When we began exploring the concept of moral injury to explain the deep distress that U.S. health care professionals feel today, it was something of a thought experiment aimed at erasing the preconceived notions of what was driving the disillusionment of so many of our colleagues in a field they had worked so hard to join.
As physicians, we suspected that the “burnout” of individual clinicians, though real and epidemic, was actually a symptom of some deeper structural dysfunction in the health care system. The concept of “moral injury” seemed to encapsulate the organizing principle behind myriad drivers of distress: the growing number of reasons we couldn’t keep the oath we had made to always put our patients first.
Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” It was originally described by VA clinicians to account for the way that the suffering of some military veterans did not respond to standard treatment for post-traumatic stress disorder. This way of conceptualizing soldiers’ suffering felt deeply familiar to us, and we thought it might provide a compelling account of the cause of the burnout we have witnessed in our colleagues and ourselves.
Posing a new question in the conversation around physician burnout, we published a First Opinion on moral injury on this date last year. We were stunned by the response. That article started an international conversation among health care professionals and others about the moral foundations of medicine and has begun to change the language around clinician distress.
Why moral injury resonates
Since our article appeared in STAT, we have discussed, debated, and reconsidered our thoughts about moral injury with audiences across the breadth of health care — in person, on podcasts, by phone and email, on social media, and from podia across the country. In the process, we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.
The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.
But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.
Day after day, health care professionals find themselves with no viable choice but to act in ways that transgress their deeply held beliefs in the primacy of care. As a result, many experience the well-understood symptoms of burnout — and they keep burning out, in defiance of the many and well-meaning interventions designed to combat it. The burnout epidemic continues unabated because the moral injury at the root of the problem remains unaddressed. Burnout may be the symptom, but in many cases moral injury is the cause.
From our conversations over the past year, we have learned that moral injury resonates because it suggests a broadly shared cause for the seemingly solitary experience of burnout. In other words, moral injury lets us understand that we are burned out as individuals because each of us is trying, in vain, to compensate for the dysfunctional way health care is structured for everyone.
Collective action for structural challenges
Those who suffer from moral injury in health care are desperate for healing. How do we do that? Each of us has been trying to fix the system on our own, in our own individual ways. Now it is time to work together to that end. Clinicians get burned out because health care is rife with double binds and no-win situations for clinicians and the patients we care for. Changing that system to make it less harmful will demand collective action from everyone called by conscience to do better.
When an individual falls ill, her or his clinician looks for the cause of the problem and its corresponding medical solution. We need to approach moral injury in the same way, knowing full well that the solutions aren’t medical but are social, economic, and political.
The conversation around moral injury, then, summons clinicians to look outside their own expertise to heal the system that is harming themselves, their colleagues, and their patients. The solutions to heal moral injury don’t look much like the medical interventions we are used to. They are more likely to come from the tool kits of epidemiology and public health, public policy and law, and grassroots organizing.
In order to make real change, we will need to engage “activists” from all aspects of the health care system — clinicians, health care administrators, policymakers, and, above all, patients and their families — to pitch in to address the structural causes of moral injury in health care.
Here are a few ways that have emerged to nudge the U.S. toward moral health care:
Value health care professionals. When clinic or hospital policies and insurance constraints force health care professionals to deliver suboptimal care to their patients, providers feel powerless. Administrators must recognize their clinicians’ expertise, earned by years of grueling training, and seek their input before implementing policies that could affect patient care. Forming focus groups of health care professionals to advise on the consequences of policy changes is an important first step toward ensuring that their voices are heard. Holding administrators responsible for the work environment in health care is a strong second step.
Privilege the patient-clinician relationship. Clinicians are stationed on the front lines of health care and are solely responsible for tailoring treatment plans to meet the needs of each patient. Insurers and health systems must allow clinicians the latitude to treat patients according to their specific needs without constraining the tests they can order, the drugs they can prescribe, or the referrals they can make without incurring undue burdens. Health care professionals abide by an oath to do no harm while doing everything in their power to heal the sick and injured — they must be trusted to uphold this oath as they are trained to do.
Reestablish a sense of community. The hypercompetitive, perfectionistic, resource-scarce health care environment has eroded a sense of community among health care professionals. Each of us instinctively guards our own territory, fearing the encroachment of others as a threat to our already scarce resources and to our professional survival. Nurses are pitted against physicians, advanced practice providers are pitted against both, and we are all pitted against patients (satisfaction surveys, anyone?). No one wins in that scenario, and patients lose the most.
Advocating effectively for the sweeping changes desperately needed in health care requires health care professionals to look in other places for inspiration and to work together toward a common goal. Industry constraints affect every health care professional in some way, and we must be united — with each other and with patients — to drive the changes we believe are necessary.
When we boil the ocean of health care down to its single organizing principle, all health care professionals — nurses, doctors, first responders, physical therapists, respiratory therapists, phlebotomists, technologists, and more — are in this together with a single goal: to provide the best care for patients. When we get back to this, we all win.
Wendy Dean, M.D., is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine. 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. They co-founded the nonprofit MoralInjury.Healthcare. The authors acknowledge Neil Chudgar, Ph.D., for critical assistance in developing and shaping this work.
This is a complex topic, in a knowledge-based/dependent industry like no other. Yes, US healthcare lost its moral compass years ago, because profit is (and should NEVER be) a primary goal of providing care to patients in their time of need. Yet there is more to it.
I’ve felt moral injury many many times, as clinician, quality and accreditation leader, as well as hospital executive, and believe there is a clear pathway out of this mess.
Rather disappointing to read Trumpian Doctrine of ‘winning’ as the finishing goal which, to me, spawns an amoral approach to healthcare provision.
Most healthcare staff in all disciplines know how best to do the jobs they were trained for. Not everyone in healthcare knows what the allied healthcare staff does on a daily basis. We all THINK we know what others do. The BEST care happens when all participants get to know each other and to appreciate their contributions. Healthcare works best when there is a TEAM effort. That being said, healthcare is a BUSINESS today not unlike other corporate practices…”can you do more?”…with less…
In my experience, it seems that health policy and practices derive in response to reimbursement. How health care entities are reimbursed results in the development of strategies to maximize that reimbursement. Take a look at the Relative Value compensation which is based on how much revenue a provider generates for the company – the more patients you see, the more revenue you generate, BUT, since there is a limited number of patients, if you get more, a colleague necessarily gets less. And if you can’t match or increase your productivity from year to year, your income goes down. This is just one example of the various compensation “incentives” in place, not just to generate revenue, but also to encourage best practices, which is not always best for every patient and can generate cookie-cutter care and unnecessary costs. I have worked 25 years in long-term care managed care organizations and despite the nasty reputation of “managed care”, it was most satisfying in that there were no productivity requirements. The requirement was to care for my panel of patients in a way that reduced their need for expensive hospital care, to judiciously select diagnostic and therapeutic options which would yield the best outcome for them, to support nursing staff and families in making informed decisions regarding age- and condition-appropriate interventions. It was win-win for everyone because this type of individualized care was also cost-effective.
What was your education level? How did you actually support families in their choice? And what was the choice of the patient? Many times there are difficult perspectives between the one who might need long term care and the famiy’s viewpoint.
You fail to mention Social Workers who are trained on the developmental history of humans ie Erik Erickson- a handy background to have.
Did you work with your local or state Nursing Home Ombusdman?
Did you actually visit the nursing homes the patients were placed in?
Smell is so important in long term health care as is the daily calendar.
One learns so much with which folks are allowed in and which are not.
A weekly Girl Scout activity and or invested church or synagogue involvement can make or break the care given by the employees to the residents as does a resident council that actually is given power.
And yes, even those with dementia issues of all kinds can with help and support sit in a meeting. Time and labor intensive but there is the priceless value of human dignity and respect.
If you worked in an office then of course no burn out issues. Out of sight is truly out of mind.
Burn out eh ! Job specific ? Not a jot but boy does it generate income and pseudo- scientific papers . Let’s hear it for the police force , fire service , non- medical professions and dare I say it , ‘ the human race as a whole ‘ . Let’s have the wider debate rather than finance self serving agendas !
Dr. Dean and Dr. Talbot
A noticeable decline in the satisfaction of medical practice began about 20 years ago and the patient-doctor relationship has been growing distant ever sense. The “Art of Medicine” has been replaced by guidelines. In 1999, pain was established as the 5th vital sign, the Institute of Medicine penned, “To ERR is Human, electronic medical records became the new financial “blackhole” and more physicians were becoming employed. Doctors employed by the same entity as nurses, loss autonomy and the respect of being a physician. Anyone could demote a physician if patient satisfaction scores were not satisfactory even if medical care was appropriate. Are we headed to becoming a retail industry. Many times, I have been threatened by patients with “Doctor, I want narcotics and if you don’t give me any I will give you a poor rating!”
Why have we let this happen? We have let others determine the best treat our patients. Where did they go to medical school. We all know opioids are addictive. The British introduce Heroin to Southern China and opium dens flourished with a generation of addicts. They have always been Schedule II and Schedule III drugs. Why then would we allow a government agency like the Joint Commission on Accreditation of Healthcare Organizations tell doctors that we need to treat pain better. Isn’t it for doctors and patients to decide? And today why would physicians allow a government agency like the CDC dictate in 2018 that the maximum amount of opioids in any patient should be no greater than 90 morphine milliequivalents (MME) and if greater should be rapidly weaned to 90 MME. Physicians are taught in medical school that rebound hypertension occurs if antihypertensive medications are suddenly stopped and that pain will increase with a risk of withdrawl if opioids are too rapidly weaned.
Burnout is a symptom of the inability to practice the art of medicine. 20 years ago I was practicing multimodal pain therapy and was routinely questioned until I presented evidence to demonstrate my claims. Today multimodal pain therapy is a metric CMS uses to measure the quality of anesthesia care. The cure for me has been to produce innovation in healthcare. How can I make healthcare better for my patients. Because of the opioid crisis I have started a medical device company, iPill Dispenser and a biopharma company, Quivivepharma to prevent opioid diversion and abuse as a way to address the opioid crisis. It has invigorated by curiosity in medicine as an art and not simply as a business. Applying business theory to the art of medicine can only end in the degradation of the quality of patient care. I used to know my patients by name. Now I know them by disease or medical record number in EMR.
Superbly depiction and conveyance of the total malaise in US health care !! The US health care system reeks of over-politisizing, administrative emphasis, cost-cutting at any and all costs, fear for legal ramifications, all resulting in total neglect of the actual subjects this system is supposed to serve : the patients.
I thank my lucky stars I do not live in the USA. Health care is incomparably better in many other western / civilized nations. And indeed: ALL working in the health care system in the USA have to fight & kick to re-work that rotten, business-oriented, profiteering (pharma, middle men), uber-controlled system.
From a dual background as Presbyterian Minister and previously professor in nursing and health sciences I have called what military folks experience- “soul damage.”
Moral injury need not be framed as the antithesis of care that’s evidence-based and cost-effective. It’s more complicated than blaming burnout on “systemization” of healthcare. It’s an important part of a bigger discussion.
I am a retired registered nurse. I lasted 35 years. I stopped working and went on disability due to moral injury and unremitting depression. My experience was mostly emergency/critical care. After my back couldn’t tolerate all the lifting and bending I became a case manager/discharge planner. That finished me off. I was absolutely heartbroken that my life’s work had deteriorated to the point that I could no longer, in good conscience, continue to advocate for a system that caused so much pain and suffering not only to patients but to those trying to care for them. God help us. Thank you to all who are perservering in the face of adversity to provide care to those they have chosen to serve.
The sweeping changes suggested aren’t sweeping enough. The system of financing health care must be changed to value health care professionals, privilege the patient-clinician relationship and reestablish a sense of community.
I agree and this area fits ALL professions. Burnout – I studied in a work group circa 1981 or 1982. It was apparent even then things were going haywire.
Also no option or discussion of ONE CAN SAY NO. Not easier killer for jobs but how do we incorporate moral integrity in our lives? Where is the blasting to all corners of the wisdom of the Perinnal sp? Philosophy of Ken Wilburr or Richard Rohr? LCWR group did extensive work on coping with this in the RC Vatican oversight process.
Ethics really it was there why didn’t anyone bother to research?