No Room for Reflection

We’ve been quiet for a very long minute. More than half a year, in fact, and we’ll have more about that in the next few days, because we realized that reflection is, in fact, crucial to the work we do. So, we’ve made a bunch of room to do that.

But, while you wait for more from us, we’re dropping a gem for you.

We had the honor of working with a remarkable intern this summer. Sophia Neilson is a rising senior at Smith College, who is focused on a journalism career. She spent five weeks with us, learning how the 43cc podcast is journalism in another medium. We’re delighted to share her first piece for us today, and will roll out a few more over the coming weeks.

To hear the associated podcast episode, you can find links here.

More soon,

- Wendy

“One day you realize this wasn’t who you signed up to be, because you’ve made compromise after compromise.”

The business of healthcare, with its emphasis on throughput, productivity, RVUs, and optimized billing, makes no room for reflection.

But what if reflection and introspection are what keep us connected to the clinician – the nurse, doctor, social worker, physical therapist, etc - we imagined we would be when entering our profession?

Clinicians enter their professions seeking challenging, meaningful work that offers a clear sense of purpose, and the noble goal of working in service to humanity. The Hippocratic Oath, for example, is “not simply about how we will do a job, it is also about who we will be when we don the mantle of ‘physician.’ It prescribes our conduct, calibrates our moral compass, and entwines both with our identity.” [If I Betray These Words – Author’s Note]

But, increasingly, the promise of the profession, and the implied, bi-directional responsibilities of that covenant, are eroding. Up to 40% of physicians endorse moral injury; their professional values don’t align with those of their organization, with the work they’re asked to do, or with how they’re asked to do it.^[1]

That dissonance is driving clinicians out of healthcare at an alarming rate. As of 2023, more than a quarter of health care workers (28.7%) and 41% of nurses indicate they intend to leave their jobs within two years.^[2] For many, that decision is not the result of a single breaking point, but of countless small compromises that accumulate over the course of their career.

People rarely abandon their values and stray from their oaths overnight. Instead, small compromises accumulate over time. Time pressure mounts, and a patient’s story is cut short; it’s easier to order more labs or imaging than to risk falling satisfaction scores and potential censure; a referral stays in-house against your better judgment - until eventually, compromises become normalized, and the clinician no longer recognize the upstanding moral being they imagined they were and would be.

None of these decisions, viewed in isolation, seems catastrophic. Most are justifiable and many are understandable, which is exactly why they are dangerous.

The greatest threat is not a single unethical act. It is the normalization of actions that take us, step by tiny step, further and further from our values.

The slippery slope of moral compromise is rarely steep enough to notice while you’re on it. The first step feels temporary. The second feels necessary. And by the tenth, what once would have felt uncomfortable has become normal. You don’t realize how far you’ve gone until it’s too late.

A 2025 study published in Annals of Internal Medicine found that the annual rate of physicians leaving clinical practice increased from 3.5% to 4.9% between 2013 and 2019. With a projected physician shortage of 86,000 by 2036, the study emphasizes the danger the rapidly growing attrition rate poses to future access to healthcare.^[3]

In what feels like a hostile environment, how do we help clinicians to stay in their roles?

We start with reflection.

Reflection creates the space to ask the difficult questions before compromises become habit. What are the values that brought you into this profession? Where is the moral, ethical, values-based “red line” you are unwilling to cross? And what does it feel like when your professional values are under threat?

Once you recognize the threat, you regain some control.

You can speak up; you can seek support from trusted colleagues; you can document concerns; you can advocate for patients; you can refuse certain compromises; and, when necessary, you can leave environments that require you to repeatedly betray your own moral judgment.

The options are rarely easy, but without reflection, they become impossible.

Clinicians who maintain their integrity are not those who never face compromise. They just keep asking: Is this still who I want to be?

^[1] Doron Amsalem, Amit Lazarov, John C. Markowitz, et al., “Psychiatric Symptoms and Moral Injury Among US Healthcare Workers in the COVID-19 Era,” BMC Psychiatry 21, no. 1 (2021): 546, https://doi.org/10.1186/s12888-021-03565-9; Seema Mantri, Young K. Song, Jennifer M. Lawson, Elizabeth J. Berger, and Harold G. Koenig, “Moral Injury and Burnout in Health Care Professionals During the COVID-19 Pandemic,” Journal of Nervous and Mental Disease 209, no. 10 (2021): 720–726, https://doi.org/10.1097/NMD.0000000000001367.

^[2] Lisa S. Rotenstein, Rebecca Brown, Christine Sinsky, et al., “The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19,” Journal of General Internal Medicine 38 (2023): 1920–1927, https://doi.org/10.1007/s11606-023-08153-z.

^[3] Lisa S. Rotenstein, Zili He, James Dziura, et al., “Trends in and Predictors of Physician Attrition From Clinical Practice Across Specialties: A Nationwide, Longitudinal Analysis,” Annals of Internal Medicine 178 (2025): 1698–1708, https://doi.org/10.7326/ANNALS-25-00564.