By Larry Borowsky
The US healthcare system harms patients and practitioners alike. But they may have the power to heal each other.
Something feels off from the moment your prosthetist walks in. He asks how it’s going, and you explain you’ve been hurting. You’re spending more time on the couch, missing work, gaining weight. You took a fall recently and had a couple near misses. He asks the right questions, but it feels like he’s on autopilot, offering up generic answers and sympathy instead of targeted solutions. That’s disappointing, because you’ve been limping around for weeks while awaiting this appointment, you drove 90 minutes to get here, and you need to leave with an action plan. So your clinician’s lack of urgency is frustrating. Irritating. Even a bit infuriating.
You recoil from those feelings because you like your prosthetist. He’s always been there for you. But you need a little extra effort today, and he’s not rising to the occasion. Quite the opposite: He seems to be holding you at a distance, which only makes you feel worse. Did you do something wrong? What’s going on here?
According to doctors Wendy Dean and Simon Talbot, you and your prosthetist might be enmeshed in a poisonous dynamic that’s spreading briskly in the US healthcare system: moral injury. “We know what our patients deserve but often cannot provide it because the business of medicine gets in the way,” Dean and Talbot write in their new book, If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First. The book documents how corporate healthcare has driven a wedge between medical professionals and the people they serve. The gap has widened into a chasm over the past half-century, and patients aren’t the only ones plunging into the abyss. Doctors, nurses, and other practitioners—including prosthetists—are getting swallowed up, too.
“They don’t want patients to suffer,” says Dean. “They would rather provide care with more time, more compassion, and more flexibility. They are doing the very best they can in a system that is working against them. And they don’t have the time or energy to change the system.”
So they wind up complicit in an enterprise that hurts the people they’re sworn to help. That’s moral injury in a nutshell. It’s a major reason so many doctors and nurses are abandoning their careers, Dean and Talbot argue. And it could be why your prosthetist is backing away when you share your problems. He’s got the training and expertise to make things better, but the healthcare industry won’t let him use every tool in his kit. He’d probably rewrite the rules if he could. On this day, unfortunately, it’s his duty to follow the rules as they exist, leaving you without the solutions you need.
And that’s an uncomfortable position for both of you.
“Prosthetists are uniquely sandwiched between the patient and the payer,” says Ashlie White, chief programs officer for the Amputee Coalition. “They’re getting paid to deliver a holistic episode of care, which the system values at a certain amount. The prosthetist has to make that price work for the patient, while navigating a system that doesn’t recognize the services they’re providing.”
Prosthetists routinely sacrifice time and money to help amputees get past the checkpoints that deny them care. But there are limits to what even the most devoted clinician can sustain. When those limits are reached, practitioner and patient suffer together. They hurt in different ways, to different degrees. But moral injury harms both parties.
Recognizing it may be the first step toward easing the pain.
DEAN AND TALBOT WERE BOTH working in the limb-care orbit when they met in the mid-2010s. Dean had recently left private practice in psychiatry to become a senior advisor with the US military’s Institute of Regenerative Medicine, which develops treatments for veterans with limb loss, burns, facial injuries, and other severe combat wounds. In her new role, she was struck by the contrast between the military’s healthcare priorities and those of the private-sector health system.
“In the military, the only role of medicine is to support the patient,” she says. “It’s a very different mindset. The goal is to get service members back as close to preinjury as possible, as quickly as possible, so you can retain a ready fighting force. If you have somebody with limb loss, you figure out how to put them back on patrol and retain their skills. It’s all about what the patient needs. Whereas in the civilian sector, even though we talk about patient-centered care, there’s always this boogeyman in the room with you: What does the healthcare organization need?”
Prosthetic technology offered a stark example of the differing approaches. “The military came on board very quickly with powered prostheses,” Dean says. Bionic arms and osseointegration were among the other breakthroughs the military embraced in the mid-2010s. But when she discussed these innovations with colleagues in civilian medicine, they’d shrug and say: That’s great, but we’ll never convince the insurers to cover that. “It gave me a window into what medicine could do, and what constraints were caused by the business of healthcare,” she says.
Dean’s regenerative medicine program often collaborated with Talbot, a renowned Harvard surgeon who specializes in hand transplantation and the psychosocial impact of upper-limb amputation. To her surprise, Dean found that even doctors as prominent as Talbot routinely felt stymied by the private healthcare system.
“These are physicians who are at the top of their fields, with the best credentials, working at the best organizations in the country,” she says. “And they still weren’t always able to get their patients what they needed.”
The more doctors and nurses they talked to, the more Talbot and Dean realized that disenchantment ran rampant within the caring professions. The patient-practitioner relationship was being supplanted by a transactional provider-consumer model. Value was being defined not by medical outcomes but by performance metrics such as relative value units (RVUs), downstream revenue, throughput, patient wait times, and denial rates. The obligation to produce results on these indicators wasn’t merely draining practitioners’ time and effort, it was changing how they made decisions and gnawing away at their identities. They were forced to steer too many cases toward the best outcome the market would bear, rather than the best outcome medicine could achieve.
Talbot and Dean wrote up what they’d learned in a widely read 2018 article for STAT titled, “Physicians Aren’t ‘Burning Out.’ They’re Suffering From Moral Injury.” Doctors, they observed, are “continually being caught between the Hippocratic oath and the realities of making a profit from people at their sickest and most vulnerable…. These routine, incessant betrayals of patient care and trust are examples of ‘death by a thousand cuts.’”
They didn’t mean “death” figuratively. In 2019, the suicide rate among doctors and nurses was twice the national average. Women practitioners died by suicide at more than three times the national rate.
“We’re here to do good and make people better,” says Dean. “Not to sacrifice our souls.”
THERE’S NO EVIDENCE THAT PROSTHETISTS are dying by suicide in large numbers. However, burnout is an ongoing concern.
“We’re starting to see evidence of some attrition,” Gerald Stark, director of clinical affairs for Ottobock, told The O&P EDGE last year. “We’re losing practitioners right after they get their master’s degree—zero to five years.” Multiple factors are driving that trend, according to a survey Stark presented last year at the American Orthotic and Prosthetic Association (AOPA) conference. They include high student debt, heavy patient loads, and the dearth of research opportunities. All were exacerbated by the pandemic.
“The financial end of it—fighting with the insurance companies, complying with Medicare regulations, and things like that—has taken its toll on practitioners,” adds Mac McClellan, longtime owner and clinician at Texas-based Prosthetic Orthotic Associates. “People put in tremendous numbers of hours per week, and more of them are spent on things that have nothing to do with why they got into the profession. They now have tons more paperwork that takes them away from taking care of patients.”
All that extra effort too often comes to naught, says Scott Hedlund, president of Orthotics Prosthetics Canada. “You know there are solutions that can enhance a person’s mobility, help them avoid trips and falls, and some of the long-term comorbidities. So it is particularly frustrating where we end up with a denial” despite filing every document and complying with every requirement. “It’s really hard to go through all that and still end up with a financial barrier that’s preventing you from reaching better outcomes.”
However aggravating these obstacles are for prosthetists, in the end it’s amputees who pay the price. Kyle Stepp has been paying it since October 2020, when he lost his left leg above the knee in a bicycling accident. He was well acquainted with the American medical complex by then, having survived childhood osteosarcoma and endured many years of limb-salvage procedures. “I’ve experienced the broken healthcare system,” says Stepp, who lives in Albuquerque. “And it is extremely broken.”
Stepp’s prosthetist came through for him in the early stages of his post-amputation recovery, loaning him a hydraulic knee and supporting his efforts to get covered by United Healthcare for a microprocessor knee (MPK). But after an initial denial and two failed appeals, says Stepp, his prosthetist abruptly gave up.
“He said, ‘This is just the way it is,’” Stepp recalls. “I learned he wasn’t really gonna fight any more, because it’s not worth his time. Eventually he told me, ‘We’re just gonna give you this other knee because we need to close out the books.’ He even said—and I cannot believe this—‘You’d be better off not having a job and signing up for Medicaid.’”
For Stepp, who’s overcome a difficult upbringing and years of medical challenges, the sense of abject defeat was shocking. “I was almost at the point where I didn’t want to wear a prosthetic,” he says. “I was like: ‘I’m done. I’ll just learn to live with crutches.’”
“I’ve seen that happen,” nods amputee advocate Brian Bishop. “The prosthetist tries to work it out, but if it’s just going to be wasted effort, sometimes they just throw their hands up in the air. And then the patient gets frustrated and says, ‘If the prosthetist’s not going to produce for me, why should I even try?’ I’ve known a couple people that, instead of settling for a second-best or third-best leg, they just decide they want to sit in a wheelchair.”
Stepp eventually did get an MPK after switching to a prosthetist in neighboring Colorado, which has a Fair Insurance for Amputees law. But he believes some providers won’t even attempt to get high-end devices for patients who have limited means and modest (or no) health insurance. “They know the family can’t afford it out of pocket,” he says. “They know they’re not going to get reimbursed through insurance.” So they simply cut to the chase, put the patient in a basic prosthesis, and save themselves the brain damage of fighting in vain for a better outcome.
Whether fairly or not (and it’s surely fair in some cases), prosthetists routinely get blamed for the sins of the system. “I hear about that a lot,” says Hedlund. “And I understand it. As much frustration as [prosthetists] feel, it’s at a much deeper level for patients.”
“The awareness that you’re not living up to your own values as a healthcare provider can weigh on an individual,” adds White, who worked with clinicians at AOPA before joining the Amputee Coalition as chief program officer. “You start to ask yourself: ‘How am I contributing to this problem? And how am I working to fix it?’”
FIXING THE DYSFUNCTION THAT PRODUCES MORAL INJURY is too big a job for any single person. It will take broad action across multiple fronts. And the coalition will have to include patients as well as practitioners. Both parties to that relationship are harmed by moral injury. Both have to be involved in turning things around.
When prosthetists try to mitigate the system’s defects on their own, they rarely succeed. “Part of what prosthetists get burnt out on is that they feel they have to be a healthcare provider, a psychologist, an accountant, and a scribe all in the same breath,” says White. “That is taxing on anybody.” She believes clinicians can be most successful by cultivating partnerships to help them deliver sustainable patient-centered care, instead of taking the entire burden of reform on themselves.
“Community asset mapping is incredibly important, because it grounds the clinic in a community with a shared commitment to looking out for patients,” White says. Amputee support groups, local nonprofits, independent living centers, religious congregations, civic agencies, and other programs can step up for patients who are in danger of falling through the cracks in the healthcare system. They can also promote better health outcomes by providing material benefits such as transportation, in-home care, financial aid, companionship, fitness training, and education.
Many prosthetic clinics have already established these types of alliances, says White, and most would welcome amputees’ help in building new connections. A strong network can buffer the patient-practitioner relationship from corporate healthcare’s worst abuses, enabling both parties to keep medical outcomes front and center.
Kyle Stepp modeled a different approach to reform this winter, spearheading a campaign to pass fair insurance legislation in New Mexico. With help from AOPA and the Amputee Coalition, Stepp stitched together a statewide coalition of amputees, prosthetists, physical therapists, doctors, and other allies. More than 100 people volunteered to contact legislators, offer testimony, coordinate email-writing campaigns, and generate publicity. By the time Amplitude went to press in late January, the bill was poised to clear the state House of Representatives and move on to the Senate.
Dean and Talbot have launched a nonprofit to accompany their book. Called Fix Moral Injury (fixmoralinjury.org), the organization is working with doctors, educators, administrators, and other healthcare stakeholders to raise awareness about moral injury and develop constructive responses to it. But you don’t have to be an activist or organizer to do something about moral injury, Dean adds. Her own advocacy is rooted in her personal experience as a patient and a caretaker. Six years ago, as her husband lay dying in an emergency room, she had to call her financial advisor to find out if the family possessed enough wealth—home, college funds, retirement savings, and loose change between the couch cushions—to cover the cost of extending his life.
Once that crisis passed (her husband survived, and their insurer stepped up and paid most of the bills), Dean faced her own medical challenge, a leg injury that, while not limb-threatening, has significantly affected her mobility. And it has given her insights about how to address moral injury as a patient.
“My physical therapist is doing his level best,” she says, “but he’s seeing three patients at once, just trying to tick the boxes and move people through the pipeline. It doesn’t matter who I am, what my goals are, what my questions are, or how I might be different from the other people on that assembly line. He’s pushing so hard to meet his productivity metrics that he’s doing things I think are dangerous for me. It isn’t the kind of healthcare I would like to get, and it doesn’t seem like the healthcare anyone would like to deliver.”
You couldn’t blame her for getting angry, lodging a formal complaint, or just ditching the guy for another practice. But Dean took a different path, defusing the tension one day by simply recognizing her clinician’s circumstances and calling them out—with humor.
“I just said, ‘It looks like you’re having a shit day,’” she says. “And he laughed: ‘Oh yeah, the wheels are off.’” Dean emphasizes that she didn’t set aside her own needs to ease her practitioner’s burden. She simply connected on a level that recognized her clinician’s humanity—and his identity. She gave him the grace to be imperfect, accepted the limits of what he could and could not control, and gave him a gentle reminder of why they had come together: to heal the patient.
“It’s just about being open and saying: ‘I see your struggle, and I’m sorry,’” says Dean. “‘I know this is hard, and I’m going to ask more of you. But I’m going to share the journey with you.’”
Moral Injury: A Survivor’s Tale
By Chris Prange-Morgan
“Don’t get me wrong,” the orthopedist said. “I love my job. It’s very satisfying when I can save someone’s limb. But I’ll be honest: Your ankle is garbage.”
His words didn’t upset me. Just the opposite: I finally felt validated.
I had sought the orthopedist’s opinion after more than a year of failing to convince a different, highly respected surgeon to amputate my leg. He’d already performed 11 operations on me, and I was facing a future that promised more pain, incapacity, and additional surgeries. The ongoing effort to salvage my limb was having a devastating impact on me and my family, yet this seemed inconsequential to my surgeon. He couldn’t seem to hear my argument that amputation would improve my quality of life.
Doctors take a Hippocratic Oath to do no harm. But what happens when the doctor’s definition of harm collides with the patient’s? I wondered why my surgeon and his team couldn’t understand the situation from my perspective. And I resented that they were recommending a course of action that might keep me hobbled for the rest of my life—and insisting that it was clearly the best medical decision.
I had an aha! moment years later during a training titled “Psycho-spiritual Risk Factors for Moral Injury in Healthcare.” As a hospital chaplain and trained social worker, I’ve seen moral injury play out over and over. But I hadn’t connected the dots between that concept and my surgeon’s reticence to amputate my leg.
During the training, I learned that the risks of any medical decision can be assessed within multiple contexts. Risk factors such as insurance coverage, provider time constraints, liability, and reimbursement pressures enter into what’s called the utilitarian model of care. In this context, actions are assessed in terms of achieving the best outcomes for the greatest number of patients.
By contrast, a patient-centered model of care is defined as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” The patient-centered context accounts for the individual and family costs associated with a given medical decision, including social isolation, pain, depression, grief, financial problems, and job loss. It’s messier than the utilitarian context, and it requires more time and energy. Those are luxuries many medical professionals don’t have.
I finally realized that my surgeon had been operating from a utilitarian perspective, which is deeply embedded in the values of the medical-industrial complex. He was applying a cost-benefit analysis that was oriented toward efficient allocation of healthcare resources across a very large number of cases. The particulars of any individual case—including mine—weren’t part of his equation. So maybe he wasn’t simply being a complete jerk. Maybe he was using a one-size-fits-all set of calculations that he’d developed over the years, a formula that probably worked for most patients. He used it in every case, and he was sticking to it in my case—no matter what I wanted.
Of course, that formula also happens to meet the needs of the hospital’s balance sheet: Orthopedic surgery ranks as one of the US healthcare industry’s top revenue generators. If I had followed my surgeon’s advice, I would have undergone many more high-cost procedures. Instead, I filed a formal grievance against him. I had a below-knee amputation performed by a different doctor. I was fitted with my first prosthesis three months after surgery, and by June I was hiking, climbing, and running again, just as I had hoped.
Amputation was the best possible outcome. I’m glad I followed my gut, didn’t back down, and refused to let the utilitarian model of care take precedence over the things that matter most to me.
Chris Prange-Morgan is an adoptive parent, patient advocate, trauma survivor, and hospital chaplain. She is the author of the forthcoming memoir Broken, Brave and Bittersweet.