The Impossible Oath

We take an oath to first, do no harm. But the harsh truth is: we will all harm patients. It’s not a matter of if, but when. Because we are human beings practicing medicine inside an inhumane system, harm is baked into the equation. So how do physicians continue to show up, day after day, knowing they will inevitably cause harm? And more importantly, what can be done to make it less likely, less frequent, and less morally injurious?

A System Designed to Fail

To understand how we got here, we have to revisit how medicine in the U.S. evolved.

In the early 20th century, doctors worked in solo practices, hospitals were locally owned, and physicians were the decision-makers. There were no electronic records, no pharmacy benefit managers, no major health insurers, just community-based care funded by a fee-for-service model.

That changed in the 1970s when physicians began forming group practices and hiring administrators. What started as a way to improve efficiency became a takeover. Healthcare corporatized, consolidated, and shifted from physician-led to executive-led. The new priority became shareholders. The goal became short-term profit.

This shift had devastating consequences. From 1975 to 2015, the U.S. lost 40% of its hospital beds. In the last decade alone, over 120 rural hospitals have shut down. Because a hospital bed costs about $1 million a year, an investment once considered essential to patient care, now is seen as a liability in boardrooms focused on margins.

Disconnection as Strategy

In If I Betray These Words, Dr. Wendy Dean interviewed physicians and healthcare administrators. Physicians were reluctant to speak up, afraid of retaliation. Administrators were hesitant too, but for a different reason: to admit the system causes harm would be to accept responsibility. And most are comfortably insulated from the daily friction of patient care.

This insulation breeds disconnection, a protective barrier that enables executives to focus on nonessential metrics, performative tasks, and KPIs. They can tick boxes and call it progress, all while ignoring the moral and human cost of what's happening in the trenches.

But that disconnection has a cost. It becomes safety for the institution, but it’s a direct road to patient harm.

What Actually Protects Patients

If we want to first do no harm, we have to preserve what makes medicine fundamentally human: connection.

Real care doesn’t happen through metrics. It happens in relationships: when physicians know their patients beyond the exam room, when they collaborate out of trust, and when they act from ethics rather than policy.

That kind of care thrives in community-based models. It erodes in corporate ones.

Take a hospital that was locally run for 85 years, where physicians lived among their patients, and decisions were made with the community in mind. In just 16 years, it changed ownership four times and became part of a $23 billion corporate empire. That hospital is called UPMC Carlisle.

This story isn’t an outlier. It’s a warning.

When Healing Becomes a Business

Whether labeled for-profit or nonprofit, the financial structure rarely protects patients or clinicians. Shareholder primacy (straight from the business school playbook) leads to tragic outcomes in medicine.

Federal mandates like the 2009 EMR requirement delivered a fatal blow to many small practices. Suddenly, it was adapt or die.

In the corporate healthcare model:

• Clinicians become cost centers.
• Patients become revenue streams.
• Every decision is filtered through billing optimization, productivity targets, and risk management.

It’s not just inefficient. It’s morally injurious.

The EMR: A Case Study in Disconnection

EMRs were supposed to streamline communication and improve coordination. Instead, they became the priority.

Now, clinicians serve the chart, not the patient. They're forced to collect irrelevant data, write templated notes, and stare at screens instead of people, all in 15 minutes or less.

As Dr. Wendy Dean writes:

“EMRs have driven clinicians apart from their patients during the day and from their families at night—without any substantive improvement in care or ease.”

Death by a Thousand Prior Auths

In the 1980s, prior authorizations were introduced to rein in high-cost care. But they've metastasized. Now, they touch everything: medications, imaging, referrals, basic treatments.

What began as a safeguard is now a gatekeeping bureaucracy. Physicians spend hours fighting for approvals that used to be routine.

This isn’t the profession most of us signed up for.

The Dream vs. The Reality

Most physicians entered medicine with a vision of abundant resources, mutual respect, and purpose-driven teams. Instead, we found:

• Gas-lighting.
• Incident reports replacing honest conversations.
• Pressure to maintain the status quo.

Each layer of oversight pulls us further from our patients and from the core of why we went into medicine.

Dr. Stuart Pollack said it best:

“The healthcare system clinicians imagined... is in direct conflict with their internal sense of morality.”

Moral Injury in Plain Sight

Moral injury is the emotional, psychological, and spiritual harm caused when we’re unable to do what we believe is right. Psychiatrist Dr. Jonathan Shay defined it as:

“A betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation.”

Every time we're told to do less for a patient, to bill a certain way, or to look the other way, we experience it.

In my own practice, it looked like:

• Being told I could only operate on the sinuses covered by insurance, even if all were diseased.
• Performing an in-office procedure that I wouldn’t be reimbursed for, because general anesthesia was the only covered option.
• Being pressured to overuse lucrative procedures that weren’t clinically necessary.

This is happening in every specialty, every day.

Betrayal Blindness and the Coping Crisis

Faced with moral injury, many clinicians go numb. Psychologist Jennifer Freyd calls it betrayal blindness: the unconscious decision to ignore injustice to preserve a functioning sense of self.

We tell ourselves we’re staying for the patients, for the paycheck, for the kids. But at some point, the story no longer fits.

The AAMC predicts a shortage of 130,000 physicians by 2034. One in five doctors planned to leave medicine by 2023. Many already have.

As Dr. Danielle Ofri wrote:

“You can keep adding work and magically it gets done... But no one is endlessly elastic. Everyone breaks.”

When Coping Turns Toxic

One dark coping mechanism: some physicians flip the script. They start exploiting the system right back. Maximizing billables. Prioritizing revenue over relevance. Choosing reimbursement over rightness.

It’s a way to feel in control. But it corrodes our purpose and leads straight to burnout.

So What Do We Do?

1. Name it. Recognize moral injury for what it is. It’s not a personal failure; it’s a systemic one.

2. Check your intentions. Are you serving the patient, the policy, or your ego?

3. Treat yourself as the first patient. First do no harm to yourself. Build boundaries. Guard your time and energy.

4. Honor your life. If you promised your kid an ice cream run after school, honor that commitment. That moment is sacred. That’s medicine, too.

A Better Oath

So is it even fair for physicians to swear to first, do no harm?

Maybe not.
Maybe the better oath is:
First, create a system that makes doing no harm possible.

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