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SURGICAL PERSPECTIVES

Stopping the Progression of Moral Injury

A Priority During Surgical Training

Lillemoe, Heather A. MD; Geevarghese, Sunil K. MD, MSCI, FACS

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doi: 10.1097/SLA.0000000000005153
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“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.”

René Leriche, La philosophie de la chirurgie, 1951

WHAT IS MORAL INJURY?

Moral injury was first described by Vietnam War veterans who felt their morality had been threatened by psychological trauma they had endured. These individuals were thought not to be experiencing posttraumatic stress disorder, but rather an insult to their own morality. For surgeons, moral injury may occur when we observe or fail to avert an act that breaches the deeply held moral belief of putting patients first.1 We experience moral injury when our patients develop complications that result from our work. Moral injury is not limited to medical error but may also arise when complications occur in the process of standard care. In this article, we describe how surgeons experience moral injury, discuss how it can progress to second victim syndrome and burnout, and highlight ways to prevent this progression.

HOW SURGEONS EXPERIENCE ADVERSE EVENTS

Nearly every surgeon will experience a major patient adverse event such as an intraoperative complication, postoperative hemorrhage or leak, or even death. Each surgeon experiences these in a different way. Through interviewing surgeons and using a grounded theory approach, Luu et al characterized four phases through which surgeons experience adverse events (Table 1).1 During Phase 1, or “The kick,” the surgeon experiences “a visceral blow to their core.” Surgeon-specific quotes describe sentiments of failure and self-loathing accompanied with physical symptoms of tachycardia and unease. Phase 2 is described as “The fall,” or “a feeling of spiraling out of control co-existent with a need to ‘right themselves.”’ This phase contains many components, including grief, explanation-seeing, and hope. In Phase 3, “The recovery,” surgeons cope with the complication. Importantly, most surgeons rely heavily on peers and discussing the event with others. The final, and perhaps the most important and variable phase, is “The long-term impact.” It is during this last phase that participants describe the cumulative impact of their adverse events. Surgeons discussed both personal growth and personal loss. One surgeon described “a piece of them being taken away with every complication.” The final phase of the surgeon experience can go one of two ways. Some surgeons ultimately create a positive outcome out of negative events and others slowly and cumulatively suffer.

TABLE 1 - Phases of a Surgeon's Response to Adverse Events. Adapted From Luu et al2
Phase Description Verbal descriptions
The kick A visceral blow to the core “There's some tachycardia and some unease. …there's still that anxiety.”“I was so distraught.”“It's like I failed.”
The fall Combined feelings of spiraling out of control combined with a need to “right themselves” “I couldn’t sleep without thinking about it…I grieve for how badly it makes me feel.”“I relive the operation and I go through the critical parts of the operation.”
The recovery Coping with the event “If you don’t get up, that's slow suicide or termination of what you do for a living.”“I’ve written a lot of SOPs [standard operating procedures]. …maybe that's my coping mechanism… how I can do it better…”
The long-term impact The cumulative effect of complications “… a piece of them being taken away with every complication.”“It makes me I think more appreciative of the tremendous distress it causes and I think that I react to that. …I think I engage it and try to make things better for the patients.”

PROGRESSION FROM MORAL INJURY TO BURNOUT

Over time, continued exposure to moral injury can lead to second victim syndrome (SVS) and burnout. A useful medical analogy is a patient who has repetitive renal insults due to long-standing, uncontrolled hypertension (moral injury), which leads to chronic kidney disease (SVS), and ultimately progresses to end-stage renal disease (burnout). “Second victim” is a term used to describe the impact of adverse events on medical professionals.2,3 Although some may take issue with the use of the term “victim” since it could imply intentionality or violent harm, it is an established term used by the Joint Commission and it seizes the attention of health care workers and policy makers. Moreover, it acknowledges the suffering of the clinician.4 The clinician as second victim feels personally responsible for the adverse patient outcome, as though they have failed the patient. A surgeon may feel humiliation and question his or her confidence and reputation.3 A recent cross-sectional study of surgeons at 3 Boston academic hospitals found that the vast majority of surgeons (>90%) have dealt with intraoperative adverse events.5 Themes stemming from the qualitative data in this study revealed a perception of peer scrutiny and a lack of support after adverse events.

It is through this lonely suffering that burnout related to moral injury may arise. Burnout is defined by Zhang et al as “a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment.”6 It is multifactorial, and while in part stems from an excessive workload, administrative burden, and the electronic medical record, the impact of repeat moral injury and weight of the “zero harm mentality” cannot be ignored.7,8 With the growing emphasis on surgeon outcomes and patient safety over the past decade has come greater scrutiny of the individual surgeon. When our clinical missteps are instantly noted and at times put on display, moral injury can be exacerbated.

HOW TO PREVENT PROGRESSION BEYOND MORAL INJURY

Education about moral injury must occur early to prevent its progression to burnout. Two major barriers to education and intervention include stigma against admitting moral injury and the hierarchy inherent to surgical culture. The stigma associated with moral injury may be linked to the mental health stigma. Both forms of stigma share an intense sense of shame and self-perceived inadequacy. Although all would agree that complications happen, admitting moral injury related to complications may be conflated with weakness. While trainees have some protection from moral injury given the oversight provided by faculty, they still experience it. The hierarchical format of surgical training creates a dynamic where those with the least amount of power often do not feel comfortable sharing feelings such as stress, shame, or sadness. It often places senior surgeons in a vaunted position. Protective equity and insulative respect acquired over a career of complex cases and good outcomes may shield attending surgeons making them seem impervious to moral injury.7 This may reduce the comfort that trainees have with seeking help.

At our institution, to address the adverse impact of stigma and surgical hierarchy, we have instituted Moral Injury Small Group sessions, led by faculty members of the Vanderbilt Resilience Rapid Response Team. Created in 2017, this team is comprised of both faculty and residents who have undergone specialized training by our Employee Assistance Program staff to identify early signs of moral injury, SVS, and burnout and provide resources to those at risk. During these sessions, attendings discuss their own voyage through moral injury openly with residents. In discussing examples of situations that have led to their own moral injury, attendings help destigmatize moral injury and simultaneously dissolve hierarchical barriers to discussing it. Currently, the sessions occur approximately three times per year during regularly scheduled resident teaching conferences. Based on qualitative feedback, residents appreciate the openness and vulnerability exhibited by faculty leaders. One resident stated the sessions were “helpful to address that we are all harsh critics of ourselves” and that they provide “ways in which we can alleviate that pressure through shared experiences.” This simple intervention has started to normalize the discussion of adverse events and the impact they have on resident well-being. Proposed future directions include incorporating education and support related to moral injury into our program's current mentorship efforts for junior faculty. We believe junior faculty are at high risk for progression to SVS with repeated moral injury during a period of their professional lives when, for the first time, there is no supervising attending to bear the force of moral injury. Our hope is that increased awareness and support related to moral injury during training and early career stages can help mitigate its potential negative downstream effects.

Another successful intervention to minimize progression include the Second Victim Peer Support Program has been described by Bohnen et al It identifies surgeons who are at risk of SVS after an adverse event. In a confidential manner, trained peer supporters reach out to the individual, offering conversation and resources.9 This program applies to both trainees and faculty members, and both groups are included as peer supporters. Similarly, the American Society of Transplant Surgeons (ASTS) has created the first specialty society-based approach, the ASTS Peer Support Network, as a benefit to its members. Self-referrals and anonymous submissions are kept strictly confidential. ASTS staff then pair individuals with the main goal to perform emotional first aid followed by other resources as needed to the affected member. Each member of the Network undergoes training by Dr. Jo Shapiro of the Center for Professionalism and Peer Support at the Brigham and Women's Hospital of Boston, MA. They have had their own experiences with moral injury and are willing to share their own pitfalls and challenges to commiserate and support fellow surgeons.10 These programs are just a few examples of educational and interventional initiatives targeting the moral injury associated with a surgical career that may help prevent subsequent burnout.

FINAL THOUGHTS

Moral injury frequently arises as part of the work we do as surgeons. While moral injury comes with the territory, burnout does not have to. Interventions such as moral injury small group sessions and post-injury peer support networks can destigmatize moral injury and break through hierarchical barriers. We assert that it should be a priority to openly discuss moral injury during surgical training to mitigate progression to SVS and burnout.

REFERENCES

1. Luu S, Patel P, St-Martin L, et al. Waking up the next morning: surgeons’ emotional reactions to adverse events. Med Educ 2012; 46:1179–1188.
2. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726–727.
3. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009; 18:325–330.
4. Wu AW, Shapiro J, Harrison R, et al. The impact of adverse events on clinicians: what's in a name? J Patient Saf 2020; 16:65–72.
5. Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston intraoperative adverse events surgeons’ attitude (BISA) Study. J Am Coll Surg 2017; 224:1048–1056.
6. Zhang LM, Cheung EO, Eng JS, et al. Development of a conceptual model for understanding the learning environment and surgical resident well-being. Am J Surg 2021; 221:323–330.
7. Aloia TA. Should zero harm be our goal? Ann Surg 2020; 271:33–36.
8. Patti MG, Schlottmann F, Sarr MG. The problem of burnout among surgeons. JAMA Surg 2018; 153:403–404.
9. Bohnen JD, Lillemoe KD, Mort EA, et al. When things go wrong: the surgeon as second victim. Ann Surg 2019; 269:808–809.
10. Geevarghese SK, Pomfret EA. Peer support networks: a local approach to the issue of moral injury in surgical training and practice. Can Urol Assoc J 2021; 15: (6Suppl): S33–35.
Keywords:

burnout; moral injury; second victim syndrome; surgical residency

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