When I began my medical practice over thirty years ago, I viewed the system as flawed yet honorable. We toiled diligently, we cared profoundly, and I convinced myself that if we simply continued to put forth our best efforts, improvements would come over time. I believed that advancements in technology, new regulations, and improved organization would eventually guide us closer to the principles of medicine. Some of those modifications were beneficial. Many were not.

To be candid, there were instances when I contributed to the problem. I gauged my value by RVUs instead of by outcomes. I adapted to the business vernacular of health care and echoed it because it felt simpler than contesting it. I accepted the compromises as a necessary part of functioning within a contemporary system. I reassured myself that I was merely fulfilling my role, even when I recognized that the framework was failing the children and families I supported.

Now, three decades into my career, I cannot ignore the reality. My cohort of physicians has not succeeded in improving health care. We have witnessed profit margins grow while the mission has diminished. We’ve seen hospitals merge, clinics shutter, and executives prosper, while children still gasp for breath in emergency rooms at three in the morning when they should have received care in a clinic that was never available in their community. We have allowed the left to criticize the system while the right assigns blame to personal choices, as the patients before us remain stuck in the middle.

A reflection on moral ambition

This is why Rutger Bregman’s latest book, Moral Ambition, resonated with me so profoundly. It presented a reflection of what I, along with many others, have forfeited throughout our journey.

Bregman illustrates how idealism and ambition frequently diverge. Idealists cling to their principles but seldom achieve significant outcomes. Those driven by ambition ascend ranks and pursue prestige yet often lose sight of their greater purpose. The vital combination (the one that genuinely transforms lives) is moral ambition: the unwavering union of determination and conscience.

As I absorbed his insights, I recognized how frequently I have swayed toward either extreme. There have been times of pure idealism, where I vehemently opposed inequities but produced minimal tangible change. Conversely, I have experienced periods of sheer ambition, where I pursued RVUs, attended meetings, and accepted the system as it was. What I have often lacked is the bravery to unite the two: to aspire not just for my own benefit or that of my institution, but for patients and equity.

The left, the right, and the pitfalls of blame

Bregman’s perspective also clarifies why our political discussions regarding health care feel so stagnant. The left typically blames the system. Every unfavorable outcome is attributed to oppression or avarice. Each disparity highlights the failures of capitalism. The outrage can be justified, but the solutions often dwindle to mere slogans or policy initiatives that fail to reach patients. Purity is safeguarded, but meaningful results are few.

On the right, the inclination is to attribute blame to individual choices. People should improve their diets, exercise more, work harder, and take accountability. Poverty and illness are perceived as consequences of weak willpower. While this may sound realistic, it overlooks how profoundly circumstances and structure influence the options available initially.

Both perspectives hold elements of truth. Systems are significant. Choices are significant. Yet neither viewpoint genuinely facilitates healing. Neither guarantees a mother timely prenatal care. Neither ensures a child doesn’t miss school due to an untreated asthma attack. Neither reduces the rate of infant mortality in economically disadvantaged neighborhoods.

What is absent is ambition; the resolve to transcend blame and genuinely address issues. Ambition that bridges divides. Ambition that is willing to negotiate with unlikely allies, construct coalitions, and make strategic compromises without moral compromise. As Bregman reminds us via the tale of abolitionists, the movement gained momentum not solely by advocating morality but by reconstructing arguments in ways that could sway a broader audience.

How my viewpoint evolved

I can trace this lesson throughout my professional journey. As a young physician, I was convinced that caring passionately and exerting effort would suffice. I believed that the system, as flawed as it was, would adapt to my commitment. That was idealism devoid of ambition.

As I progressed into leadership positions, I permitted myself to be engulfed by the culture of measurement. I met RVU targets, monitored margins, and conversed the business language back to administrators. I reassured myself that this was the role of a leader. That was ambition, but devoid of morality.

Now, with the clarity of hindsight, I perceive that neither approach has sufficed. My generation has overseen more consolidation, greater corporatization, and increased detachment from the communities we were meant to serve. We were not powerless, but we lacked ambition in the appropriate ways. We did not harmonize our ideals with the bravery to effect change.

What moral ambition could signify today

So what would reclaiming moral ambition in health care look like?

In the clinic, it would entail refusing to condense our work to mere throughput and productivity.