I'm struggling, but I'm not burned out. I love taking care of my patients and doing clinical work. It's everything that gets in the way that I find intolerable.
—Anonymous physician
Almost all of our colleagues are experiencing some level of distress, but most reject labeling it burnout. They used the term because they had no better way to frame what they felt.
We first began talking to physicians, nurses, and other health care professionals about their experience five years ago. One thing was clear: They resented the intimation that they were the problem, that they were not resilient, efficient, or resourceful enough to manage their demanding careers.
One study validated their resilience, concluding that even “significantly higher resilience scores than the general employed US population” did not protect physicians from burnout. (JAMA Netw Open. 2020;3[7]:e209385; https://bit.ly/3HFOCnf.)
Decades of research and countless interventions like meditation, sleep, and exercise borrowed from the $4 trillion U.S. wellness industry have barely budged burnout statistics. A good physician reconsiders the diagnosis if repeated interventions fail to resolve a patient's condition. It is time to do the same with the crisis of distress in health care, which was exacerbated by the pandemic but certainly not caused by it.
What's Really Going On
Burnout is a constellation of symptoms most physicians can probably recite—emotional exhaustion, a sense of ineffectiveness, and depersonalization or detachment. But the term fails to capture the sentiment we have repeatedly heard: Physicians' greatest distress stems from their inability to get their patients the care they need, or, as Ed Yong put it, health care workers “can't handle being unable to do their jobs.” (The Atlantic. Nov. 16, 2021; https://bit.ly/3HKM9YT.) It is “the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control,” as we noted three years ago. (Fed Pract. 2019;36[9]:400; https://bit.ly/3N5vRL5.)
Reframing the distress as a systems failure rather than the lack of character implied by the label burnout resonates powerfully with physicians. Individuals risk moral injury when they are faced with “[p]erpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” (Clin Psychol Rev. 2009;29[8]:695; https://bit.ly/3b3eIo2.) Those deeply held moral beliefs in health care are the oaths physicians take, whether explicit or implicit, always to have patients as their priority.
Moral injury in health care is knowing a patient needs a medication, test, or intervention, only to spend hours on the phone trying to get authorization and failing. It is the nurse whose unit is regularly understaffed who knows she will have to choose again between doing an hour of documentation or checking on the patients she hasn't seen for an hour. It is the physician who must break the news of a cancer diagnosis to a patient, knowing the time she has with him is inadequate to allay his fears.
Solutions directed at individuals are appealing because they are quick and uncomplicated and require less engagement by already strained systems. These are essential support, but they have failed as stand-alone interventions and will continue to do so. Addressing moral injury will require a long-term commitment to lasting change with interventions at multiple levels nearly simultaneously.
Physician distress is at crisis levels. Initiatives to support individuals who are acutely struggling and overwhelmed are a given, but they are Band-Aids for multitrauma and insufficient as stand-alone interventions.
Organizations must also recognize the plethora of operational barriers to effective, efficient care and address them methodically. The starting point is soliciting feedback from those who make up the workforce about what challenges they face every day, keeping in mind that asking for feedback and not following through on change only magnifies the betrayal they already feel.
Treating Moral Injury
Organizations are having a powerful moment. The workforce is eager for change and action. They know what health care systems can do with the right motivation because they saw field hospitals spring up overnight and telemedicine explode during the pandemic. They are, however, waiting to see if their own well-being will motivate leadership to pivot to cultures of psychological and physical safety, where they are valued for their ideas and for speaking up, where their leaders have their backs and give them top cover.
Health care is complex, as are the solutions to its challenges. Overwhelmed organizations, though, continue to look for simple approaches with modest operational impact—a weekend course, a retreat, or online learning—but fixing moral injury is about the culture and commitment of each organization to treat patients the way they wish to be treated.
Creating that culture will not happen in an hour, week, or month but when executives and front-line physicians commit to working together. The best starting point for that kind of change is a culture of curiosity (asking physicians what they need to be successful), coproduction (creating collaborative solutions), and community (success depends on physicians and executives thriving), where all levels of the organization are engaged with building better, including:
- The C-suite: Engagement and champions at the highest levels of the organization are the engines of change and models of culture and behavior for the workforce.
- The connectors: Managers, the liaisons between the C-suite and the front-line physicians at the coalface of patient care, are ideally situated to recognize patterns and cut across silos in the organization.
- The physicians at the coalface: Those who care for patients are eager for new approaches. Inviting them to offer solutions will leverage significant energy within the organization, increase engagement, and give them a renewed sense of ownership.
Dr. Deanis a psychiatrist, writer, speaker, podcast host, and president and founder of Moral Injury of Healthcare, a nonprofit organization that provides training and consultation to organizations focused on alleviating distress in their workforce. (www.fixmoralinjury.org.) Dr. Talbotis an associate professor of surgery at Harvard Medical School and a surgeon in the division of plastic surgery and the director of the upper extremity transplant program at Brigham and Women's Hospital in Boston. He is also a founder of Moral Injury of Healthcare. Follow Dr. Dean on Twitter@WDeanMD, Dr. Talbot@simontalbotmd, and their organization@fixmoralinjury.
