Healing the ‘moral injury’ of clinicians will take a village

When two physicians wrote recently in STAT that their colleagues aren’t burning out but are instead suffering from “moral injury,” they struck a nerve. Thousands of physicians across the country talked about it on social media and discussion boards; rapper and internist ZDoggMD spent nearly 30 minutes discussing it with his followers.

This is a subject that clinicians have been talking about in differing, veiled terms for years. It’s reflected in the quiet whispers that something is wrong — something more than mouse clicks and workflows.

Is it any surprise that a broken system has produced a broken workforce?

Take a random sample of 100 doctors. Fifty of them are emotionally drained, 40 have symptoms of depression, only 54 would choose medicine if they could do it again, and half hope their children don’t choose the profession. Even more sobering, six of them have thought about suicide in the last year.

Yet for the profound pain of the profession, a quick scan of solutions offers up pleasantries like “accomplishing a few tiny things … going for ice cream … [or] spending the afternoon relaxing.” To be sure, there’s a place for meditation, journaling, and yoga. But none of this gets to the heart of the personal toll of practicing medicine in a manner so antithetical to the values and intrinsic motivations to heal.

Before the appearance of the electronic medical record, no matter how much paper was on physicians’ desks that required attention, they had the inviolable space of the exam room. Adding the computer changed that dynamic, opening that sacred space and bringing in countless rules and regulations designed for billing and scheduling — from CPT and ICD-10 to ACO and MACRA.

It’s not that health care shouldn’t have entered the 21st century. It’s that all the demands leave little time for clinicians to move from “What’s the matter?” to “What matters to you?”

Who really cares about “What matters to you?” Not insurers — the electronic medical record doesn’t have any boxes to check for that question and the discussion that follows. But doctors and patients care about it deeply as a way to get to know each other as human beings, learn each other’s values, and build a trusting relationship. That’s not billable, to be sure. But building these relationships is essential.

In a country where health care costs are driven by treating chronic conditions like diabetes and depression, trusting relationships are required to help patients make the changes they need to achieve better health. Indeed, the only path to a healthy country leads through the millions of patient-clinician relationships, where the art and science of medicine meets the values and needs of patients.

Our current health care system is designed to short-circuit these relationships and limit time with patients, making providers’ collective guilt soar. When they should be building connections with their patients, their eyes are on computer screens. When they should be asking about a patient’s depression, they wait until next time because three minutes isn’t long enough to start the conversation. When they should be actively listening, they’re checking off boxes for insurance companies.

The health care system that clinicians imagined they would be working in when they began their professional training is not only markedly different than what they had hoped for, it is at odds with their internal sense of morality.

That is the heart of moral injury.

Moral injury challenges clinicians’ fundamental assumptions about their own moral compasses, integrity, and commitment to others. Providers suffer silently knowing they could have, should have, didn’t, or can’t. What’s more, they face these soul-spotlighting questions on their own.

A colleague who coaches physicians with burnout recently remarked that the most common question she hears from clients is this: “Are other doctors having as much difficulty as I am?” With spaces for camaraderie and connection increasingly rare for today’s clinicians, and with their general reluctance to divulge their emotional experiences to one another, many face this existential reckoning alone.

Doubling down on relationships

Elizabeth Metraux, a colleague of ours at Primary Care Progress, leads an initiative to collect stories from clinicians nationwide in all stages and disciplines of primary care. In a session at the Aspen Ideas Festival, she shared a prevailing theme in her conversations. Much as Tolstoy once penned that, “Happy families are all alike; every unhappy family is unhappy in its own way,” the same appears true among clinicians. While the sources of professional dissatisfaction vary, the sources of fulfillment are consistent: It’s all about connection — to patients, to colleagues, and to the calling of medicine. Indeed, nearly three-fourths of providers view their relationships with patients as the most meaningful part of their work.

If it’s all about connection, then uniting and building community must be the first step in the healing process.

In his book, “Achilles in Vietnam,” clinical psychiatrist Dr. Jonathan Shay, writing about combat veterans, says that healing the wounds of moral injury first requires a “communalization of pain.” Rita Brock, co-director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas, explains that the whole community must take “responsibility for helping those with moral injury.” Nancy Sherman, a professor of philosophy and lecturer on moral injury at Georgetown University, describes how guilt and shame can tear individuals into pieces; healing this type of rupture necessitates “trust and hope and empathy.”

Those restorative emotions generally don’t materialize spontaneously and independently. They are made real only through the relationships found in caring communities.

Clinicians are beginning to start the process of communalizing their pain with peers — acknowledging that their crisis is a moral one and the way forward is a shared journey. Through experiences that highlight vulnerability, storytelling, and connection, the process of “soul repair” is underway as thousands of physicians are sharing their experiences and supporting one another in peer groups and other informal settings like Schwartz Rounds that honor humanistic approaches to caregiving and increase compassion and meaningful collaboration between medical professionals and their patients.

This community building needs to go further, however, with increased opportunities to build and strengthen connections between clinicians, other members of the care team, and patients. By identifying common pain points and solutions that stand to benefit all parties, more passion, perspectives, and resources can be brought to bear to effect real change.

Systems evolve only when pressure is applied — ideally from all directions. Patients and other purchasers of health care need to start asking payers and practices the right questions — like how they’re reducing useless burdens on clinicians and what they’re doing to enable strong, continuous, trusting relationships between patients and care teams — and demand meaningful answers. At the same time, clinicians need to form alliances with patients and peers to push for the kind of systems change that is so desperately needed to right this wrong.

We also need to ramp up resistance at the individual level — taking a cue from colleagues who have found ways to push back on the current system to do what’s right for their patients: Looking at the patient instead of the screen. Seeing one fewer patient each day to enable a few extra minutes with everyone else on the schedule. Recognizing that sometimes it’s more important to meet a patient’s needs than to excel on a population health report card, or to ask the questions needed to get to know the patient rather than asking four additional review-of systems questions needed to bill at a higher rate. This resistance isn’t easy, but neither is the continued subordination to a system that’s failing all of us.

If violations of the patient-clinician relationship are at the core of moral injury, then it’s time to re-establish the sanctity of that space — medicine’s collective true north.

Treating the symptoms of clinician burnout isn’t enough. The health care community and those it serves must come together and apply pressure to address the underlying disease — the moral injury threatening patients, doctors, relationships, and the soul of the medical profession.

Andrew Morris-Singer, M.D., is founder of Primary Care Progress and a general internist at Oregon Health and Science University. Stuart Pollack, M.D., has been a practicing general internist for 27 years, the last seven co-leading a medical home at Brigham and Women’s Hospital in Boston. Matthew Lewis, Ph.D., is a consultant and educator on the use of narrative.