The Case for Agency
A new viewpoint piece in JAMA argues that physician well-being requires both comfort and meaning. The authors, Tung, Palamara, Ripp, and Saddawi-Konefka, say that medicine swung too far from its old culture of self-sacrifice toward a newer focus on reducing friction and easing workloads. Neither extreme works on its own. What physicians need, they say, is an integrated approach: make the work bearable enough that the deeper rewards of medicine can actually be felt.
It’s a thoughtful argument. I think it’s also incomplete.
What the JAMA Authors Get Right
The authors frame the problem using two ideas from philosophy.
Hedonia is the well-being that comes from comfort, like fair pay, manageable schedules, and less paperwork.
Eudaimonia is the well-being that comes from purpose, such as feeling your work matters, that you are growing, and that you are part of something bigger than yourself.
Their key insight is that these two things need each other. Comfort without meaning turns medicine into a transaction. Meaning without comfort is just a fancy word for exploitation. Both things are true, and the examples they offer are genuinely useful.
AI-powered documentation tools, for instance, don’t just save time. They free the physician to actually look the patient in the eye. That’s comfort enabling meaning. Hard to argue with.
But here’s what I keep coming back to. The framework treats the physician as someone to whom things happen. Systems must be built for them. Interventions must be designed for them. Leaders must communicate the link between operational changes and professional values. In this model, the physician is the beneficiary of good organizational design. They are not the designer.
And that, I think, is the blind spot in most of the physician well-being conversation.
The World That Is Gone
Until recently in the US, the question of how physicians fit into organizations didn’t matter much. Doctors ran their own practices. They made their own schedules. They decided how long to spend with a patient, how to document the visit, whom to hire, and when to go home. The practice was small. The physician was, by default, the leader of a team of five or ten people in a building they probably owned.
That world is largely gone. Today, the majority of American physicians are employed by hospitals or large health systems. They practice inside organizations with thousands of employees, complex hierarchies, and competing priorities. The corner office belongs to someone with an MBA, not an MD.
This is not, in itself, a tragedy. Large systems can do things small practices never could. But here is the problem few want to name: physicians were never trained for this. Not for working inside large organizations. Not for leading in them. Not even for following effectively in them.
Medical education teaches you to diagnose. It teaches you to treat. It teaches you to make decisions under uncertainty with a patient’s life on the line.
What it does not teach you is how to run a meeting.
How to give feedback to a colleague.
How to build a coalition across departments and disciplines.
How to delegate.
How to read the politics of a budget cycle.
How to influence people who don’t report to you.
These are not soft skills. Together, they are the operating system of organizational life. And most physicians enter leadership roles, or even just employment roles, within large systems without any training in them at all.
Purpose Doesn’t Fix a Broken Committee
The JAMA authors note that the old model of medicine “relied on the concept of eudaimonia — well-being derived from purpose, excellence, and service.” They say this model “became unsustainable as modern health care systems increased in complexity.” That’s accurate as far as it goes.
But I’d push the diagnosis further. The model didn’t just become unsustainable. It became irrelevant to the daily experience of the physician who now sits in a conference room, not an exam room, trying to figure out why some workgroup hasn’t made progress in eighteen months.
Purpose doesn’t help you there. Neither does a better schedule. What helps you there is knowing how to lead.
The Problem With “Moral Injury”
I should be honest about where I stand on one piece of this conversation.
Over the past several years, the term “moral injury” has become the dominant frame for physician distress. It’s borrowed from military psychology, where it refers to the damage caused when a soldier is forced to act against deeply held moral beliefs.
Applied to medicine, it captures something real: the anguish of being unable to provide the care you know a patient needs because the system won’t allow it.
I understand the appeal of that language. It validates the physician’s experience. It names the pain. And it correctly locates at least part of the problem in the system rather than in the individual.
But I worry that the moral injury frame, as it’s commonly used, does something else too. It casts the physician as a victim of forces beyond their control. It says: the system is broken, it is breaking you, and the damage is being done to you. There is truth in that.
But it is not the whole truth, and when it becomes the whole story, it leaves physicians with nowhere to go. If you are injured, you need healing. If you are a victim, you need rescue. Neither posture equips you to change the system that injured you in the first place.
The JAMA piece doesn’t use the term “moral injury,” but it hints at it when it talks about “moral distress” and “environments that generate” it. And the authors’ solution, i.e., better organizational design, follows logically. If the environment is the problem, fix the environment.
I don’t disagree. But I’d add something. Fix the environment, yes. And physicians must also learn to be the ones doing the fixing by excelling beyond the exam room — in the conference room.
The Missing Ingredient Is Agency
There’s a version of this argument that sounds like blaming the victim, and I want to be careful to avoid it.
I am not saying that overworked, under-resourced physicians just need to try harder. I am not saying that systemic problems are really individual failures in disguise. The administrative burden is real. The loss of autonomy is real. The moral weight of practicing in systems that put revenue and bureaucratic process ahead of patients is real.
What I am saying is that the response to those realities matters. And the response that serves physicians best is not just comfort, and not just meaning, and not just the two of them stitched together.
It’s agency.
The ability to act.
To shape the environment rather than merely endure it.
And agency, for physicians working inside complex organizations, requires leadership skills.
It requires knowing…
How to speak so that administrators listen.
How to build trust across professional cultures that see the world very differently.
How to navigate politics without losing your soul.
How to hold onto your values while compromising on tactics (or as a friend says, how to be firm in the center while being squishy around the edges).
These are learnable skills.
They are not taught in medical school.
They are rarely taught anywhere in a physician’s career.
What a Capable Workforce Looks Like
The authors of the JAMA piece propose that we should measure success not just by the absence of burnout on a survey, but by signs of sustained engagement:
- voluntary teaching
- mentorship
- participation in quality improvement
- retention.
I agree. Those are signs of a workforce that has found purpose.
But I’d add one more indicator: Are physicians stepping into leadership?
- Are they volunteering for committees and workgroups because they see something that needs to change and decide to act?
- Are they building coalitions?
- Are they running meetings that matter?
- Are they having the difficult conversations they used to avoid?
That is what a physician workforce with agency looks like. Not just comfortable. Not just purposeful. But capable. Capable of leading in the very systems that, right now, are leading them.
The JAMA authors are right that you can’t have meaning without a foundation of comfort. What they don’t quite say, and what I believe is equally true, is that you can’t have either one sustainably without the ability to lead.
Comfort is given to you.
Meaning is found within you.
But agency and leadership are what let you build a world where both can thrive.
