseases, preventative care, it, I believe, becomes more about healing and the human connection.
Tell me a little bit about bearing witness. One of the most beautiful things about friendship is witnessing another person's life. Is that part of a credo in medicine
it's not written explicitly like that to bear witness, but it is written in the ethics code that you are there to guide, to do no harm, there's many times when we don't have a cure, we can't fix it a lot of it is just helping somebody cope with their body and what's happening. In psychiatric training, I learned a lot about the value of words, the value of being with someone, of listening, sometimes shutting up is like the best thing you can do, and it's really hard, it's hard for me, words matter, that's another theme in the book, is I think people underestimate the importance of words, And they underestimate the importance of just being with another person they underestimate that quite a bit.
And that has been compromised. Why haven't we adapted to this complexity it sounds like it's financially driven
is, but it's not. The common narrative is that it is all about money and it's greedy CEOs versus noble doctors and nurses. I think that's a false narrative in some ways and oversimplified. Yes the business model has to support the clinical model, and I'm 100 percent believer in that but for moral injury the things which heal it don't cost anything. One of the most important things we know from the military is that talking about moral injury, identifying it, saying what it is,, that's part of the healing.
When I share my story about things that have happened to me and then others are telling me, it's not like I can go back in time and undo that medical board , but it is healing you can
process it together with other people. Words
matter and people, someone who's truly empathetic and listening, it is healing. Sometimes the fixes don't even cost money. But they're uncomfortable
They take time.
Yes. And no, I, again, I think time is a convenient proxy for connection. You can spend hours with someone and have no connection. You can spend five minutes with them and have a deep connection. So I think it's a proxy for connectedness, but it's actually not what we all want. We say we want time, but what we really want is connectedness.
So what's the solution
synchrony. There are solutions. Words matter a lot. Something feels wrong inside and we don't know what to call it. We don't know how to identify it. We don't talk about it. We feel embarrassed or ashamed. The first step is
understand your emotional state and what's going on talk about it have others be empathetic and kind. The second step is finding ways for a clinician to become a leader, and for them to truly work in collaboration with the business. That's what it takes to change the business model, you have to speak the same language, you have to align. And then the other part is. I do believe we're on the cusp of some amazing tech and AI that if we use it correctly can really make a difference in the day to day. Those little paper cut injuries, you know, I said, you can have death by a thousand cuts. I do believe we're at that moment where we can get rid of all those little paper cuts, but Doctors and others are very understandably wary about technology because the stakes are high.
Doctors are supposed to be a hundred percent. If the tech is 80%, that's not okay. Can't be 80%, can't be 90. The app can't fail because we're not allowed to fail. Absolutely. So 95% isn't good enough. 99% may not be good enough. We're expected to be a hundred percent. So don't bring me a tech tool that only works 95% of the time. Because I'm not going to want it.
There's a lot of pressure, aI overall. But this is the front lines these are people's lives.
Same as the military. would you want a soldier to go into a situation where their life is in danger and your Humvee is 80%?
The automated drivers, the standard they're held to is much, much higher than the human driver standard of error?
Even before autonomous driving when the cars became computerized that couldn't go wrong, but yes crucial when you're talking about opening somebody up any thoughts, on a global level, culturally, what this moral injury might signify in all industries right now?
I guess two things. I think we're struggling To know that the baby boomer experience is not our experience. We had a whole bunch of expectations that were based perhaps just on one generation and we're not universal, but yet we've based everything around that mental model.
I think that's a global struggle, especially for people my generation. I've hopefully come to peace with it, but it's still kind of hard. Right. Um,
right. You feel a little bit like a failure. I grew up with a lot more privilege than . My kids, they have pretty much everything they need.
Right. But it's not, I, I went to summer camps all summer. I had a horse. Same thing. It didn't seem to cost as much to have that, not that I knew the ins and outs, but it came more easily to my parents. My mother never worked. My dad, money seemed to come easily to him for a time. We had more privilege .
Now it seems like a steep mountain to climb and it's coming to terms with it's never going to be the same.
I actually had my parents tell me that something was wrong with me and that I had mismanaged my money when I got out of my residency and was in debt and had a child a second on the way I actually had them tell me that,
yeah, that adds literally insult to moral injury.
So I think that we're struggling with that. The second thing I think we're really struggling is Our understanding of work and money and the connection between work and money because our culture is based on this idea that money is tied to work and different work has different money. So we're in this mental model and we're kind of struggling with that because as the robots come and the AI comes, we're like, wow, they can probably do my whole job. what does that say? You can either get fearful about that and be like, Oh my God, what am I going to do? I don't have a job.
I won't have any money. Or you can say, well, if I still can make the money and the robot does my job, like what does that mean? So there's like this disconnect between this time and money and work. I think that it's like the elephant in the room. Yeah. So the elephant in the room, if we don't need to work and our whole American culture of busyness is based around being busy, busy, busy work, work, work, and that's value.
That's a false. Yeah. Myth anyway, because as we all know, once you get up to the higher level, you realize it's all just made up you realize the corporate ladder is just an illusion you get to the top and you're like I still don't feel good, right? So I think we're really struggling with the elephant in the room, which is do we need to work? What is the work worth doing for humans? What work should robots do? And then does money need to be tied to work?
This is existential stuff
This is excellent. I think that's what's in the back of our minds That's why I started this podcast
this to talk about this what is going on and what are we going to do especially the Western capitalistic model of How we, extract value or create value for ourselves and what that all means as people.
If you look back, this isn't the way it used to be in the 1800s. If you were successful, you didn't work. Are you kidding? Work was like so low brow.
No, you had leisure. Leisure was the pinnacle of success.
This is how my mother thinks. She's an aristocrat in her own mind, and she thinks. Yeah, like
we, we go through these cultural movements, and we don't realize when we're in the middle of the culture that it's just a cultural moment. I think we're on the precipice of another movement I'm always laughing at the conversation around millennials and Gen Z's, they think they don't have to work hard and blah, blah. Well, maybe they don't, maybe they're right and we're wrong. And we just need to like wrap our heads around this.
But we need money!
That's what I always say. But that's because the money's connected to the work, but what about if it becomes disconnected from the work?
So we all get our universal income Or
yeah, what if we universal income or what if the symbolic token of money becomes less important like my kids, my teenagers, for example, are shockingly uninterested in material objects. When it comes time for their birthday I'm like, please, your grandparents want to get you present. They're like, I just want my screen.
My mother, who's in her 80s she holds over my head this diamond ring that she, she took, it's a long story, but I'm like, I don't care about the diamond ring and my kids certainly don't care about the diamond ring.
I was going to leave you this diamond and that diamond. I only want things so I can tell a story around the thing and have, some sort of Talisman or something to remember, but not because I want a diamond cocktail ring to wear to the cocktail party to show the Smiths how wealthy we are, whatever.
And my kids are interested in the arts as well as academics and I'm like, If you want to be an artist who's to say that may have more profound value to society than being a doctor, but right now it's all tied up in the money.
That's what I've always said, but it's all well and good when the coaches say, do whatever you want to do and be, but , I need to pay the bills.
And so maybe the future
will detach the money from the time
you've just hit the nail on the head of the whole reason why I'm doing this.
You've been listening to Actual People. This show is written, directed, and executive produced by me, your host, Chauncey Zolkin. Show sound designed by Eric Aaron. Click on the link below to subscribe so you don't miss a single episode, and don't forget to leave a review. I'll be sharing my favorites. You can find our socials and all links to deeper dives into these topics at chauncey zalkin.
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