Moral Injury, Moral Courage, and the Business of Medicine

What happens when a healthcare system organized around profit repeatedly gets in the way of doing what is right for patients? Physicians for a National Health Program (PNHP) calls one consequence moral injury: the distress physicians experience when the system prevents them from providing the care they believe patients need. PNHP president Diljeet Singh, MD, DrPH, joins Stefan and Saul to discuss the organization's recent report on moral injury and the financialization of American medicine. Saul strongly shares PNHP's commitment to universal health care—but challenges whether the language of moral injury puts too much emphasis on what the system does to physicians and too little on physicians' own agency and responsibility within that system. What follows is a candid and provocative exchange that begins with substantial agreement about what is wrong with American health care and the need for universal coverage, but moves into harder questions about moral distress, physician complicity, professional responsibility—and how much courage we should expect from doctors when doing the right thing comes at a personal cost.

Fazlur Rahman, a retired oncologist, is the author of The Temple Road, a richly evocative memoir about growing up in what was then East Pakistan, before it became Bangladesh. His second book, Our Connected Lives, chronicles several patients he cared for during his 35 years as a cancer doctor in West Texas – and his relationships with them in the rural region where he was the only oncologist. Fazlur is a gifted writer who became a beloved physician in a community that needed him. Fazlur also faced prejudice along the way, and his story is a reminder of how much America gains from those who come from seemingly far-off lands.  It is an inspiration and illustration of humility, presence, compassion and joy in patient care.

Most of us who care for patients can remember seeing a name on the schedule and feeling our heart sink. What makes some clinical relationships so difficult? Is it something about the patient—or something about the interaction itself? Dr Jeffrey Jackson has spent more than two decades studying this question. His research has shown that difficult encounters are associated not only with patient characteristics but also with physician factors, including the clinician's approach to psychosocial issues. In this conversation, we explore what his work can teach us about why encounters become difficult, how trust can gradually emerge, and why some of the patients that physicians initially dread eventually become among the most meaningful to care for. Along the way, we discuss chronic pain, personality disorders, longitudinal relationships in primary care, the role of physician self-awareness, and the difference between caring for patients and trying to control them. This episode asks what it means to remain present with patients whose suffering—and whose behavior—challenge us the most.

Over the past several years, contextualizing care has surfaced repeatedly on On Becoming a Healer. In 2025, contextualizing care was incorporated into new Foundational Competencies for Undergraduate Medical Education. Around the same time, co-host Saul Weiner worked with the Institute for Healthcare Improvement (IHI) to develop an online course designed to teach these skills, called Contextualizing Care for the Clinician (IHI Open School). Now that the course has been added to IHI's subscription-based Open School curriculum, making it available to learners at hundreds of subscribing institutions, we thought it would be a good time to revisit several conversations from past episodes that illustrate what contextualizing care is, why it matters, and how we can teach it.

What if many of the core assumptions of modern psychiatry are wrong? In this episode, we speak with internist and author Dr. Khameer Kidia about his provocative new book, Empire of Madness: Reimagining Western Mental Health Care for Everyone. Kidia argues that mental illnesses are often understood too narrowly through a biomedical lens and that psychiatric diagnoses may function less as explanations for suffering than as labels we apply to it. As he puts it, "generalized anxiety disorder doesn't cause anxiety; rather, anxiety causes generalized anxiety disorder." Drawing on experiences in both Zimbabwe and the United States, Kidia challenges us to reconsider how culture, inequality, migration, social isolation, debt, and political structures shape psychological distress. He discusses evidence that conditions such as schizophrenia present very differently across cultures and explores why outcomes in some lower-income countries may surpass those in wealthier nations despite far less reliance on psychiatric medications. Throughout the conversation, we return to a practical question: How should clinicians care for patients when the roots of suffering often lie beyond the reach of medicine itself? We explore how a deeper understanding of the social and political dimensions of mental health might change the questions physicians ask, the assumptions they bring to clinical encounters, and the ways they connect with patients.

In last month's episode we learned that there is no evidence that time limits that impose any sort of pressure on even a small percentage of students improves test validity and that, in fact, there is ample research showing that they make tests less valid and less equitable.   In this episode we discuss how, despite the data, the NBME denies accommodations on the USMLE exams to over half of medical students who have a documented learning disability and are approved for accommodations at their medical school (e.g., extra time). We talk with a leading medical educator who is co-author (along with last month's guest and co-host Saul Weiner), of a paper published last month in the journal Medical Education, titled The myth that slow test-takers are worse students: Implications for time-limited testing. The publication is Open Access, so fully accessible to everyone. In this episode, originally aired in 2023, our guest discusses a published national survey she and her colleagues conducted to assess the scope and harmful impact on medical schools and their students of current NBME policy on accommodations. We conclude with a discussion about how the NBME could make the test fair and valid for everyone by functionally eliminating time limits. 

There is a widely held misperception that being able to complete a test quickly is an indication of mastery when compared with those who need more time. As a result, it is often difficult to obtain accommodations on high stakes examinations, including the MCAT and USMLE exams.  Many students who request extra time because of a disability are denied accommodations and many other students who need it aren't eligible (e.g., English is a second language) or are inhibited from applying (e.g., Veterans, students from certain cultural backgrounds). In this month's issue of the journal Medical Education, titled The myth that slow test-takers are worse students: Implications for time-limited testing (open access), the authors review the evidence that time pressuring even a small proportion of students taking an exam makes it less valid and less equitable, and that a simple solution would be to give everyone the time they need.  In this episode, originally aired in 2023, we hear from one of the authors about why it's past time to do away with time limited tests for everyone.

In a recent five-part series in the New England Journal of Medicine on the future of primary care, the author asks: "Has the long-term general doctor become obsolete? In other words, should the dying primary care system be saved?" The question itself is unsettling. Could a health system function effectively without primary care? What happens to patients when no one is responsible for truly caring about them and guiding them safely through the health care system? Today many, perhaps most, Americans don't have a doctor like that. But is that okay? Research by one of the hosts, based on thousands of recorded physician–patient encounters, suggests that physicians who consider the circumstances, needs, and priorities of each patient when planning their care are uncommon. In this episode, we introduce you to a primary care physician with his own practice in a mid-size Western city who, like many others — but far too few — provides this indispensable service to his community. He is a skilled and deeply knowledgeable clinician, a caring advocate who knows his patients well and finds the work deeply rewarding, despite the daily frustrations of insurance denials, specialists who don't return calls, and a payment system that measures almost everything except how well physicians care for people when they are sick. There is also a major medical education challenge. What is poorly understood is that producing an excellent primary care physician is often harder than producing an excellent specialist. The work depends less on mastering technical procedures and more on integrating complex information, building long-term relationships, and making collaborative decisions under conditions of uncertainty. Far too few graduates of U.S. medical schools and residency programs are being prepared for — or supported in — this kind of work. In a profit-driven health system that can at times be predatory, where patients are exposed to unnecessary procedures while their mental health and well-being are overlooked, the absence of accessible, high-quality primary care leaves patients vulnerable and often very alone.

Forty-five percent of patients who die by suicide saw a primary care physician in the prior month. Physicians screen for suicide risk just half the time when seeing patients under treatment of depression.  Meanwhile, suicide rates continue to rise in the United States and are the second leading cause of death among young people.  In this episode, Saul interviews co-host Stefan, who is leading a national study of suicide in patients on chronic opioids who take their own lives after their physician tapered or cut off their opioids without their consent. They discuss the rich literature, theoretical and empirical, on why people take their lives, what stops them, and what a caring health professional can do to make a difference. Please note: if you are in crisis, US-based crisis supports are available by calling 988, and at https://988lifeline.org. An international listing of hotlines is offered at https://blog.opencounseling.com/suicide-hotlines/. 

Unfortunately, bad leadership is common, with 50% of American's leaving a job because of a bad boss, and medicine is no exception.  Saul and Stefan, with a combined 60 years in academic medicine and clinical practice, share personal experiences and anecdotes that highlight the characteristics of dysfunctional and toxic leaders, and discuss their implications for health care training and practice environment, including the trickledown effect on patients. They consider why and how bad leaders end up in positions of power, and what to do about it, acknowledging the difficulties in identifying and promoting effective leaders.