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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  • Bravo! I’m a physician and reading this article cuts to the heart of the matter! I think I lost it many years ago when I treated an uninsured 19 year old type 1 diabetic in the ER who had already lost his vision in one eye due to cataracts. All he wanted was a script for insulin. He was employed full time at a fast food business, but health benefits were not offered. As I spoke to him I noticed a pregnant young lady sitting in the chair place in a corner of the exam room. She was his girlfriend and they were expecting a baby! This young man was sincere, hardworking and like anyone else looking forward to a life with his family. I explained I could write the script but the cost of getting the insulin could still be considerable. And that was all I had the resources to provide.
    I left work so angry that day! How could we as a country allow this to happen to good people?! How does a 19 year old in the wealthiest nation lose his vision in an eye from a completely preventable and treatable cause? There are hundreds like him I’ve seen since then with different stories, but similar circumstances. Moral injury indeed! We are being asked to do the impossible task of standing in the breach of a broken health system. I’m not burned out, I’m pissed off. People deserve better!

    • Thank You . There are so many stories like this . I work as a Registered Nurse in Mental Health in Ireland . A few years ago , a young American adult was admitted to our unit in a psychotic state. The history was , having taken a low paid job in Seattle , health benefits were lost , and could no longer pay for anti – Psychotic medication . In a delusinal state , he had flown from Seattle to Dublin , and were picked up by police in a very distressed condition . After a number of weeks , he was flown back home , accompanied by two nurses . There are many similar stories , not all with as happy endings as this. Most of us in Western Europe find it difficult to understand why basic medications for long term disabiling conditions , are so expensive for so many . Have a look at the UK general election at the moment , and the row re UK v US style healthare .

  • I suggested councilling and debriefing of medical workers because they work/perform duties in a constrained environment. I was the only trained and skilled physician in the speciality in a two thousand bed hospital, a young nation of a population of about thirty million people and over sixty percent below forty years old. The long working hours were a result of overwhelming sick people. I had to be ethical in my healthcare service provision, teach under and post grad students and technologists. The departmental administration was also part of my work. This called for recruitment of Doctors who had finished their medical school, gave an in-house on job training and rotation in all the medical displines before proceeding for specialists training of their choice. I never rushed anything. We carried out departmental consultation if in doubt of anything. We carried out a turn around time survey for patients in the department under my supervision with the technologists and records officers. This helped to give an indication on how to manage different sections in the department , re organize patient flow and bookings. We developed teamwork and improved on patient booking day /time of the week. We still gave quality services to an even larger client population with a minimal number of skilled medical workers. The developed in house trainings lead to an increased human capacity and retention within the hospital. I spent thirty nine years in the same hospital and helped improve services in other departments, some private hospitals and clinics because the human body is universal and so is clinical treatment and protocols. The other things that I looked after were my personal eating habits and rest. I took balanced meals in moderation and spared some thirty minutes rest/nap at lunch time. I had a minimum of six hours of sleep ( this was interrupted in many instances during early morning hospital adminstration/ management meetings or conference travels. Physicians should be further trained in governance and public procedures so that they know how to lobby for funds from their Government for health economics and improved budget allocations. I personally undertook the training from our country school of Governance. Interaction with none medical professionals and rural communities usually helps you as a physician to understand and improve on services from their critisims and suggestions. I can still be a physician in another life again. The provision of a quality service and positive outcomes/ recovery are still the driving force. Sidika

  • I have retired from public service after 39years of service at our National referral hospital. You have precisely hit the nail on the head with the truth. We need to incorporate medical workers councilling program in our medical institutions to debrief workers from the situations they go through during their career path. Sidika

  • there is a way out and i know many doctors who have taken it- functional medicine. they have dropped out of the insurance system with it’s diagnostic codes and computer requirements. they see 4 or 5 patients a day for an hour each, instead of 30 for 7 minutes apiece. they don’t work for the drug companies but serve, guide and teach their patients. they aren’t merely managing symptoms while the patient gets worse and worse with increasing side effects from more and more medications. they employ health coaches to free up their time for the real serious cases.
    they aren’t overweight, miserable and unhealthy themselves. take a look at the staff of any american hospital. most of them will need the bed as soon as you are done with it. how can a profession inspire confidence when it’s practitioners all look so sick? i’ve sat at my 95 year old father’s bedside in hospitals where he is healthier than the nurses tending him!
    i can see how it would stress you- you pump patients full of poison, you charge money and they die anyway- probably because, not inspite of, what you’ve given them. the standard of care for type 2 diabetes, a dietary disease, merely speeds up the progression. how many people die of cancer treatments more miserably than they would die of the cancer itself?
    then there is the hopelessness- they have all this so called training (only drugs and surgery) and yet they don’t seem to believe that the human body can heal. how many times have i heard “oh, your father won’t make it; he’s too old” or “there’s nothing we can do; go home and get your things in order.” it must require a mind numbing level of cognitive dissonance to be so futile when you have so much student loan debt!
    get out of the box. the only medicine out there isn’t western pharmaceutical medicine with all it’s tests and procedures that lead no where. the US spends more on healthcare than any other nation and for that we are far down on the list of outcomes.
    i broke a write in italy 10 years ago and was treated by happy pleasant doctors in a state of the art hospital and paid 36 euros to get a copy of my x-rays to bring back to the states. i never saw a doctor who looked over stressed, over weight or hopeless. they spent time with me, looked me in the eye and seemed to care about me as a person. when i asked what i owed, they were embarrassed. “no, no” one of them said “i did nothing.” maybe, but she spent 20 minutes with me which is almost 3 times the average american doctor visit. she was kind and reassuring. i thought she did a lot.

    did you know that you can order your own lab tests and pay directly for them?- a fraction of what they’ll bill to your insurance and much less than your co-pay. that’s because our system is a criminal scam fraudulent enterprise. no wonder doctors who work within the system feel bad, but don’t say they can’t figure a way out. they can. many just won’t. they made a deal with the devil.

    the way out is to get out. stop taking insurance. negotiate directly with your patients. then you can afford to spend time with them and you’ll watch them get well, really well.
    where i live many doctors have like a CSA for farmers, where you pay them a small monthly retainer and for that you get a certain amount of care. other doctors offer group classes- why see one type 2 diabetic at a time when you can see 20 of them, have cooking classes, take them to the grocery store and teach them how to shop.
    the current system will crumble. it has to. it’s unaffordable and not very effective except for acute trauma and infectious disease. and that’s what it was set up to deal with. that it tries (and fails miserably) to treat chronic illness as if it were an acute problem is a money grab.
    it can’t happen soon enough nd many patients will suffer and die while we wait

  • Can’t feel sorry for the doctors. In my 53 years I have only had two good doctors each of them for about two years. the rest have all been dangerously irresponsible or try to make as much money off of me as they possibly can. “Just keep coming back!” While providing less then acceptable healthcare. It’s a complete and utter nightmare for the patients. Talk about PTSD? I have PTSD. I didn’t even have to go to war or be a doctor to get it.Two of the reasons, out of the many, happen to be doctors. Four of my immediate family and two of my close friends died due to the negligence of doctors and I don’t have a big family and I don’t have very many friends. I myself was maimed due to the negligence of a doctor. Now I am unable to work and I can’t get disability bc the doctors and attorneys (politicians in training) screwed that up too! One tiny step in the wrong direction and I’m on the street. I currently live in the back storage area of a small monument shop. I am blessed enough to have a bedroom/kitchen and a kitchen/bathroom that’s all kind of squished together. I am eternally grateful for the person who made this possible. So yeah, Everyone has problems but the doctors get paid big bucks to have their problems. I bet they get to eat food every day. A large majority of Americans don’t have that luxury. Everyone gets burned out. The only difference is that when we get burned out we don’t kill and maim people. We’re talking about our lives here! Not just a bad day at the office. This is the road they chose and like I said they get paid big bucks and still take advantage of us to TAKE as much money as they can get their hands on! Somebody needs to tell them to get it together or get out and stop killing and maiming people “all in a days work”. I understand that their work is hard but life is hard. Life is hard for everyone else BECAUSE of the medical industry and the insurance industry and the pharmaceutical industry, politicians, lobbyists, etc. All we ask for is quality health care but it just doesn’t exist anymore . So scary and frustrating!
    BTW I think your article is pathetic and disturbing to say the least. It made my skin crawl. You wouldn’t happen to be a Democrat would you? I agree with Randal James Dotts…How dare you? His rendition of how it was is spot on. My Dad is a Vietnam vet marines. I know all too well about the horrors and issues they come home with. They never go away

  • Fantastic article that aligns with my thoughts after working in the state Medicaid behavioral health system. So well done, thank you

  • This article is an abomination and severe insult to combat veterans, especially those with PTSD…..TO USE THEM AS THEIR YARDSTICK IS BEYOND CONTEMPT….there is no comparison at all….when was the last time civilian physicians were routinely shot at, in fear of their life, worried they would run over an IED, exposed to the frigid cold and extreme heat, have to eat slop to survive, have to routinely carry 3/4 of their body weight over agonizing terrain, look down their rifle at the enemy, their eyes, to shot and/or kill them, look at the horrors of war with all the innocent victims, many children, have recurrent nightmares of what they did downrange, attack their spouses while sleeping, always look for the exits and must sit with their backs not exposed to an open area, have smells immediately take them back to the combat zones….

    HOW DARE THEY…..I’ve been in medicine, as an EMT since 1975, I was a medic with the 1st 75th Ranger Battalion and 24th Infantry, since graduating from Duke’s PA program in 84, worked as a PA in many emergency/internal medicine milieus…. regretfully I am NOT a combat veteran, but I have treated many combat veterans over the past decades and many of my “training experiences” were like Combat veterans (use of live ammunition drills —-not blankes—, treat many injuries similar to my combat brothers/sisters, exist for months surviving in freezing/wet and dangerous high temperatures with only the equipment on my back/in my ruck……

    I AM ENRAGED AT THEIR ARTICLE…..I want all my COMBAT VETERANS TO PROVIDE THEIR OPINIONS…

    • I have witnessed first hand many of the issues brought out in this article…..I have worked as an independent practitioner, with only phone calls available to my “supervisor physician”…..I have also worked with HMO/PPO’S and wittinessed medical malpractice and treatments withheld in order to get large end of year bonuses or their admin not making their multimillion salaries……I have taught medical/PA/ARNP students and amazed at what they did not know while doing rounds…..the younger providers do NOT know how to practice medicine that does not fit into their evidence based medicine models…. they do not know how to even describe heart murmurs without ultrasounds to tell them…..they will not pit in the long hours that many specialists require— it was even discussed that residency programs extend their duration to make up for those hours….I know first hand having to fight with insurance companies to get my patients the standard work-up and or treatments mandated without spending hours on the phone with someone who has no medical training to get their permission…..I had to resort to telling them when I am sued for malpractice I will have their name turned over to the DA for them practicing medicine without a license—finally they would give in…..I read so many medical records which are literally copied and pasted from previous notes, with only minor alterations at best but usually not even that…..fighting with admin to have records transcribed so that more patients can be seen during my timeframe called work; my typing is not the fastest what with hunting/pecking the keys…..during my career I have always fought for my patients and have written complaints to the state department of medicine for licensing which resulted in that HMO being closed down…..I have reported physicians who ran pill mills…..I have written the inspector general and Congress outlining medical malpractice within the VA; I was subjected to being ostracized, moved to a room without windows, all my patients taken away as I sit in my office doing nothing; the VA drowned me in paperwork as they realized they could outlast me both in time and money; watch other physicians who joined my cause suffer a stroke from the harassment of the VA payback with the end result being nothing changes as the congress in in bed with high up admin within the VA…..the continued “DENY TILL DEAD” policies in delaying or denying medical and psychiatric care for veterans with service connected injuries.

      I do agree with many of the issues brought out in this article but until we deal with governing our own professions, reigning in insurance outrageous profits, getting rid of corrupt medical admin/politicians etc.m nothing will ever change… the moral compass of medicine needs to be recalibrated with a correct azimuth. I have now become so disillusioned with the current medical environment and realizing the corruption from lobbyists and our electorate I have retired as they have won…..sad state of affairs

  • This article sums up totally the way I am feeling now.I am at a physical and emotional crossroad,and have become stationary with no incentive to move yet.

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