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 can be 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.
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, according to the Department of Veterans Affairs, “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 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 ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician well being — this is the crux of consequent moral injury.
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, driving 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. Patient satisfaction scores may have the unanticipated consequence of driving inappropriate care where physicians feel unempowered to speak ‘hard truths’. Electronic health records track productivity and business metrics, but significantly reduce face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and overreact to results — at times actively harming patients to avoid lawsuits.
Navigating an ethical path among such intensely competing drivers is 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 demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These incessant betrayals of patient care are “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 were 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 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, hiring corporate wellness officers, or pushing solutions onto providers with resilience training or flexible schedules won’t solve the problem. We should not need Code Lavender teams in major medical centers, dispensing the types of support first responders provide in disaster zones, just so physicians can get through the day. 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. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially-responsible decisions.
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 know their physicians are, almost literally, dying to take care of them. Patients must take back the relationship with their physicians from those who control it now—from the hospital employers, insurers, and healthcare systems.
In these ways we can stop the cycle of moral injury inflicted by the business of health care and start healing physicians and their patients.
Simon G. Talbot, is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine. This article is adapted from STAT.