At the hospital where I spent most of my career, I once had five sinus patients on my operating schedule and only enough Nasopore for four of them.
Four patients would get what I normally used. One would get something I considered substandard. How does a surgeon decide who the unlucky patient will be?
Nobody in administration made that decision. Nobody stood in the operating room and told me which patient would get the inferior product. I made the decision myself, in the middle of my workday, with five patients who had entrusted me with their care. It was enraging.
That is the part of moral injury that I think gets overlooked. It's not simply frustration with bureaucracy or dissatisfaction with your employer. It's the experience of knowing what your patient needs and being unable to provide it because of constraints imposed by a system that is managed from the C suite. Worse, you're the one left holding the responsibility for the compromise.
I recently talked about this with Dr. Liz Malphrus, a plastic surgeon and host of the podcast Cut and Tell. Liz worked in health policy before training in surgery, which gives her a perspective on the business of medicine that most of us were never taught to develop.
Our conversation got me thinking about how much of what we call burnout is actually a collision between our professional values and the systems in which we're expected to practice. Here's what I took away from it.
Why moral injury hits surgeons so hard
The culture of our profession has barely changed in a century, while the economics surrounding it have changed beyond recognition.
We're trained to give without limits. The patient comes first. You do whatever needs to be done. You don't abandon your patient. We internalize these expectations long before we have a paycheck, mortgage, or family depending on us.
Meanwhile, more and more of the decisions that shape our work are made by people who, as Liz put it, "don't answer to patients. They answer to shareholders."
Put those two things together and you have a workforce that is remarkably easy to exploit. We keep absorbing the difference between what the system provides and what the patient needs. We make compromises. We stay late. We find another workaround. We tell ourselves it's just part of the job.
Neither of us is against business. Modern surgery depends on investment, equipment, infrastructure, and people who understand money. The problem isn't that healthcare has an economic component. The problem is what happens when the priorities get inverted.
I keep coming back to Simon Sinek's idea of the infinite game. Leaders take care of their people. Their people take care of patients. And patients, in turn, sustain the business. When the shareholder comes first, badness ensues.
And the people closest to the patient are left trying to make an increasingly dysfunctional system work.
Most surgeons don't know how they get paid
I recently spoke at a GI symposium and asked the audience what goes into an insurance claim.
Nobody knew. A room full of physicians.
A claim has five basic components: the diagnosis code (ICD-10), the procedure code (CPT), your provider number (NPI), the payer, and the facility. That's it. Five pieces of information.
Yet between those five data points and the money that eventually reaches a practice sits an astonishing chain of intermediaries, each adding a layer of complexity, cost, and delay.
Liz's point is that this knowledge gap leaves physicians vulnerable. We're a profession built around acquiring expertise. We spend years learning anatomy, physiology, pathology, and surgical technique. But most of us never learn how the business we're working in actually works.
I lived this for years in private practice without questioning it. I had one brain focused on what the patient needed and a second brain trying to figure out how to word the note so the insurance company would pay.
One insurer wanted specific language about the nasal cavity before it would cover an endoscopy. Another didn't care. I created templates to satisfy insurance rules. I rarely stopped to ask who had written these rules, what evidence supported them, or why I had accepted the premise that complying was simply part of being a good physician.
Liz calls the result an administrative arms race. Hospitals hire people to fight denials. Insurers hire people to issue more of them. Each side adds another layer of personnel, technology, and overhead. The physicians and patients are left in the middle, paying for a battle neither asked to fight.
None of that makes anyone healthier.
Rules written by people who never meet the patient
In my operating room, the team counts 4x4 gauze sponges during nose and sinus cases.
You cannot physically lose a 4x4 in a nose.
The count makes sense for an open abdomen. It makes no sense for nose and sinus cases. But the policy doesn't distinguish between the two. So we count.
Liz described how these rules often come into existence. Something goes wrong once. An administrator responds by adding a checkbox, required form, or another step to the workflow. The new requirement is then applied to every case and patient, whether or not it addresses a meaningful clinical risk.
The person who created the policy rarely experiences the cost of implementing it. We do. Our nurses and techs do. Our patients do. The cost accumulates in small increments until an entire workday is spent accommodating requirements that may have little to do with the care we're trying to provide.
This is Goodhart's law: when a measure becomes a target, it ceases to be a good measure. We become so focused on satisfying the checklist that we lose sight of what the checklist was supposed to accomplish in the first place.
Most administrators believe they're making care better. I don't think we need to assume bad intentions to recognize bad outcomes. What's missing is a feedback loop. The consequences of these decisions need to reach the people making them.
Know your worth
When I asked Liz what she most wanted surgeons to hear, she gave me the mantra she adopted at the end of residency: "Know your worth."
Patients come to the hospital to see us. The system cannot function without surgeons. And yet we're the ones who have been trained to put our heads down, work harder, ignore when our boundaries are violated, and accept whatever comes next.
I think a lot of that compliance is rooted in fear.
We have a non-compete. A mortgage. Tuition payments. Student loans. Families depending on our income. We have spent so much time and money becoming surgeons that the prospect of walking away from a particular job, institution, or arrangement can feel like losing everything.
Underneath all of that is a belief that sounds something like this: If I don't have this job, I have nothing.
That's a remarkably precarious place to negotiate from. It's a codependent relationship with the profession. As long as our sense of safety depends entirely on an institution, we're going to keep signing the form, clicking the box, and agreeing to one more unreasonable request.
The work is learning to separate our identity and security from the institution that employs us. That doesn't mean everyone needs to quit, start a business, or become a locums surgeon. It means recognizing that your job is something you do, not the entirety of who you are.
The safety has to come from inside us first. Then we can begin to recognize and use the leverage we already have.
Pick one fight
Liz's practical advice is to choose one issue you care about and make yourself heard. Go to the committee meetings. Ask questions. Keep asking until someone listens.
One of her faculty mentors, a breast surgeon, decided the postoperative bras stocked by the hospital weren't good enough for her patients. They were the bras the hospital had always used. She pushed until they were replaced.
I love this example because it isn't a grand gesture. It's a surgeon noticing something that could be better for her patients and deciding she wasn't going to accept the status quo simply because it had always been the status quo.
My example was a consent form.
I told my clinic staff we would no longer ask patients to sign a consent form for flexible laryngoscopy and nasal endoscopy. I didn't believe there was a clinical reason to require a separate written consent for these routine office procedures. They pointed me to the hospital policy. I sent an email asking for the safety data behind it.
I got no pushback.
I work locums now, which means the hospital needs me more than I need it. I recognize that not everyone has that kind of leverage. A surgeon with a restrictive contract, a large financial commitment, or limited employment options may have a very different calculation to make. I'm not suggesting that everyone can simply refuse.
But I have started setting a few non-negotiables of my own. I no longer do peer-to-peer calls or prior authorization paperwork. Required hospital modules happen on paid time. Yours will look different. What matters is that you identify where you're willing to draw a line.
Professional sovereignty doesn't require you to win every battle. It requires you to participate in the decisions that shape your work rather than automatically surrendering your judgment to someone else's policy.
Three places to start
Learn how a claim becomes cash. Liz's podcast, Cut and Tell, has a full season dedicated to how physicians get paid. Start there. You don't need to become a billing expert, but you should understand the economics of the work you're doing.
Name one non-negotiable. Decide on one thing you're no longer willing to do unpaid, outside your scope, or without a defensible clinical reason. Start with something small enough to act on.
Pick one fight and see it through. Find a policy or process that affects your patients or your ability to practice well. Ask questions. Find the people responsible. Make your case. You may be surprised by what changes when someone finally speaks up.
Understanding how the system works is half the equation. The other half is understanding the fear that keeps us participating in it.
Because sometimes the biggest barrier to exercising our power isn't the administrator sitting in an office somewhere. It's the belief that we have no choice but to comply. It's the fear of being difficult, losing our job, disappointing someone, or being labeled a problem.
That's the inner work we do inside Empowered Surgeons Group, my coaching program for surgeons. We work on recognizing the beliefs and behavioral patterns that keep us stuck, reclaiming our agency, and building professional identities that aren't entirely dependent on one institution or one job.
The healthcare system isn't going to change because we become better at tolerating it.
But we don't have to wait for the system to change before we start exercising the power we still have.
You can hear my full conversation with Dr. Liz Malphrus on the Surgeons with Purpose podcast.
