by Doris C. Gundersen, MD
Featured in the May-June 2019 Colorado Medicine Colorado Medicine.
For the last decade, much attention has been paid to the alarming rates of burnout among physicians. Physician health programs, medical specialty societies and hospital wellness programs have aimed to address the epidemic by primarily focusing on what the individual physician can do to prevent it: exercise, meditate, eat nutritiously, practice mindfulness, take vacations, “unplug” from electronic health records on evenings and weekends. The list goes on and on. However, the concept of burnout resonates poorly with physicians who are in fact resilient and resourceful – traits necessary for successful entry and achievement in the medical profession. More recent scrutiny of the problem has revealed that the greatest driver of burnout is our broken health care system.
Most physicians enter medicine with a deep desire to help people, a willingness to make significant sacrifices (often including a disregard for one’s personal health) and a devotion to providing high-quality care and healing to patients. However, the house of medicine’s values and morals often conflict with the priorities of an increasingly business-oriented and profit-driven health care environment. Physicians must contend with patients’ financial constraints related to the high cost of health care insurance and pharmaceuticals, sometimes limiting what care can realistically be offered. Physicians, while expected to be productive, are distracted by administrative burdens (prior authorization requests) and tasks unrelated to providing good medical care. The fear of discipline or litigation is constantly in the background. Patient satisfaction scores and online provider scores serve as additional sources of stress. The basic tenets of the Hippocratic oath conflict with the current business of health care in which the primary goal is making a profit from people who are sick, suffering and vulnerable.
The term “moral injury” historically was used to describe soldiers’ responses to their actions in war.¹
“Moral injury results when soldiers violate their core moral beliefs, and in evaluating their behavior negatively, they feel they no longer live in a reliable, meaningful world and can no longer be regarded as decent human beings.”²
Moral injury occurs when there has been a betrayal of what is right by someone who holds legitimate authority in a high-stakes situation. Moral injury is an injury to an individual’s moral conscience resulting from an act of perceived moral transgression, which produces profound emotional shame. More attention has been paid to moral injury in physicians as they experience failure in consistently meeting the needs of patients while attempting to ethically navigate intensely competing drivers.³
To stem the tide of physician burnout, compassion fatigue, depression, addiction and suicide, the concept of moral injury needs to be considered more carefully. Those in leadership positions need to recognize that conflicting and competing demands (i.e. prioritizing profit over high-quality patient care) create moral exhaustion in physicians. Eliminating or at least reducing some of these demands is one way of caring for physicians, which translates into better patient care and good business.
2. Rita Nakashima Brock and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War, 2012, p. 15