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.
I watched this process happening with nurses during my chaplaincy training. The older nurses, who were more thorough, more personal, and more likely to speak up if their nurse’s intuition tingled, were being replaced by a next generation of nurses who never spoke up, and zipped around scanning bar codes and pushing medications. A few more years of this and the moral injury won’t matter, because the people in the profession won’t know the difference. Since the concept of moral injury comes from the military–consider that for WWI and WWII, the U.S. government had piles of propaganda to convince enlisting men that here was a good and necessary fight. Having lost any legitimate claim to justified war in Vietnman, there was a terrible time of moral injury. But the modern military, and especially the privatized military, isn’t concerned about a righteous fight. “They are sitting on our oil” seems to be sufficient reason for enlisting and deploying. Of course, after the tour, the moral injury is acute…
You are burnt out because you are a line worker in a medical sweat shop. You are paid to move product (patients) as quickly as possible and to maximize profit and minimize cost for your employers (insurers and hospital systems). You are easily replaced by a younger worker with a serious amount of debt to be serviced. You can be easily manipulated into working harder for less because of your compassion and sense of duty to the patient. This is the natural and logical endpoint of a capitalistic system. I am not critical of it I merely want to point this out. Because when maximizing profit is the goal, and it is, nothing else matters until it affects profit. Complaints and suggestions have no bearing on profitability and so are meaningless. They do serve as a distraction from the large amounts of money being channeled from the system into other hands namely stockholders, executives and administrators. If you are responsible for a system that is making billions of dollars annually you do not change it. Even better if you have an advantage which literally is your money or your life. No one is forcing anyone to buy medication or receive medical care, but there is no better marketing tool than death or illness to aid in the pricing of these products and services. This is why insulin prices have been increasing 40% a year, why my health care mutual fund has been consistently returning 12% annually on my investments and why health care executives make 10 to 50 times more annually than the physicians who actually generate the profits. Profit and the monetary wealth it generates are the goal of our healthcare industry, just as it is in all industry. I learned long ago that just because you don’t like the diagnosis and don’t want it to be true does not change the physical reality of the illness and you do no one any favors by not calling attention to it.
“We also need to ramp up resistance at the individual level”
You suggest doing this by either seeing fewer patients or ignoring various quality measures – in essence, taking a pay cut because the system is so abusive.
Doing so doesn’t change the system, it’s just admitting failure.
I have a perspective on this issue that may not conform to the waterfall of ideas that many physicians, ethicists, philosophers have about this phenomenon of physician fatigue, or moral injury, if you will. I worked in the medical profession for over 15 years. I have known many physicians both personally and professionally and I went through the metamorphosis of paper to binary record keeping. My wife was a high-level clinician. She became seriously ill a couple years ago, but actually died from a series of Medical Errors that still boggle my mind. I became very distrustful of physicians and of the medical profession in general. I still am; for good reason I think. I moved from my home on the east coast to another part of the country and I now see two physicians regularly for age-related issues. One of them is a urologist. He has an impressive set of credentials after his name: MD, MSc, MBA. He is clearly very educated. He has clearly spent a lot of time, as that MSc degree indicates, doing research. He has a good bustling practice in a relatively small town. I have gone back to graduate school in History to help with the grief of losing my wife of many years, and over a few visits we discussed school and he was pleased that I was in school. On my last visit to see him, he came into the exam room, grabbed a chair and sat down; asked me a few questions about symptoms and how I was feeling. We then spent 20 minutes talking about the evolution of the Comanche Tribe in Western North America, and specifically about the Comanche-Apache Wars of the Eighteenth Century. I was stunned at how much he knew about the Comanche Tribe. He knew where the migrated from to end up on the Southern Plains. He knew their history of warfare and the extensive trade routes they developed very early. My point here, is perspective. This is a man who is engaged in life, not solely in work. He loves to learn. He knows his profession very well; but he knows many other aspects of life very well too. It may be that if physicians, and others in the Medical Profession, who make very costly mistakes sometimes due to a cluttered mind and a feeling of being rushed, might take a little time to engage with the world in which they live, they may find a common bond, here and there, with a patient or two that will make that relationship more human and less robotic for both doctor and patient.
“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.”
THIS x infinity
As CEO of ProQualitas Health I’m very glad to hear about human answers to thousands of caregivers and doctors that are living in a silence and on the shadow of injurys; they are victims ( second victims) specially during a never events or whatever about a patient safety incident, victims probably of a lack of leadership or a management model without commitment on prevention of clinical incidents and patient safety standards assurance.
I find it difficult to believe you are a CEO of anything, Martha. Your reply made no sense; maybe because your only period was at the very end. What did you intend to say?
Deb
It is true, Deb, that Martha’s post lacks an articulate quality, and I had to read it twice to extract its meaning (at least I think I understand it). I believe she is saying that the physicians in question are suffering under a system that is mismanaged from a patient safety perspective.
ProQualitas Health appears to be a Swiss company, so that may partly explain the seeming incoherence of Ms. Schiller’s post.
Right on – A step in the right direction is the growing popularity of independent physicians offering direct care contracts. We have pushed to have Congress to allow payments for these contracts from health savings account funds. The U.S. House passed a bill H.R. 6199 that needs a fix at the Senate level. Please Call you Senators to allow these funds to be used in any way the patient believes is beneficial, including independent physicians and NOT corporate interests.
This has been my experience as a patient. My doctor told me to get an ultrasound, but she didn’t say why. I feel fine, my blood tests are all normal, etc., etc., but she wants me to get an ultrasound, at the hospital where she rents her office space, and that charges me $100 copay for a $1000+ procedure. I know that ultrasounds don’t cost that much. So I didn’t do it. When I went back to my doctor a year later, I was still healthy and all my tests were still normal. She was angry at me because I didn’t do what she told me to. Like it is my fault that the trust between myself and her is broken.
But if not sure, why didn’t you ask? What if the ultrasound was supposed to be done to screen for a potentially serious condition? Think of it as an underlying disease like cancer that was likely to be present in 10% of the patients like you. Out of 10 “Sherri”s who skipped the test, 9 will be happy thinking they out-smarted their greedy doctor while 1 will have to deal with consequences of delayed diagnosis of a serious disease…