Moral injury: The problem facing physicians

Doctors are dissatisfied and demoralized with how they are required to practice today, and as a result physician burnout is taking a huge toll on medicine. Innumerable surveys show that more than 50 percent admit to at least one symptom of burnout and that many are relocating in hopes of finding a better practice climate, or exiting clinical practice through early retirement, moving to administration, or simply leaving medicine altogether. But we contend burnout is an inaccurate diagnosis for the condition and instead, that physicians are experiencing moral injury.

Moral injury is generally defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” This concept better describes the untenable double- and triple-binds that physicians are finding themselves in, whereby the countless roles they are expected to undertake often place them in conflict with their primary moral imperative: taking care of the patient.

The underlying problem is, we are being pulled in too many directions. We took oaths to put the needs of our patients above all else, but over time that priority has eroded in the face of economic drivers in healthcare and competitive realities. Too often now, physicians must choose between the needs of their patients and the demands imposed by their employers, productivity metrics, insurance companies, mandates to reduce “leakage,” and satisfaction surveys. The patients’ needs cannot always win-and often don’t.

Physicians are not taught when, why or how to set boundaries, nor are we often encouraged or empowered to do so. In fact, much of a physician’s training contravenes establishing boundaries of reasonableness or responsibility. Lacking comfort and experience in refusing requests or setting limits, physicians fail to demand or negotiate acceptable expectations regarding tasks, responsibilities, allegiance and priority.

When asked to assume responsibility for some aspect of patient care, no matter how thin the thread tying them to that burden, physicians are usually loathe to refuse it. As a result, physicians have gradually taken on the job of data entry clerks, insurance go-betweens, educators in healthcare literacy, coders/billers, and chiefs of customer service.

As the list of responsibilities grows, doctors have not negotiated sufficient off-loads. While other providers such as nurse practitioners, physician assistants and registered nurses have assumed some patient care tasks, the ultimate responsibility for that care typically still resides with the physician. We are a hyper-responsible, control-freakish lot because legislation requires it and everything in our preparation and training has conditioned us to be so.

Not surprisingly, physicians incur moral injury in the face of these competing allegiances and, among other consequences, it is driving the physician suicide rate to more than twice that in the general population. Yet despite a decade of recognition and a rapidly proliferating industry to promote wellness, studies indicate the problem has only grown worse.

Any physician whose treatment for a patient failed so profoundly would reconsider whether the diagnosis was accurate and the treatment strategies well-aligned. In this case, the problem is that moral injury, rather than being an individual challenge with individual solutions, is actually a symptom of underlying dysfunction in the healthcare system, a dysfunction that results in doctors being torn between competing allegiances.

The systemic nature of the problems means they are not amenable to easy solutions. Nevertheless, it is essential to begin making inroads into the crisis of moral distress. The first step is to recognize the untenable conflict for physicians imposed by multiple competing allegiances in order to begin establishing boundaries around those obligations. Being caught in the double- and triple-binds of serving opposing masters is a major contributor to moral distress.

And while resilience is important for any high-intensity career, the solution in this case is not simply to train physicians to be more resilient to a system that disempowers them but to create a system in which the physician is enabled, empowered, and encouraged to do the job of taking care of the patient above all else.

In addition, we need health systems led by practicing clinicians who are committed to improving clinical care. Those leaders understand, on a visceral level, the day-to-day challenges of trying to care for patients. They understand, for example, that accomplishing a single task in an EHR might require clicking through a dozen windows and re-populating fields. They know where the EHR needs to change to improve the user experience and to facilitate care, rather than interfering with it.

Those hospital leaders also have a mandate to communicate to their physicians not just what salary they are worth, but the unique value physicians as a whole, and individuals in particular, bring to the organization. By pushing back against unreasonable insurer requests, unproven requirements of the Joint Commission, regulatory demands, pressure to adopt a retail model of care, which undermines the doctor-patient relationship, and redundant institutional requirements, clinician leaders demonstrate to their physicians that their time and efforts matter, and that they are an asset worth protecting.

Medicine also needs a robust process for identifying young physicians with leadership potential and investing in developing those skills. The military has done this for decades, largely successfully. While we are not advocating a “military” style of training, there are lessons we can learn about how to spot those with leadership talent, when and how much to invest in developing them, and what are the skills one needs to hone in order to lead effectively.

Finally, we must refuse to accept competing allegiances, nonsensical responsibilities and any solutions that erode relationships with our patients. Only by saying “no” to some of what is now asked of physicians can we begin to break the binds that tie us to moral distress and injury.

Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Dean is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine.