Defining Moral Injury and Its Impact on physicians

Mar 3

We often talk about burnout in medicine and how many people suffer from it. Some hospitals have a wellness program or a wellness officer in order to improve the mental well-being of its staff. Many medical schools offer mandatory “wellness” lectures and encourage students to make time for exercise, meditation, yoga, or other mindfulness-based activities. But guess what? None of that matters, because our problem is not burnout, it’s moral injury!

Moral injury is defined as “a strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code” (Litz, BT. et.al., 2009). These events, if not processed appropriately, can lead to feelings of shame, guilt, and changes in an affected person’s perception of themselves. Further, as a way of coping with the event, many students and physicians can find maladaptive coping behaviors such as substance use disorder (SUD), major depression disorder (MDD), generalized anxiety disorder (GAD), and/or self-harm. Moral injury is often seen in trainees as feeling exhausted, feeling more cynical or disinterested in their work; all of which leads to decreased productivity.

Did you know that we lose about 400 medical students, residents, fellows, and attending physicians every year to suicide? The American Foundation for Suicide Prevention (AFSP) notes that the suicide rate in male physicians is 1.41 times higher than the general population and for women, the suicide rate is 2.27 times greater than in the general population. The AFSP tried to warn medical administrators about this back in 2002 when 15 mental health experts met in Philadelphia, PA to evaluate the “state of knowledge about physician depression and suicide and barriers to treatment.”

They went on to issue the following statement:

“The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians' seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.”

20 years later, I am not so sure that we have that much progress. 28% of residents experience a major depressive episode versus 7-8% of non-physicians of the same age. The AFSP believes that the leading factors for these statistics include increasing unsustainable workloads, work inefficiency, lack of autonomy, and work-home conflicts. The long-term effect of these issues lead to many administrators and PDs/APDs putting trainees and physicians on probation, performance improvement programs, or misdiagnosing the behavior as ‘professionalism’; they do not realizing that the physician’s performance is secondary to a much bigger problem.

A 2021 article in The Lancet: Psychiatry shared that the most common cause for moral injury in all healthcare workers right now is the broken healthcare system in the U.S. This has also been reinforced by the U.S. Department of Veteran Affairs and the National Center for PTSD. In a system that has become increasingly capitalistic with more private equity companies taking over healthcare, it’s no wonder that moral injury is increasing given that most physicians look at their work as a calling and personal mission, not just a job. In the last decade, private equity ownerships of specialty practices, nursing homes, and EDs has tripled, with the firms collecting over $750 billion over the last 10 years. A 2021 study showed that when private equity firms take over nursing homes, there is a 10% increase in mortality of those residents due to decreased nurse to staff ratios, and diverting patient care funds to private equity owners. We saw this time and time again during the height of the pandemic. Private equity owners have also started to extend their reach in dental care; just Google “private equity and dentistry” and see what comes up. One of the first stories that appears is about Zion Gastelum, a 2-year-old from Arizona, who in 2017, died of brain damage after undergoing root canals and having crowns put on 6 baby teeth at Kool Smiles Dental Clinic. It was later found that the practice had been overtreating children from lower income families on Medicaid as a way to boost profits.

Hospitals and clinics continue to blame “staffing issues” for the lack of good healthcare available when there are plenty of people out there willing to work, but only under humane conditions. This leads to residents, fellows, and physicians having to work even harder than they already are on tasks that leave them unsupported and inefficient. Other sources of moral injury I believe contribute to the declining mental health of our medical trainees and physicians, just from my experience include:

Not being able to get necessary tests and imaging for patients due to insurance pushback
Productivity based pay leading to shorter visit times so that physicians can get bonuses that ultimately go back to paying down astronomically high school loans
Short patient visits that don’t allow physicians to conduct thorough histories and exam, thereby increasing the risk of misdiagnosing patients and/or providing expensive and unnecessary treatments
Patient satisfaction scores that induce self-blame, resentment, and shame in a system that doesn’t support giving physicians enough time to thoroughly examine and listen to their patients
Increasing demands of patients with new found access to their physicians through online scheduling and portal systems
Understaffing
Inefficiency of office workflows and EHR systems

And through it all, we think we can push through. We think we are resilient, tough, and intelligent enough to extricate ourselves out of the messiness of moral injury, but we just can’t. Eventually we fall, and we fall hard. Unlike burnout, which is something that I believe we have more control over, when it comes to moral injury, we are witness to system failures that don’t allow us to practice in a way that not only protects and heals our patients, but also nurtures our calling and desire to help others. All the aforementioned bullet points are issues that hospitals, administrators, and now, private equity firms have control of; this takes the autonomy and ability to take care of our patients out of our control.

I actually resent the term ‘burnout’ because it implies a failure of our resilience, knowledge, and resourcefulness that we worked nearly a decade, or more, to hone. This also disrespects the years of sacrifice and missed milestones, as well as the immense financial debt, that has accrued from our training.

Ultimately, massive institutional and medical cultural changes are desperately needed, but what we need NOW are hospital leaders that not only care for their patients, but also for their physicians, APPs, and all other healthcare staff. We need these same leaders to give physicians the autonomy to see patients and trust that they will make rational, evidence-based, and fiscally responsible decisions for their patients. We need to return medicine to what it once was for hundreds of thousands of doctors, a calling.

Final Thoughts

Stay tuned for when I share what some of the most important institutional changes have been found to improve patient care, increase physician mental well-being and decrease the impact of moral injury.