#62 Burnout and Moral Injury
For those who work in an ICU - or with any patients for that matter -the concepts of burnout and moral injury are no stranger. In order to mitigate the effects of these forces, it’s important to understand them. Join Nick and Cyrus, as they sit down with an incredible guest, Dr. Venktesh Ramnath, with the hopes of doing just that. On this episode we step away from the pressors and central lines and focus on the contributors to burn out and moral injury in the medical field while developing some strategies to combat them. Listen, watch, learn and let us know what you think!
Guest: Dr. Venktesh Ramnath, MD
Professor of Medicine, UCSD
Medical Director for Critical Care and Telemedicine Outreach, and ICU Medical Director at the VA San Diego.
Burnout, Moral Injury, and the need for “Health Architects” with Dr. Venktesh Ramnath
In this episode, Cyrus and Nick sit down with Dr. Venktesh Ramnath—intensivist, educator, and author—whose career spans rural, community, academic, and international ICU leadership. His training includes Harvard, Mayo Clinic, Cornell, and the Harvard Pulm/CCM program (MGH, Brigham, BIDMC). He now serves as Professor of Medicine, Medical Director for Critical Care & Telemedicine Outreach, and ICU Medical Director at the VA San Diego.
We explore why burnout has become such a defining issue in critical care, how the concept of moral injury helps explain what clinicians are feeling, and why Venktesh believes clinicians must embrace the role of “Health Architects.”
How We Got Here: Burnout, Conflict, and Mistrust
Dr. Ramnath reflects on the emotional toll of working in the pandemic-era ICU, referencing his Los Angeles Times (2022) op-ed describing hostility from unvaccinated patients—accusations of “poisoning” or “punishing” people—and how that mistrust left lasting scars on care teams.
He describes four major contributors to modern burnout:
Information overload & misinformation
Brandolini’s Law (“The energy to refute misinformation is 10× the energy to produce it.”)
Technology overwhelm
Choosing what to adopt, what’s obsolete, and how to integrate new tools.
Complex care networks
Vertical transitions (primary → tertiary → quaternary)
Horizontal complexity (multiple consultants, fragmented communication)
Financial pressure on systems and patients
“If you can’t keep the lights on, you’ll have no patients to see.”
Medical debt remains a major driver of U.S. bankruptcy.
These forces create cracks—places where patients fall through, and where clinicians absorb the resulting blame.
Moral Injury: When Work Conflicts With Values
A central theme is how clinicians sometimes avoid hard truths—delaying prognosis discussions, softening recommendations, acquiescing to unproven therapies—to dodge conflict with families locked in denial or influenced by social media experts.
These “defensive” strategies may protect clinicians briefly but erode professional integrity over time. This is the essence of moral injury: being forced to act in ways that conflict with one’s training or values.
Responding to Misinformation Without Losing Your Composure
Venktesh argues that composure beats outrage, especially when misinformation is politically charged. Drawing on Lee McIntyre’s “Scientific Attitude”, he emphasizes:
Curiosity (“Help me understand what you’ve heard.”)
Evidence-based thinking
Transparency about uncertainty
Avoiding the false idea that empathy means agreement
He also warns against the reflexive “the patient wants ___,” which can undermine trust and disengage clinicians from shared decision-making.
What Clinicians Can Do: Rebuilding Agency and Connection
Venktesh believes burnout usually arises from two losses:
Loss of agency
Loss of human connection
Rebuilding these requires both personal and system-level strategies:
Restoring Agency
Involve staff in decisions that affect their workflow.
Use evidence and clarity to cut through overload.
Normalize “I don’t know—let’s learn together.”
Rebuilding Connection
Make space for debriefs and peer conversation.
Use curiosity as a default stance in conflict.
Recognize that empathy ≠ agreement.
Self-Compassion and “Refilling an Empty Tank”
Venktesh critiques the false equivalence between resilience and coping. Instead, he advocates self-compassion, drawing from The Mindful Self-Compassion Workbook (Neff & Germer):
Kindness: “I did the best I could.”
Mindfulness: “What am I feeling, and why?”
Common humanity: “Others feel this too—I’m not alone.”
This mindset helps prevent compassion fatigue and restores meaning.
Workforce Stress & Leadership Challenges
We discuss the workforce exodus—experienced nurses retiring early, physicians stepping away—described in Venktesh’s LA Times and San Diego Union-Tribune (2025) pieces. Leadership strategies for retention include:
Creating psychological safety
Protecting staff from administrative noise
Modeling moral courage in difficult conversations
Encouraging honest discussions about prognosis early
Reducing fragmentation (e.g., sequencing consults thoughtfully)
The Health Architect Model
At the heart of his work is the idea that clinicians should act as Health Architects—professionals who design systems that enable human flourishing, not just treat disease. Wellness isn’t the absence of pathology; it’s the pursuit of potential.
He encourages clinicians to ask:
“What are the yeses you keep saying no to?”
and
“Where can you say no to create space for what matters?”Resources Mentioned
Book: A New Oath: How to Find Meaning, Overcome Burnout, and Improve the Doctor-Patient Relationship as Health Architects
Substack / Podcast: Be A Health Architect — https://be-a-health-architect.substack.com
Twitter/X: @VenkteshR | @BeAHealthArchitect
The Scientific Attitude — Lee McIntyre (MIT Press, 2019)
The Mindful Self-Compassion Workbook — Neff & Germer
Brandolini’s Law (The Bullshit Asymmetry Principle)
LA Times & San Diego Union-Tribune articles on burnout, mistrust, and administrative burden
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