Confronting burnout and moral injury in medicine

Over the last few years, I have frequently been asked to address burnout among physicians and discuss this issue at conferences or medical school meetings. This was a discussion I felt comfortable with as my specialty, emergency medicine, was one of the first to raise this issue, especially as it related to the length of time physicians are willing and able to provide direct patient care.

Having spent a large part of my career as a physician executive, I also frequently get approached by colleagues who ask for advice about “getting out of clinical medicine” or “moving” into administrative positions. In my experience, both burnout and interest in leaving active medical practice have increased in recent years.

Setting my discussions about leaving patient care aside, my advice regarding burnout generally covered the usual ways of dealing with stress, with my personal bias emphasizing exercise, supportive communication with friends, family and counselors, re-establishing a work-life balance and finding an area of passion in one’s practice.

When I assumed the role of dean of an osteopathic medical school, I had the opportunity to work closely with soon-to-be-physicians. Observing their desire to succeed in their career, their true interest in helping patients and the sacrifices they were willing to make to reach this goal, I started reflecting on how this enthusiasm among new and eager physicians in training can turn into burnout as they progress through their training and years of practice as physicians.

From enthusiasm to burnout

One evening during dinner with a friend, she started complaining about her recent visit to her primary care doctor, how she felt rushed by the physician and uncared for. Without thinking, I answered, “She probably has to see three to four patients per hour, which does not give her much time to care, especially if she has to be on the phone getting preauthorization for a test, procedure or special medication.”

“Then she should find a different place to work,” was my friend’s response.

Driving home after dinner, it became clear to me how eager students can become physicians struggling with their profession. Physicians are often directly across from the patient with the intention of giving excellent care. The patient sees them as the decision-maker and source of that care, while the care the physician wants to provide is profoundly influenced by things beyond their control.

Insurance companies determine formularies and authorization requirements for tests and eligibility for tests. Physicians’ employers (i.e., hospitals, large physician practices, practices owned by different types of business entities) all determine productivity requirements, staffing patterns, support staff availability and other important parts of the caring process that can impede a physician’s ability to give the best care. When a physician is not able to provide the care they would like to because of these forces, it can be profoundly disheartening.

Addressing moral injury

To change this, we often speak about health care system changes in the literature discussing burnout. This made sense to me, but I knew I was missing something. I knew there was more to the story than the frustration of dealing with administrative obstacles.

The following Sunday, while reading The New York Times article “The Moral Crisis of America’s Doctors,” I found the terminology and missing concept I was looking for. The article references a 2018 article by Simon G. Talbot and Wendy Dean, in which the authors use the term “moral injury.”

Moral injury is a term from military literature and refers to “doing something that violates one’s own ethics, ideals or attachments.” Jonathan Shay identifies moral injury as a psychological trauma resulting from (1) a betrayal of what is morally correct, (2) by someone who holds legitimate authority and (3) in a high-stakes situation. It is important to distinguish this from PTSD. Moral injury is also different than burnout.

We as physicians know most of the time the right care and the best way to diagnose and treat. We promise this care to all our future patients at the end of medical school, and we promised ourselves that we would excel at providing such care. Many times, when we study late nights or skip a Friday night event with friends so we can be ready for Monday’s exam or be prepared for rounds, we say to ourselves, “This will make me the physician I want to be and allow me to provide the best care possible.”

When we then find ourselves in this conflict, looking into our patient’s eyes and knowing the obstacles to providing that promised care and then seeing the obstacles become reality and requiring changes in therapy, we experience moral injury because we know the care we might provide might be compromised.

Strength in numbers

Everyone in the medical profession must band together to alleviate the circumstances that cause moral injury in medicine. Not only to preserve ourselves (which obviously is of paramount importance) but also for the good of our patients.

We need to strengthen the organizations that represent our patients, and, therefore, our patients’ interest through membership support and active engagement. We need to align with patient interest groups to show our support for their concerns. We need to work in our own organizations—no matter how small or how large—to institute changes. One small change at a time will make a difference in our daily experience, and many of these changes will add up to a system change. We need to be involved in the administrative aspect of our systems so we are heard and can represent our patients’ needs.

Ultimately, we want to feel that same enthusiasm and excitement when we have a patient encounter that we felt many years ago when we received the letter or email telling us we got accepted to medical school.

Related reading:

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Physicians and mental health: Making medical license applications less punitive to doctors who seek help