Mental health

Confronting burnout and moral injury in medicine

Regarding burnout in medicine, “I knew there was more to the story than the frustration of dealing with administrative obstacles,” writes Jerry Balentine, DO.


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.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

Related reading:

Taking a holistic approach to voting in the 2024 election

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


  1. Todd Smith

    I practice in rural West Virginia. I have provided care to patients in both inpatient now. Patient settings for the past 24 years. I am literally tired of reading articles about physician burn out. As I have said on multiple instances, I would love to spearhead a unified group that consist of physicians and this group would be able to aggressively have a unified voice so that we would be able to provide the necessary changes that are required in order to make physicians happy again. I agree with the unification. We are in a downward spiral that will not end. Our only hope is unification. With hard work this can be done. I look at my generation of physicians and think that one day we are going to be sick and unfortunately will be there to take care of us.


    1. Richard W Koss, DO

      Well said Dr. Smith. Until all doctors realize that the insurance companies and CMS are practicing medicine without a license, nothing will change. Doctors take insurance and do the billing is a “courtesy” and not required unless you sign up or Medicare/Medicaid. Like the IRS forms no one can understand the confusing verbiage… so the government requires the doctors to attempt this ridiculous process. The insurance companies are protected under the ERISA laws. So no one can bring legal action against them. Until Doctors understand this and the AOA/AMA push to have insurance companies legally responsible for their actions just like the physicians are nothing will change. Doctors need to demand a change.

  2. Sean

    I think these comments are insightful and thought provoking. Glad to hear the variety of roles you have served in both as an ER physician, role in admin and then as dean of a medical school. As a currently practicing DO with a large health system, I think one must underscore how many aspects of our daily lives are beyond my control directly as a physician. My employer ultimately determines how many support staff we will fund, and when to replace people that leave, how many MAs we have and how much time we will “allow” them to work on prior authorizations weekly. Then if I were to try to help out an overweight patient that meets criteria in theory to get their Wegovy, Zepbound or other med covered, there is a >80% chance I receive a prior auth request to attempt to get their insurance to cover this medication. Same goes for almost every diabetes or inhaler I prescribe as a PCP. So even though physicians know what to do in the vast majority of cases, we are left “begging” the insurance company if they will pay to do the right thing. Currently we are in a losing battle for us as physicians and our patients, but the middle men (insurance companies, PBMs, pharma, our big health systems) make $ hand over fist due to our due diligence and care for our patients. We have been, and continue to be taken advantage of. I know this and most currently practicing physicians know this. I have decided to primarily focus on what I can do within my own power. That is keeps me going.

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