When Tonatiuh Lievano Beltran worked at an inpatient child psychiatry ward, he felt as though he was always walking a fine line.

On the one hand, Lievano knew that many of the young children he was treating would benefit from personal, positive interaction — but balancing the pressures of being a person and a provider could prove personally challenging.

A fourth-year student at Harvard Medical School, Lievano said he faced a “constant tension” between the responsibility to do right by his patients and the need to maintain his own mental health.

Throughout the course of their training to become doctors, many medical school students have come to face the same challenges as Lievano.

After graduating from medical school, students either go on to a yearlong internship or immediately begin their residency training, which lasts from three to seven years and centers around a specialty. Following residency, some trainees move on to a one to three year subspecialty fellowship, but most directly become physicians.

Along the way, many of them realize the consequences of recent changes to the medical landscape — including increasing corporatization and consolidation of hospital systems and the fallout of the Covid-19 pandemic.

According to Wendy Dean, president and co-founder of Moral Injury of Healthcare, there has been a dramatic shift in how physicians work over the last 15 years.

Physicians increasingly struggle to balance upholding the Hippocratic oath — which demands physicians do no harm — while also meeting the demands of employers and hospitals.

The result, Dean said, is burnout and moral injury.

‘Capacity Disasters’

During a pediatrics rotation, fourth-year HMS student Brian E. Benitez treated a baby whose mother only spoke Spanish — but was given discharge instructions in English.

While Benitez re-explained the instructions in Spanish and raised the issue with his supervisor, the experience made him realize how many past patients might have gone home with no understanding of their follow-up care.

The problem, Benitez said, is one of limited staffing and capacity.

“There are other situations where it’s clear that help of that kind would be necessary, but we just don’t have time or it’s ‘outside of my scope’ or we just have so many other things to do that we can’t give that attention to people,” he said.

“We’re overworked,” Benitez said. “Everybody’s overworked.”

Benitez’s experience isn’t unique. For many students, medical school can serve as a jarring wake-up to the harsh realities of medical practice.

Hugh C. Shirley, a fourth-year HMS student, said “we’re now dealing with patient capacity disasters on a daily basis.”

“Hospitals are always full to the brim, and it creates a lot of pressure on providers to get patients in and out of the door as quickly as possible,” he said.

The number of matriculants increased nationally by 1.2 percent in 2023, but there is currently a shortage of doctors because residency programs have failed to keep up with the growing number of medical school graduates. In 10 years, there could be a shortage of 50,000 primary care providers.

This increased gap between the need for and availability of medical professionals, Shirley said, has resulted in greater depersonalization in healthcare.

“This shift towards shorter visits, more profit-driven healthcare, more insurance oversight,” he said, “has made it more difficult for doctors to have meaningful relationships with their patients.”

“That’s daunting to think about — how many amazing doctors came before me and how challenging it was for them to deal with these things, and how some of them found it was not worth it for them anymore,” he added.

Harvard Medical School is located at the Longwood campus. Today's HMS graduates are entering a medical landscape increasingly stricken by burnout and moral injury. By Jonathan G. Yuan

Irving A. Barrera Lopez, a first-year student at HMS, said the struggles of staffing shortages are also compounded by the increased corporatization of care — a realization that has made him wary about pursuing clinical medicine.

In particular, Barrera pointed to the quantification of care through “relative value units,” a standardized measure used to calculate physician payment and insurance reimbursement in the United States based on time, skill, training, and intensity.

“Pretty much everything’s very based on supply and demand and getting reimbursed,” Barrera said.

Barrera said while he arrived at HMS hoping to pursue a career in psychiatry, learning about the pay gaps between specialties has made him hesitate.

A “more procedural specialty,” Barrera said, receives “higher compensation versus someone who just does a patient visit, like a general practitioner or a psychiatrist.”

“That’s something that I definitely keep in mind: ‘Well, I’m gonna have to work the same amount or a lot of time with considerably less remuneration.’”

But more than just turning him off of certain specialities, Barrera said the focus on tracking RVUs for physician reimbursement has made him “a bit scared of also going into the clinical side of medicine.”

“Of course, I want to be in charge of taking care of patients,” Barrera said, but “am I going to be able to be fulfilled if I have this other pressure from meeting expectations, meeting X amount of hours?”

‘Like a Betrayal’

The dissonance noted by HMS students also reflects broader changes on the national stage.

According to HMS Assistant Professor of Anaesthesia Shahla Siddiqui, even for doctors well out of medical school, the focus on efficiency in the industry is a consistent struggle.

“Hospitals and our performance is measured by not our attitudes to patients and the lives that we touch, but by our outcomes,” Siddiqui said. “It depends more and more on efficiency and outcomes, rather than the human element of patient care.”

Part of the industry’s increasing focus on efficiency has led to a shift away from traditional manual methods and toward the implementation of the electronic health system.

This change, HMS Associate Professor of Anaesthesia Shiqian Shen said, is “de-humanistic.”

During patient interactions, rather than being able to dedicate his full attention to the person before him, Shen’s attention is partially diverted toward navigating the digital system.

“A lot of times I myself spend more time looking at the keyboard or a computer screen than the patient,” he said.

The introduction of electronic recordkeeping isn’t the only change that has hit U.S. doctors. According to Dean, the president of Moral Injury of Healthcare, physicians are losing their autonomy as providers as they become increasingly sucked into larger, for-profit systems.

“It used to be that we were mostly independent clinicians who went to hospitals that were our workshops,” she said. “But we were still independent — we could choose to go to a different hospital if we didn’t like that one, if it wasn’t meeting our needs.”

By Jenny M. Lu

Now, Dean said, nearly 70 percent of physicians are employed by a hospital, health system, or large practice — leaving them without the same autonomy to decide how they practice.

According to Dean, whose organization works to address moral injury across the healthcare industry, the resulting moral injury — a “betrayal by a legitimate authority in a high stakes situation that leads you to transgress deeply held moral beliefs and expectations” — works alongside traditional burnout that happens as a result of “the demand-resource mismatch.”

In addition to the industry-specific changes, national and international changes have also reverberated across healthcare, changing the need for and provision of care.

In particular, Dean likened the pandemic to the stress test that the U.S. financial system underwent in 2008 — “but instead of having dramatic reforms,” healthcare went back to “business as usual.”

The politicization of health in the wake of the pandemic and the Supreme Court’s decision to strike down Roe v. Wade — which codified national protections for abortion access — has also posed an additional burden for doctors.

“Physicians in some states are not able to provide the care that they feel that the patients need,” Siddiqui said, which causes “moral injury around how people think and behave and how they have to work.”

‘Make Them More Resilient’

As the medical landscape continues to change, HMS administrators said their curriculum seeks to prepare students for emotional burdens and burnout.

HMS Dean for Medical Education Bernard S. Chang ’93 said HMS has “strengthened our commitment to helping our students understand what they are getting into.”

During their first year, HMS students take IN 555: Introduction to the Profession — a weeklong class that emphasizes both the sacrifice that comes with being a doctor and the importance of maintaining one’s personal wellbeing — and PWY 120: Essentials of the Profession I, which covers topics including health policy and medical ethics.

Two years later, students take PWY 220: Essentials of the Profession II, a course that focuses on similar concepts with the addition of clinical experiences.

HMS also offers The Developing Physician, which is a longitudinal component of the first two and a half years that offers students the opportunity to reflect on challenging experiences — such as dealing with a patient’s death — alongside peers and a faculty facilitator.

HMS Dean for Medical Education Bernard S. Chang '93 said the school has increased programming to prepare future doctors for professional life. By Addison Y. Liu

Before graduation, students are also required to take PME 550: Clinical Capstone — a course designed to prepare them for internships.

Chang said these courses help students “process some of the emotionally traumatic things that happened as part of medical school to help make them more resilient — to help mitigate some of the things that lead to burnout.”

HMS Assistant Professor of Population Medicine and Essentials of the Profession course director Laura F. Garabedian wrote in an emailed statement to The Crimson that “physicians need to be prepared to make tough decisions with limited resources, and these decisions should be grounded in ethical principles, which we teach in the course.”

Chang said one of the key lessons from the pandemic for him was a reminder that “medicine is a profession of sacrifice — of selfless sacrifice.”

“It’s not our job to be able to remove all stress and remove all negative emotions,” Chang said. “It is our job to help our students understand and get better at how to react to these things that happen when you are in the healthcare profession.”

Some students have reacted positively to the HMS administration’s efforts to incorporate burnout education into the curriculum.

“That’s been a really nice space to think of those things and express those fears,” first-year HMS student Ruhi Nayak ’23 said. “I think that the fact that other students also share those fears is honestly comforting.”

“The trainees coming out of here,” first-year HMS student Muhammad S.A. Abidi said, “I think we’re able to advocate for ourselves and our patients at the same time.”

—Staff writer Akshaya Ravi contributed reporting.

—Staff writer Veronica H. Paulus can be reached at veronica.paulus@thecrimson.com. Follow her on X @VeronicaHPaulus.