Viewpoint: Physicians aren't burning out; they're suffering from 'moral injury'

Despite widespread conversations on physicians experiencing burnout, these providers often face an unrecognized threat to their well-being — moral injury, Simon Talbot, MD, a reconstructive plastic surgeon at Boston-based Brigham and Women's Hospital, and Wendy Dean*, MD, a psychiatrist and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine, write in a STAT op-ed.

Eight insights from the op-ed:

1. Moral injury is often mischaracterized, portrayed as burnout among physicians, the authors write. "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."

2. Burnout includes exhaustion, cynicism and decreased productivity — and over half of physicians report at least one of these symptoms, the authors write. "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," the authors say.

3. The authors call burnout a symptom of the nation's broken healthcare 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 healthcare ecosystem to a tipping point and causing the collapse of resilience," they argue.

4. "Moral injury" was first used to describe how soldiers responded to what they did during war, defined as 'perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations,' the authors say.

"The moral injury of healthcare 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 healthcare," the authors write.

5. Dr. Dean and Dr. Talbot discuss how most physicians choose medicine by following a calling, entering the field with a desire to help people while facing lost sleep, lost years of young adulthood, financial instability and disregard for personal health.

"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," the authors say. "Failing to consistently meet patients' needs has a profound impact on physician well-being — this is the crux of consequent moral injury."

6. As the healthcare environment becomes increasingly business-oriented, physicians must consider various factors outside their patients' best interests when making treatment decisions, the authors say. Financial considerations of hospitals, insurers and patients, for example, often lead to conflicts of interest. EHRs also overwhelm busy physicians with tasks outside of having high quality face-to-face interactions with their patients.

"Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting," the authors write. "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."

7. Healthcare executives must recognize and acknowledge this is not an instance of physician burnout to ensure compassionate, engaged physicians are leading patient care, Dr. Talbot and Dr. Dean say. "Physicians are the canaries in the healthcare coalmine, and they are killing themselves at alarming rates (twice that of active-duty military members) signaling something is desperately wrong with the system," they write.

8. Leadership must be willing to acknowledge the human costs and moral injury of the competing allegiances physicians face, and then minimize those competing demands, the authors argue.

"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," the authors write. "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 healthcare."

*Editor's note: This story was updated on Aug. 3 at 12:39 p.m. CT to include Dr. Wendy Dean as an author of the op-ed. A previous version of this article did not include Dr. Dean. Becker's regrets the error. 

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