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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  • Dr gives service, patient brings chicken. Have done ER x 35 Years. In old days, no middle men and women. No one has cajones to strike or unionize. Not only answer but best in this dystopian world

  • Dr. Block

    Trying to provide this type of care is one of the reasons doctors are feeling the way they do…….there is just NOT enough of everyone and anyone to go around….including other health fields such as providing good care in nursing homes, assisted living facilities, home health care, etc. The ones providing the care are “warn down and out”! This is a pipe dream.

  • What do you mean by “a truly free market of insurers and providers…”? How will your suggested system provide and pay for good health care for everyone? That is a moral responsibility for a civilized nation.

    • My opinion is that in the USA no true free markets will ever exist under the current legal structure of corporate entities. The fallacy of competition from out of state insurers offered by the ACÁ Marketplace is made all the more cynical when one researches the parent company ownership of smallest payers are the same big players with total political and financial wherewithal. United, CIGNA, BCBS, ANTHEM own the majority of smaller local State and municipal insurers. There can be no real free market under legal mergers and acquisitions by corporate behemoths. Another aspect is integration and consolidation the hospital chains like Tenet, HCA and Baptist health systems. Once Humana was a hospital company too but they concentrated in insurance and claims adjudication services for TRICARE and nationwide and local managed care organizations and MSOs. If patients only read and understood what the complexity of healthcare delivery services leaving the pharmaceutical variable out of that equation, they would all exit to Canada or Mexico en mass. That leaves us the physician to scratch a living from our God-given talents that puts all the negative consequences on us and exonerates all liability from insurance payers. What complicate matters more is the trial lawyers ASSOC is heavily represented in Congress whontgemselves are mostly attorneys by training executing laws in favor of a parasitic system sucking the lifeblood out of the physicians by imposing such administrative legal burdens on Doctor’s practices and the healthcare industry as a whole causing the excessive rise in costs to practice maintain liability insurance, order repeat diagnostic and imaging tests etc. Even if Doctors decides not to accept insurances and collect a fee for services rendered to patients, most physicians will still need to engage with the other parasitic industries that have entangled intimately throughout the years of evolving healthcare practices and politics. Good luck with the truly free market of any kind in America.

    • My opinion is that in the USA, no truely free market will ever exist under the current legal structure of corporate entities. The fallacy of competition from out of state insurers offered by the ACÁ Marketplace is made all the more cynical when one researches the parent company ownership of medium to small payers are the same big players with total political, financial influence and wherewithal. Payers like UNITED, CIGNA, BCBS, ANTHEM own the majority of smaller local State and municipal insurers. There can be no real free market when legal mergers and acquisitions by corporate behemoths are permitted at such scale. Another aspect is integration and consolidation hospital chains like Tenet, HCA and Baptist health systems. Once Humana was a hospital company but it concentrated in the insurance and claims adjudication side i.e. TRICARE and TRICARE PRIME nationwide and local managed care organizations and MSOs. If patients only read and understood what the complexity of healthcare delivery services are (leaving the pharmaceutical variable out of that equation), they would all exit to Canada or Mexico en mass. That leaves us, the physicians, as the lowest rung on the ladder and easiest prey to the predatory tactics of merciless personal injury attorneys, avaricious insurance payers and the inadherent patient who neglects their health and require higher utilization of the health systems resources to demonstrate our medical competence by display an allegiance to the system and not the patient and from limiting their care. Doctor’s today are left to scratch a living from our God-given talents. This puts all the negative consequences on us and exonerates all responsibility from insurance payers. What complicates matters more is influence of the Trial Lawyers Association, which is heavily represented in Congress who themselves [congressman] are mostly attorneys by training, executing laws in favor of a parasitic system sucking the lifeblood out of the physicians by imposing such administrative legal burdens on private Doctor’s practices and the healthcare industry as a whole causing the excessive yearly rise in costs to practice, maintain liability insurance, order repeat diagnostic and imaging tests etc. Even if Doctors decided not to accept insurance and collect a fee for services rendered directly to patients, most physicians will still need to engage with hospitals, the other parasitic industries that have entangled intimately throughout the years of evolving healthcare practices and politics [Stark law unsafe havens]. Good luck with the truly free market concept of any kind in America.

  • I completely agree with all aspects of this article! I have been in practice for 26 years and medicine has completely changed! It is SO difficult to take care of our patients now as our top priority. Yes we need leadership- that have been in practice long enough to have seen and experienced this change. I am still hopeful that this will happen. Sadly we the physicians are also patients.It is a lose- lose for us the way it is now

  • No. We need a different word. “Morale Injury”, compassion fatigue on steroids and more — but what medical providers experience is not Moral Injury.

    Sit with a patient who has killed in the line of duty, or perhaps one who accidentally killed their own child, and one knows the difference.

  • Wow. Just wow. Finally someone wrote something that captures how so many of my colleagues and I feel. I love patient care and spend about 1.5-2 hours nightly after my kids are asleep doing charts and catching up on work. All of us keep saying we don’t need coloring pages in our clinic or massage breaks no physician can attend. We need real solutions to the enervating mess that is modern medicine as summarized by this article. It’s soul sucking and not what I trained to do.

  • 100%. Agree. Spent 2 hours getting a “predetermination” for a PET scan that was not needed but a clerk at the hospital demanded it. Ugh

  • Hell yes! Largest primary care practice in NC, went w Duke this year as Blue Cross not negotiate and Obama cut my Medicaid 25%. Just spent first day w new computer system, Epic, built by nerds who have never seen a patient in their lives in private practice!!

  • In response to C. Hammack I must address his/her points bullet by bullet because so much misinformation and negativity have influenced the perception. Firstly the idea that Doctors aren’t in it just for the money. If the consideration of debt and years of training vs. Workload quotient are calculated, most physicians are paid minimum wage today. Secondly, most doctors work for groups or institutions that demand less than 15 minutes per patient new visit and most times overbook that time slot with an “emergency” giving Doctors less than 7.5 minutes to determine a working diagnosis and prescribe medicine, order relevant tests, and fight the computer for competing administrative interests that have little baring to the patient’s welfare and wellbeing. This part is the reason patients feel doctors are uncaring. Patients have no idea of the pressure from management, government regulators and insurance payers to comply with needless documentation guidelines on a computer program that flags the doctor at each encounter for immunization, smoking, BMI, and prevention protocols which most patients don’t follow anyways. The justification for highest fee is made clearer when one understands the cost of providing medical care in the USA. No one speaks of the liability and overtesting dictated by defensive medical practices by physicians because they have been educated with the mantra that attorneys are the first in line patient’s advocates, nurses second and hospitals third. But the physicians are just opportunistic money hoarders out to extract every penny from patients. Corporate based Medicine is the most business profit driven healthcare delivery system. Yet they have touted to government and the populous to believe theyre the best cost savings model over private physicians’ practices. This is the model C. Hammack is missing most from the comments yet she/he has been driven to see Doctors under contract by low paying insurances which monopolize healthcare delivery and have made profit the primary market of high quality medicine under the guise of systematic corporate algorithms.

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