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Physicians aren’t ‘burning out.’ They’re coronavirus coverage.

suffering from moral injury CONTRIBUTE

By S I M O N G . T A L B O T and W E N D Y D E A N / J U L Y 2 6 , 2 0 1 8 Reprints
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hysicians on the front lines of health care today are sometimes described as

P going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often
face a profound and unrecognized threat to their well-being: moral injury.
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Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as

post-traumatic stress; among physicians it’s portrayed as burnout. But without
understanding the critical difference between burnout and moral injury, the wounds 8 questions we still have
about Trump’s case of
will never heal and physicians and patients alike will continue to suffer the
Covid-19
consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and

decreased productivity. More than half of physicians report at least one of these. But See in one minute how
Covid-19 has torn across
the concept of burnout resonates poorly with physicians: it suggests a failure of the U.S.
resourcefulness and resilience, traits that most physicians have finely honed during
decades of intense training and demanding work. Even at the Mayo Clinic, which has
been tracking, investigating, and addressing burnout for more than a decade, one-
third of physicians report its symptoms.

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We believe that burnout is itself a symptom of something larger: our broken health
care system. The increasingly complex web of providers’ highly conflicted allegiances
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— to patients, to self, and to employers — and its attendant moral injury may be
driving the health care ecosystem to a tipping point and causing the collapse of
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resilience.

Related: Fighting the silent crisis of physician burnout

The term “moral injury” was first used to describe soldiers’ responses to their actions
in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning
about acts that transgress deeply held moral beliefs and expectations.” Journalist
Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense
of morality, and relationship to society.”

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The moral injury of health care is not the offense of killing another human in the Nov. 16, 2020
context of war. It is being unable to provide high-quality care and healing in the
context of health care.
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Most physicians enter medicine following a calling rather than a career path. They go
into the field with a desire to help people. Many approach it with almost religious
zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs,
family strain, financial instability, disregard for personal health, and a multitude of
other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal
which, starting in the third year of medical school, is sharply focused on ensuring the
best care for one’s patients. Failing to consistently meet patients’ needs has a
profound impact on physician wellbeing — this is the crux of consequent moral
injury.

Physicians are smart, tough, durable, resourceful

people. If there was a way to MacGyver themselves
out of this situation by working harder, smarter, or
differently, they would have done it already.

In an increasingly business-oriented and profit-driven health care environment,

physicians must consider a multitude of factors other than their patients’ best
interests when deciding on treatment. Financial considerations — of hospitals, health
care systems, insurers, patients, and sometimes of the physician himself or herself —
lead to conflicts of interest. Electronic health records, which distract from patient
encounters and fragment care but which are extraordinarily effective at tracking
productivity and other business metrics, overwhelm busy physicians with tasks
unrelated to providing outstanding face-to-face interactions. The constant specter of
litigation drives physicians to over-test, over-read, and over-react to results — at
times actively harming patients to avoid lawsuits.

Patient satisfaction scores and provider rating and review sites can give patients
more information about choosing a physician, a hospital, or a health care system. But
they can also silence physicians from providing necessary but unwelcome advice to
patients, and can lead to over-treatment to keep some patients satisfied. Business
practices may drive providers to refer patients within their own systems, even
knowing that doing so will delay care or that their equipment or staffing is sub-
optimal.

Navigating an ethical path among such intensely competing drivers is emotionally

and morally exhausting. Continually being caught between the Hippocratic oath, a
decade of training, and the realities of making a profit from people at their sickest
and most vulnerable is an untenable and unreasonable demand. Routinely
experiencing the suffering, anguish, and loss of being unable to deliver the care that
patients need is deeply painful. These routine, incessant betrayals of patient care and
trust are examples of “death by a thousand cuts.” Any one of them, delivered alone,
might heal. But repeated on a daily basis, they coalesce into the moral injury of
health care.

Physicians are smart, tough, durable, resourceful people. If there was a way to
MacGyver themselves out of this situation by working harder, smarter, or differently,
they would have done it already. Many physicians contemplate leaving heath care
altogether, but most do not for a variety of reasons: little cross-training for alternative
careers, debt, and a commitment to their calling. And so they stay — wounded,
disengaged, and increasingly hopeless.

Related: On the other side of physician burnout

In order to ensure that compassionate, engaged, highly skilled physicians are leading
patient care, executives in the health care system must recognize and then
acknowledge that this is not physician burnout. Physicians are the canaries in the
health care coalmine, and they are killing themselves at alarming rates (twice that of
active duty military members) signaling something is desperately wrong with the
system.

The simple solution of establishing physician wellness programs or hiring corporate

wellness officers won’t solve the problem. Nor will pushing the solution onto
providers by switching them to team-based care; creating flexible schedules and float
pools for provider emergencies; getting physicians to practice mindfulness,
meditation, and relaxation techniques or participate in cognitive-behavior therapy
and resilience training. We do not need a Code Lavender team that dispenses
“information on preventive and ongoing support and hands out things such as
aromatherapy inhalers, healthy snacks, and water” in response to emotional distress
crises. Such teams provide the same support that first responders provide in disaster
zones, but the “disaster zones” where they work are the everyday operations in many
of the country’s major medical centers. None of these measures is geared to change
the institutional patterns that inflict moral injuries.

What we need is leadership willing to acknowledge the human costs and moral injury
of multiple competing allegiances. We need leadership that has the courage to
confront and minimize those competing demands. Physicians must be treated with
respect, autonomy, and the authority to make rational, safe, evidence-based, and
financially responsible decisions. Top-down authoritarian mandates on medical
practice are degrading and ultimately ineffective.

We need leaders who recognize that caring for their physicians results in thoughtful,
compassionate care for patients, which ultimately is good business. Senior doctors
whose knowledge and skills transcend the next business cycle should be treated with
loyalty and not as a replaceable, depreciating asset.

We also need patients to ask what is best for their care and then to demand that their
insurer or hospital or health care system provide it — the digital mammogram, the
experienced surgeon, the timely transfer, the visit without the distraction of the
electronic health record — without the best interest of the business entity (insurer,
hospital, health care system, or physician) overriding what is best for the patient.

A truly free market of insurers and providers, one without financial obligations being
pushed to providers, would allow for self-regulation and patient-driven care. These
goals should be aimed at creating a win-win where the wellness of patients correlates
with the wellness of providers. In this way we can avoid the ongoing moral injury
associated with the business of health care.

Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women’s

Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean,
M.D., is a psychiatrist, vice president of business development, and senior medical officer
at the Henry M. Jackson Foundation for the Advancement of Military Medicine.

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About the Authors Reprints

Simon G. Talbot
" sgtalbotmd@gmail.com

Wendy Dean
" wdean@moralinjury.healthcare
! @WDeanMD

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M E N TA L H E A LT H PHYSICIANS

Glen McFerren, M.D.

F E B R UA R Y 2 1 , 2 0 2 0 AT 6 : 2 4 P M

Thank you for this. I retired last year after almost 40 years and said I was “burned
out” but that didn’t feel quite right. This article is much closer to the truth. It just
felt like Medicine was broken, and I couldn’t face another day in its present form.
Changes have to be made.

Augustus Kigotho
F E B R UA R Y 2 0, 2 0 2 0 AT 1 1 : 5 3 P M

I am the Director of an Emergency Department with a complement of 33

Emergency Specialists.Without an iota of doubt,I can confidently say there exists
a serious level of disengagement which I now realize is from “Moral Injury”.This
article has given me an insight into the problem and will be sharing with them.I
would really appreciate more literature on solutions to this pervasive and
endemic challenge. Thank you very much.

Richard O. Brower, Jr. MD

F E B R UA R Y 1 9, 2 0 2 0 AT 7: 0 4 A M

Drs. Talbot and Dean, thank you for your clarification of what the press calls
“physician burnout”. Changing the label to “moral injury” identifies the problem
as not physician weakness, but as a pernicious assault on the moral values of the
medical profession. Your article does a great service to the profession of
medicine!
Richard Brower, MD

David Oxman
F E B R UA R Y 1 1 , 2 0 2 0 AT 1 0 : 1 1 P M

Good to see you speaking out about this Simon

Darcy Copeland
F E B R UA R Y 5 , 2 0 2 0 AT 5 : 2 5 P M

As a nurse who has studied moral distress for several years I’m not sure that I see
a difference in what nurses have been referring to as moral distress for 20 years
and what physicians are now referring to as moral injury. Is there reason to
believe that when nurses are unable to provide high quality care that their
suffering is different than when physicians are unable to provide high quality
care? Barriers to quality care, financial restrictions, EHRs and fragmented care
have been major contributors to nurses’ moral distress. “Moral distress” has been
in the nursing literature for 20 years. Does this concept not apply to physicians? In
what ways is the nursing term moral distress inadequate to describe the
experiences of physicians? Would it be in our mutual interests as healthcare
professionals to use the same term to describe these experiences in order to move
a research agenda in the same direction rather than perpetuating a division?

Laurence J. Sloss M.D.

F E B R UA R Y 6 , 2 0 2 0 AT 6 : 0 1 P M

Though the initial posting focused on MDs, there was no shade thrown on
nurses or any other hands-on healers. We are all in this together, trying our
best to serve our patients and our community despite the overbearing
presence and malign influence of an ever-growing, grossly overpaid and self-
serving managerial class. The medical professionals and those for whom they
care should set the standards and make the rules. Management should see to
it that the system provides the needed tools and support; they have no
legitimate role in setting professional guidelines, standards and workflow.

Ana Hernando
F E B R UA R Y 1 1 , 2 0 2 0 AT 3 : 3 5 P M

Darcy,
From my understanding, moral distress is a precursor to moral injury. If
moral distress is left untreated, then the full effects of moral injury are felt. I
believe the most important revelation is that those in the healing arts
(doctors, nurses, therapists, etc) are not suffering from “burn-out”. I became
an occupational therapist and I loved working with my patients. My soul
could not be settled with the pressure on productivity and payor source and
not on the patient. I left what I call traditional treating and shifted into
holistic integrative work. I am not, nor ever have been “burned-out”, I
recognized that I was under moral distress and I shifted my way of practicing
before I suffered moral injury.

To your health and well-being.

Ashleigh
M A R C H 9, 2 0 2 0 AT 1 : 5 7 A M

Wonderful point! It’s much to do with the silos; working together, separately.

Tara
D E C E M B E R 1 0, 2 0 1 9 AT 1 0 : 5 6 A M

I think doctors need to be honest tell u what u don’t want to hear because most of
them tell u what u want to hear because money or inheritance a proposed

Wendy Talbot
D E C E M B E R 3 , 2 0 1 9 AT 5 : 1 1 P M

Bravo. You describe the experience of many professions and make so many valid
points. I wholeheartedly agree. Thank you for taking the time and speaking out.

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