Correspondence
It’s time to talk about
physician burnout and
moral injury
Physician burnout has increasingly
become a focus of public health
concern. Notably, workplace burnout
has been recognised in the ICD-11 as
a diagnosable condition (diagnostic
code QD85), “resulting from chronic
workplace stress” and encompassing a
constellation of exhaustion, cynicism,
and reduced efficacy.1 Psychiatrists who
support physicians affected by burnout
are left to consider the possibility of
differential diagnoses or comorbidities.
The dynamic challenges of medical
practice might give way to moral
injury, a syndrome which has gained
considerable traction in mental-health
studies of military populations, where
it has been consistently linked with
adverse outcomes such as suicide,
depression, anxiety, and substance use
disorders. Understandings of moral
injury as a psychopathology have
already been applied to non-military
populations, including health-care
providers.2
Moral injury constitutes a substantial
source of mental health morbidity,
the result of having transgressed or
violated core moral boundaries.3 The
morbidity encapsulated in moral injury
reflects the challenge of reconciling
the gap between what happened and
what should have happened, especially
in highly stressful, high-stakes
circumstances. For some physicians,
this gap might challenge their own
values and norms, giving way to
painful emotions such as shame,
guilt, self-condemnation, feelings
of betrayal, difficulty trusting, and
difficulty forgiving.3,4 In cases where
this gap becomes exceptionally trying,
symptoms of moral injury might also
lead to self-destructive behaviours.
No accepted clinical threshold has
yet been proposed to identify cases
of moral injury. Validated scales and
measures exist for assessing exposure
to potential morally injurious
www.thelancet.com/psychiatry Vol 6 November 2019 e28
experiences and the symptoms of 3 Koenig HG, Ames D, Nash W, Büssing A.
Editorial: Screening for and treatment of moral
moral injury.3 Efforts are underway to
adapt these tools for use in different
injury in veterans/active duty military with
PTSD. Front Psychiatry 2019; 10: 596.
professional groups and sociocultural 4 Kopacz MS, Lockman J, Lusk J, et al.
How meaningful is meaning-making?
settings. These tools could be used to New Ideas Psychol 2019; 54: 76–81.
develop an understanding of moral 5 Oquendo MA, Bernstein CA, Mayer LES. A key
injury in physicians, informing both differential diagnosis for physicians—major
depression or burnout? JAMA Psychiatry 2019;
future research and clinical practice. published online July 17. DOI:10.1001/
Although various supportive therapies jamapsychiatry.2019.1332.
are available, there is currently no
accepted clinical gold standard for
treating either burnout or moral
injury.
Some researchers have voiced a
concern “that burnout not become the
catchall term for emotional distress
experienced by physicians.”5 Overlap in
conceptual understanding and signs
and symptoms warrant that moral
injury be included in any discussion
of physician burnout. Including moral
injury in such discussions might also
help combat the stigma surrounding
mental-health disorders and treatment,
not least of all among physicians. This
issue concerns not just the welfare of
the physician, but also those they serve.
We declare no competing interests. The views
expressed in this letter are those of the authors and
do not necessarily reflect the policy or position of
the US Federal Government or US Department of
Veterans Affairs. Institutional support for this
manuscript was provided by the VISN 2 Center of
Excellence for Suicide Prevention (Canandaigua, NY,
USA). All authors proportionately contributed to
the writing of this manuscript.
*Marek S Kopacz, Donna Ames,
Harold G Koenig
marekskopacz@hotmail.com
Institute of Medicine, Education, and Spirituality,
Ochsner Clinic Foundation, New Orleans, LA, USA
(MSK); US Department of Veterans Affairs, Mental
Health and Chaplaincy, Durham, NC, USA (MSK); US
Department of Veterans Affairs, VISN 2 Center of
Excellence for Suicide Prevention, Canandaigua, NY,
USA (MSK); VA Greater Los Angeles Healthcare
System, Los Angeles, CA, USA (DA); David Geffen
School of Medicine, University of California, Los
Angeles, CA, USA (DA); Duke University Medical
Center, Durham, NC, USA (HGK) ; and Department of
Medicine, King Abdulaziz University, Jeddah, Saudi
Arabia (HGK)
1 WHO. ICD-11 for mortality and morbidity
statistics (version 04/2019). QD85 Burn-out.
https://icd.who.int/browse11/l-m/en#/http://
id.who.int/icd/entity/129180281 (accessed
Sept 17, 2019).
2 Ford EW. Stress, burnout, and moral injury:
the state of the healthcare workforce.
J Healthc Manag 2019; 64: 125–27.