Physicians 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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  • doctors don’t suffer from “moral injury” while mutilating infants, males in particular, for profit under the guise of neonatal circumcision. they totally disregard the hippocratic oath of “first do no harm,” which was inspired by Imhotep. the first thing doctors do to most boys here in the US is make them feel pain and shed blood; some of the infants die from shock or hemophilia, others are forced to incur sexual reassignment surgery to be female, or have lifelong social, physical and psychological traumas that are mocked and ridiculed by the medical industry. they are more like hired mercenaries, assassins even, in “the battle of the sexes.”

  • Of all the comments that have been posted on this story that is now over a year is to me the most poignant as a patient. It is exactly how I see and feel it when I go to the doctor…..most of it just a waste of time because of all the busy “ness” that is required of you….and god, don’t dare interrupt your typing! And your brutal honesty about doing and recommending things for patients that are darn right “risky” but nevertheless you are “required” to prescribe. Myself, and hopefully MANY more start to question and say “NO” to the dangerous drugs such as biophosphonates for most women. Good Luck to you Marianela.

    This article has definitely hit home as it is still “has legs” and it is over a year old. Good job.

  • This article hit really close to home. I am a resident that has been struggling with burnout for a while, and recently I decided to seek help, so I’m getting the whole mindfulness and healthy diet thing, which definitely helps as a symptom reliever but is not a solution.
    Doing things for your patient that you know you shouldn’t be doing, or when there is a better alternative, is frustrating. Spending hours in a computer entering data that is mostly irrelevant to your patient’s issue and most of the times repetitive, being forced to type while a patient is sharing with you something that matters to them, feels wrong.
    Now I’m left wondering if my burnout could be disappointment in myself for not being and doing what I always envisioned I would be and do: the compassionate attentive doctor that does what is best.

    • Marianela–your last sentence is the very crux of moral injury. The system has let you down, not the reverse. But we are trying to change that, and this article is just the start. There’s always room for one more to join us. (moralinjury.healthcare)

  • When was the last time you saw a doctor who had an office with one nurse and a front desk person, and that was the whole office?
    As medicine becomes more and more monopolized by corporate interests, doctors just become the ponds in the game. Merger and acquisitions continue to gobble up smaller practices leaving patients with no other option but to go see a larger corporate sponsored doctor from a huge medial facility. These large facilities breed cold relationships between doctors and patients, not always but as an average, yes patients and doctors lose that subtle nuance in a relationship. Now, in addition most physicians are introverts. Very book smart but often socially awkward. Frequent human interaction all day, every day can be exhausting to an introvert. Which can lead to anxiety and depression. Not every smart person should become a doctor. What are these doctors to do? Thus the frequent dissatisfaction with their work and life. Nihilism begins to set in. Just an observation working with lots of doctors.

    • I live in a town where there are several private practice doctors. As far as I can see, he is fully booked, takes insurance, as a receptionist, filing clerk, an insurance claims person and a couple nurses.

      I’m in mental health and in private practice. Not everyone is cut out to be a private practice. But it is a choice for all of us. Not all small companies are gobbled up. Some/a lot of people/doctors jump into the jaws of the monster because they want to be part of it. They want the money and security of big business. They want to jump into the big wheels that are already turning. They don’t want to do the work or spend the money to run their own private practice. Most never even consider it as an option.

      Of course, and then there are prices to pay. Sad to watch someone who refuses to let go of the cookies so they can pull their hand out of the cookie jar. There are people who would rather keep up the image and lifestyle than to have good mental health and relationships. And somehow would rather commit suicide then give it all up. Money, in short, is a trap. Not just for doctors but for many of the high-end income professionals. Hence, the high suicide, drug and alcohol dependence rate among other behavioral issues that are destructive.

      I’ve worked with doctors and families of doctors ( attorneys, politicians, athletes and celebrities ) I’m not sure what being an introvert has to do with those choices. I think it falls far below the list of how one is brought up ie childhood experiences, self worth, value grooming, bullied, greed, pride, competitiveness and image.

      Good mental health ( suicide prevention) for practitioners or anyone must start with the individual. Hospitals will not take care of their people/doctors. I am convinced that some larger hospitals actually have dismemberment and life insurance on some of their practitioners.

      It’s too bad that doctors don’t realize how much power they have. Organize and band together. Stand up for what’s right and what is a good not just for themselves but also for the people that they serve. We all need each other to be healthy and stable.

  • As system pressures rise we see managers faced with ethical concerns competing with budgetary ones. I work in the UK NHS and bullying is a serious problem there. Leadership must address problems in open and honest ways: The outrage at institutionally condoned injustice is a very emotive trigger.

  • Well said. I have watched this as ALL our neurologists & neurosurgeons have left ( or are in the process of leaving) because of internal medical pressure to save money instead of lives. Literally! Most have relocated. Some retired. Some have found a way to experience a rebirth of their passion of healing by finding & joining with others like themselves who pour out themselves to stretch themselves with continuous compassion & research into new areas that build up their ability to save lives. It is what saves their life, giving them new energy & hope & determination. Yes, I have been blessed to have such physicians in my life. It’s why I have a life!

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