P

hysicians on the front lines of health care today are sometimes described as 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.

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 will never heal and physicians and patients alike will continue to suffer the 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 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. 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 — 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 resilience.

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.”

The moral injury of health care 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 health care.

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.

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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  • This applies to advanced practice clinicians and nurses too. I tire of a system that seems to expect me, as an FNP, to perform like a physician, and pays me a lot less. Also I have worked with physicians who do not seem to work as hard as I do.

  • Judy, I would beg to differ. It is not Allopathic medicine which is killing people. Allopathic medicine is brilliant but only when the need is at a level that requires allopathic medicine rather than lifestyle changes and more “natural” interventions.
    It is the business of medicine that is killing people. It is the corporate business world which is killing society worldwide right now, not just medicine. And most third world countries need plain old good nursing!

  • Suffering moral injury in an immoral business makes sense. Allopathic medicine is the disease killing everyone. It is unsustainable, corrupt to the core, archaic, brutal, ignorant about health and substandard in almost every case. If these people want to be of service to themselves and humanity, they should switch to natural health care. If not, they made their choice. See Dr. Kelly Brogan she did it.

  • As serious and widespread these issues of health care workers health and well-being are, it does not appear that they are on the agendas of occupational health programs or by OSHA. These are clearly work-related health and safety problems.

  • I have always tried to do the right thing at the right time for the right reason for my patients. I have also advocated for nurses continuously. Sadly, to little effect. Increasing staffing adversely affects the corporation’s bottom line and erodes the salaries of administrators. Nurses are forced to do more with fewer resources AND spend more time in front of a computer than the patient.
    Over the years the paradigm and nomenclature of care has shifted completely from “patient care” to customer service. The newest mantra is “patient centered care”. That is only new for the marketing departments of hospital corporations and insurance companies. It is the single most driving force of a physician care from which Primum non Nocere was derived.

    I believe that healthcare should be a right and not a privilege. We should have access to a same health care as the Senate and the Congress.
    If the Federal government were not so inapt in running programs I would be completely in favor of a federal health system. I believe the entities most opposed to a Federal system would include trial lawyers, big insurance companies, big pharmaceutical companies, and the supposedly “not for profit” hospital corporations.
    I absolutely love being a physician, solving problems and helping my fellow citizens. I also abhore the system with which I am forced to work.
    There are multiple facets to the problems we face. Another of which is what I refer to as the “McDonald’s mentality”of Americans. Everyone seems to expect a perfect result irrespective of the condition with which they present. There is a large difference operating on a relatively healthy 70 kg 60 year old male as opposed to a 60 year old, 130 Kilogram diabetic, smoker, with severe congestive heart failure. Americans do need to take some responsibility for their own health. They also need to demand of and pressure The Congress and the Senate to make real changes rather than insist upon “meaningful use “.
    This article articulates, very well, the disenchantment and despair that I feel and see all too often in my colleagues.

    • As much as I agree with the substance and spirit of Zachary’s post above, it is seriously flawed with some of the solutions, including healthcare being a “right.” This is fine as long as it is presented as a system that is workable by ordinary people and takes care of those unable to pay etc. This is how the system was as late as the 1960’s when the Hippocratic Oath was taken seriously. Now, with government intervention, including the Medicare “deal” made in 1965 with hospitals and the AMA, we have a crony capitalist corrupt system flush with money that is poorly spent and subject to every tort attorney and administrative whim. This is the cause of the main problem with our “system” – the wholesale marketization of healthcare led by mega-corporations paying their CEO’s eye-watering salaries and a cadre of administrative middle-men working to justify their salaries by cutting corners. Gone are the days when communities ran their own systems and were morally and ethically bound to good service and affordability.

      I don’t agree that obese smokers were necessarily at fault for their health problems and do not feel that making them scapegoats or having the heavy hand of government edict as a solution. The easy way of giving patients “responsibility” is to have them pay for the care and not have the petty larceny of “don’t worry, insurance will pay for it” as part of our cultural vernacular.

    • Unfortunately most America are deliberately and seriously misinformed. Look at the health information in the mass media, local news, and on the internet. Most of it is tied to marketing. A commercial for the latest Pharma products, is sandwiched between fast food offers. Small town newspaper health “advice,” and tabloid newspapers peddling “cures” while deceiving people.
      Our government was supposed to works for us, not the billionaire profiteers here. Every time someone remarks negatively about the “Government,” they are mindlessly repeating the propaganda. The reason the government has failed, is because it was infiltrated by the very forces it was supposed to regulate. The so called opiate epidemic is a very clear example, yet they are still avoiding the problem, while Gas Lightning the public.
      The government is not even allowed to collect useful healthcare data, the industries found it could be inconvenient.
      The News and publications like this never tell us how much we are already paying for healthcare, @10K a year per American, and more than half have no healthcare. The facts are censored because they make the case for Single Payer.

  • I am thankful to Dr. Talbot for his writing because of all the attention and commentary the piece has received. Particularly Mavis Johnson’s historical accounting of the division among the many disciplines in the hyerarchy of institutional healthcare provision and competing interests among them. The poignancy of territorial wars among doctors, nurses and non-MD specialists which led us to the present chasms among professions struggling for superiority forgetting the principal directive that is the sacred welfare health and wellbeing of the patient. It’s no wonder how these divisions lent credence and impetus to government regulators and departments of health to integrate corporate management systems and industry into the traditional practice of medicine. Now we understand as providers of one professional degree or another MD, DO, PA, RN, CRNA, CRNP, DPM etc, that unless we unite as a group to dismantle to current state of our healthcare system and rebuild it in the spirit of high achievement toward best practices in utmost patient outcomes we will continue to languish under the present system.

  • A few years ago the Nurses threatened to go on strike, due to continuous under-staffing. The Physicians remained conspicuously silent. They refused to back the nurses, instead they attacked them. They mindlessly signed Gag Orders, in order to work at the big medical corporations. Physicians failed to stand up over the years, believing themselves to be superior to the other hospital staff. Now they are being used too, micro manged and forced to see too many patients. They allowed themselves to get bogged down in paperwork. Not one of them spoke up about the onerous and by design useless information, they are expected to gather at each patient encounter. The medical industry has more to do with profit than health. Physicians believed the data gaps would protect them.

  • Great piece of writing, Simon. Solid insights into the issues that physicians face. Unfortunately most hospital administrators and systems turn a blind eye and deaf ear to the truths that are appearing as they are still out to sink their hospital competition is a misguided fight for market share.
    We’re more of the public to understand the crap that goes on in hospitals, the less they would trust hospital systems to do what is in the best interest of citizens who become patients.

    • Well said Doctor. A LOT of the public IS catching on and doing what they can try on their own to avoid the System.

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