Physician Burnout- Why it is really moral injury

Compassion fatigue, burnout, PTSD, and moral distress are terms we use to describe the result of prolonged stress in the line of duty. It’s important to understand these terms properly because then we will understand the current war cry of those working in healthcare today: It’s not simply being tired or burned-out (physician burnout), it’s moral injury.

Understanding Burnout

In the article Reframing Clinician Distress: Moral Injury Not Burnout, Drs. Simon Talbot and Wendy Dean discuss the origins of the terms ‘physician burnout’ and ‘moral injury’.

The term ‘burnout’ was coined by Freudenberger in 1975, who identified it as the presence of symptoms like malaise, fatigue, frustration, cynicism, and inefficacy that emerge when the workplace makes excessive demands on energy, strength, or resources of workers.

This definition suggests that the problem lies with the worker, who doesn’t have enough inner resources to cope in a particular work situation. It is therefore also the worker’s responsibility to find a solution, to buck up and to soldier on.

This was the belief and frankly the culture in medicine before the pandemic. The outbreak of COVID-19 has escalated this problem of physician burnout beyond measure and beyond endurance.

In their STAT article, Talbot and Dean write that ’’the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work.’’

Why it is Moral Injury

The concept of moral injury originated from servicemen who returned from war with PTSD-like symptoms, but didn’t respond to PTSD treatment. It was discovered that their particular distress was not caused by the mortal threat of dying, but by a threat to the core of who they were. These soldiers were forced to participate in or witness actions that went against their personal moral code. The psychological injury this caused is called moral injury.

Talbot and Dean explain in their STAT article that, “The moral injury of healthcare is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of healthcare.’’ It is bearing witness to events in which you are powerless to intervene.

In healthcare, moral injury occurs when a nurse, physician, administrator, or other healthcare worker has to do something, witnesses an action, or fails to prevent an action that clashes with their deeply held moral beliefs. For them, that loadstar is the Hippocratic Oath: to put the needs of patients first.

Incidences that might lead to moral injury include:

• Doing something that goes against the oath you took;
• Doing something that clashes with your beliefs;
• Failing to take action according to your beliefs; and
• Observing or hearing about an act of omission.

These kinds of situations leave deep psychological impressions and cause moral distress, including feeling guilt, shame, and anger at having been let down and having let yourself down.

Covid-19 has increased incidences that may lead to moral injury such as:

• Working with insufficient protection and supplies for yourself, your peers and your patients;
• Having to decide who gets the medical care and who goes without;
• Having to allocate limited resources to equally needy patients;
• Feeling betrayed by medical institutions or government agencies who have failed health care workers, their families and patients;
• Having to balance or supplant their own physical and mental health care needs with those of patients; and
• Having to choose between caring for infectious patients and keeping their own families safe.

Why it’s Not Burnout but Moral Injury

Moral injury stems from a disconnect between the ideals that people enter the medical field with and the reality they meet when they start working.

For myself and most doctors and nurses, entering healthcare is not a career, it’s a calling. They enter healthcare with a compassionate heart wanting to be of service. However, at times, when those expectations meet the real world, the care-giver is deprived of the support and resources to deliver the best possible service.

In modern healthcare, even before the pandemic, health care workers sometimes felt like they were serving a different master: the hospital’s revenue, the insurance company’s bottom line, the electronic health record, the fear of medical malpractice and their medical board.

The point is, the healthcare environment has changed. It’s no longer solely focused on providing compassionate care to patients, it’s also now driven by profit motives. As providers we now wrestle with the electronic health record, which takes away attention we should be giving to the patient.

Add to that the conflicting financial demands and realities of different parties — those of the patient, the hospital, the insurer, and those of the doctor, and you have an environment that is extremely difficult to operate in. This environment has put health care workers in a position where they constantly have to sacrifice the healthcare they were called to provide in deference to profits. This burden is moral injury, not physician burnout.

The Effect of COVID-19

The pandemic has brought about a sudden shift from patient-centered ethics to public health ethics. This is one of the factors that has led to moral injury among health care workers, says Fahmida Hossain, a Ph.D. candidate and bioethicist at Duquesne University in Pittsburgh, in her article on moral injury among nurses during the pandemic.

Where patient-centered ethics focuses on care for an individual patient, public health ethics focuses on the greater good for society, explains Hossain.

COVID-19 and the scarcity of resources have brought nurses, and physicians, face to face with ethical dilemmas that bring with them unbearable moral distress. For instance, deciding who should receive treatment, or who should receive treatment first.

’’Moral distress occurs when nurses cannot follow their creed; COVID-19 places nurses in situations where they are forced to choose one patient’s well-being over that of another,’’ writes Hossain.

Huge levels of distress are caused by the inability of healthcare workers to provide the compassionate care they were trained to and want to give. The pandemic has taken away time and resources and brought facility constraints that make compassionate care difficult to deliver. Many feel overwhelmed and helpless as patients in their care have to die without loved ones at their bedside. I can tell you firsthand that watching loved ones attempt to say their final goodbyes to my patient over FaceTime is one of the worst things I had to witness. Hossain quotes one healthcare worker saying: “That’s a tough thing to watch every single day, to watch somebody die without their family there.” Time and time again, healthcare providers watched their patients say goodbye to their loved ones through a phone.

Government incompetence in many, if not all countries, has burdened healthcare workers with another moral dilemma. Their failure to provide adequate personal protective equipment (PPE) has forced many to consider whether they are prepared to endanger their own health in order to care for patients. That’s an impossible choice that will send anyone with a conscience around the bend, never mind a compassionate person who has dedicated his or her life to the comfort and care of others.

In addition, many news headlines show grim stories of physicians and nurses committing suicide in the height of the pandemic.

Addressing Moral Injury

The moral distress that healthcare workers have been and are still experiencing must be addressed. If the resulting feelings of overwhelm, frustration, and chronic physical and emotional exhaustion are not addressed, the psychological fallout could be catastrophic. This is not trauma that will disappear and be forgotten with a few drinks or a vacation. These needs dedicated and long-term intervention if health care workers are ever going to return to anything that resembles normalcy.

In an article that appeared in the New England Journal of Medicine, the authors Dzau, Kirch, and Nasca call for five high priority actions at the organizational and national levels to safeguard the health and well-being of clinicians during and after the pandemic. They wrote:

• Integrate the work of chief wellness officers or clinician well-being programs into COVID-19 “command centers” or other organizational decision-making bodies for the duration of the crisis.
• Ensure the psychological safety of clinicians through anonymous reporting mechanisms that allow them to advocate for themselves and their patients without fear of reprisal.
• Sustain and supplement existing well-being programs.
• Allocate federal funding to care for clinicians who experience physical and mental health effects of covid-19 service.
• Allocate federal funding to set up a national epidemiologic tracking program to measure clinician well-being and report on the outcomes of interventions.

While these strategies may help to address the moral injury suffered as a result of the pandemic, they fail to address the shortcomings in the system that exacerbated the crisis, like shortage of personal protective equipment, limited availability of testing, and scarcity of resources like ventilators.

They also don’t address issues that led to moral injury among clinicians before the pandemic.

Developing Moral Resilience

Developing moral resilience can be of great value in unusual situations like the COVID-19 pandemic. In an article that appeared in the Journal of Medical Ethics, the authors explain how communities of practice (CoP) can help to build the moral resilience of healthcare professionals so they can cope with inevitable moral distress.

Moral resilience is seen as a positive response to distress. One definition of moral resilience that the authors quote is ’’the ability to deal with an ethically adverse situation without lasting effects of moral distress and moral residue, which requires morally courageous action, activating the necessary supports.’’

The writers suggest adopting collective moral resilience. This is a new concept that originated in previous emergency and disaster situations and helps to put personal resilience into perspective. Collective moral resilience is a capacity that arises when a group that shares trust and connectedness shares their challenging situations by thinking about them together and talking about them with each other. This can sustain moral integrity or restore it in the face of moral suffering.

How do CoPs help with that?

In health care, a CoP can be created as a safe space to share experiences, find solutions in coping with difficult situations, share vulnerability, discuss ethical problems, and more.

The thinking is that sharing experiences will bring about a new perspective on the situation, so it’s not seen as entirely negative. People can also share how they handled difficult situations.

The authors write, “We hypothesize that CoPs provide a process to explore moral distress through social support and connectedness, and that this connectedness has the potential to generate practical wisdom.’’

Moral resilience is supported by self-stewardship, which is the ability to pay attention to one’s well-being. This is not selfish. Physical, emotional, and psychological health are non-negotiable prerequisites for those who provide healthcare to others.

Improving Work Culture

In addition to CoPs, creating a positive work environment can help reduce moral injury. Having the right culture can take some time for larger institutions because they may need to completely restructure and retrain several people. It is important that companies take the time to make sure they are inclusive and create a supportive environment.

Afterall, those in the trenches can spot those who are struggling. It is important that the staff looks out for and checks in on one another. Too many healthcare professionals have struggled through the pandemic, it is time to start showing more kindness, empathy, humor, and compassion.

Just like in a CoP, employees will be able to lean on one another, get the right support and gain new perspectives on how to handle difficult situations.

How Entrepreneurship Can Help

Many healthcare professionals make great entrepreneurs. In fact, being an entrepreneur can be a great way to combat moral injury for several reasons.

For myself and other healthcare entrepreneurs I know, being an entrepreneur allows you to put your creativity towards solving a problem for a larger audience, not just the patient in front of you. Trying to make a difference for a community helps to assuage the moral injury one feels after seeing systems fail and communities and patients suffer.

To learn more about entrepreneurship, check out Entrepreneur Rx. This book gives you insight on how to start a successful business. Even though it was originally written directly for physicians, any medical provider will benefit from it.

Accompanying this book is a podcast with the same name. Each week join me as I interview other physicians who have successfully started their own businesses. In doing so, they have worked to secure their futures by creating alternative sources of income and opportunities.

Final Thoughts

At the end of the day, the issue of moral injury is not a new one. Those working in healthcare have been intimately familiar with the condition for years. The pandemic has simply brought it more clearly and more dramatically to the forefront. By understanding that this is more than just physician burnout, we can hopefully begin to address and correct the problem.