This initial decade of my journey as a millennial doctor is beginning to appear as disjointed on my résumé as it has felt in truth, pursuing even a sliver of the stability that physicians of my father’s era took for granted. Concurrently, the turmoil created by market dynamics such as vertical and horizontal integration within insurance and hospital systems, buyouts of physician practices and surgical centers backed by private equity, and now, every four years, significant changes to governmental regulations impacting an industry that now accounts for 17.6 percent of our GDP, or 4.9 trillion dollars (roughly 14K per person), has resulted in what essentially feels like career whiplash. I’ve held roles as an employee, self-employed individual, and currently as an independent contractor, within for-profit, nonprofit, and religiously affiliated systems, across the Deep South, Midwest, Mid-Atlantic, and the Rocky Mountain West. There exists no safe haven. My eldest child has resided in four states over her twelve years, and we are actively seeking our next residence. This time, we’ve widened our search to include other countries, hoping that a system that doesn’t refer to patients as “customers” might be somewhat insulated from the harsher impacts of a purely commercial approach to healthcare.

In the decade since I completed my residency, burnout has emerged as one of the most resonant terms to describe what feels like a crucial turning point in medical practice. I can’t recall whether we had any formal discussions about burnout during my medical education, nor would I have been able to focus on such trivial matters in my demanding residency when basic bodily needs—sleep and nutrition—consumed so much of my “personal” time. Now there is a newer initiative to redefine “burnout” because it places the responsibility for the problem, and consequently the solution(s), on the individuals affected to take more action (yoga, meditation, healthy eating, or exercise) when by definition, they already feel like ashy remnants barely holding onto the withered threads of their humanity. Instead, perhaps this movement is more accurately viewed as an accumulation of moral injury, which occurs when the values, objectives, and priorities of the system we work in clash sharply with our personal moral code. Moral injury is a subjective psychological condition of emotional pain resulting from observing or engaging in actions that breach our internal ethical principles for how things should ideally be. In medicine, this affects every physician daily. Every time we observe or provide care that fails to align with the treatment standards we desire for our loved ones or the care we would expect for ourselves, moral injury ensues. It may seem like just a minor wound, but it can still smart. It compromises our integrity in the same way that the most harmless cut or insect bite can trigger necrotizing fasciitis. What begins as a small hurt, nothing significant, can transform into severe pathological shifts across various autonomic and emotional systems.

Honestly, I don’t believe moral injury accurately encompasses the entirety of the experience either. I am not a moral philosopher, yet I recall bits from my college “Intro to Ethics” class, particularly the dilemmas posed by utilitarianism, where the stated aim was always to maximize good for the greatest number (although some utilitarians become quite animated by the inclusion or exclusion of nonhuman sentient beings). The challenge lay in the fact that changes in knowledge, particularly concerning future outcomes, could shift the moral perspective of current actions. For example, redirecting a runaway bus to prevent the death of an innocent child in the road, while sacrificing three adults on board, is altered depending on whether the child is a future inspirational leader or a future sociopathic tyrant, or whether the grownup on the bus is the dictator or the saint. I departed from ethics feeling as though no one possessed better answers than my instinctual reactions, which I now understand are influenced by whether I perceive flowers or garbage in my surroundings and my overall risk tolerance, likely tied to my genetic dopamine receptor variations.

Thus, claiming ignorance regarding anything but basic canonical knowledge of virtues or opposing cardinal sins, I believe the most effective way to articulate the ethical dilemma of contemporary medical practice aligns with the notions of Catch-22 or Sophie’s Choice, where there truly is no decision for the burned-out practitioner that is free of deeply adverse ethical and emotional consequences. It embodies learned helplessness, like the rat in the electrified cage from Psych 101. If you resign or retire prematurely, you risk leaving your colleagues even more understaffed and stretched to meet systemic demands, your patients facing compromised access to care, a lack of knowledge or underutilized skills and expertise, not to mention the “