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I spent several hours last year at a CME event required by our hospital system. The topic was physician burnout, and a midlevel mental health provider gave a lecture on how to take care of ourselves. She suggested that we practice meditation, exercise regularly, eat healthy foods, spend more time with family, and take mini-breaks during the work day. One of my partners across the room texted me, “I could be doing some of those things if they didn’t require me to be sitting here all evening.” It seemed that the system was part of the problem.
In a widely quoted piece, Simon Talbot and Wendy Dean explained why physicians like me don’t appreciate advice on how to manage work stressors. They wrote, “The concept of burnout resonates poorly with physicians: It suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work.”1 Advice about how to combat burnout feels condescending. Even worse, it suggests that the physicians are somehow responsible for the problem.
Talbot and Dean suggested that burnout isn’t the issue. Instead, they argued, it is a symptom of a larger problem they describe as “moral injury,” which arises from a conflict of values. Moral injury—which is similar to post-traumatic stress disorder—was initially described in war veterans, and it results from “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs.”2
As for physicians, we took an oath to put the needs of our patients first, yet we face competing demands from an increasingly profit-driven and complex system. Insurance companies, pharmacies, pharmacy benefit managers, private equity firms, and pharmaceutical and device companies strive to enhance quarterly profits. We work within this system for the interests of the individual patient, and this puts the ophthalmologist in the center of a conflict.
Could this conflict cause moral injury in physicians? I thought of some examples which suggest that it does.
Shortly after my practice implemented Epic, I developed neck and back pain from craning to look at patients. But could the real issue be something deeper than my physical symptoms—and the solution more profound than the need for a massage or a scribe or a tablet? Ophthalmologists observe the facial expressions and body movements of the patient sitting in the exam chair. However, the emergence of EHRs has diverted our thoughts from the patient to the screen. Is it possible that EHRs are competing for our attention and that the patient is no longer our primary concern? Could this cause a moral injury?
One of my patients has a worrisome visual field, and I recommended magnetic resonance imaging of the brain and orbit. However, he can’t afford the test. Does the hospital system charge too much for the MRI? Is the insurance plan shifting too much cost to the patient? What if he has a tumor and can’t afford additional testing or treatment? What is my malpractice risk if no MRI happens? It’s my job to negotiate a solution for this patient, and I worry about him when I’m at home. Perhaps, as Talbot and Dean wrote, “Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting.”
Perhaps moral injury develops from the steady accumulation of conflicts like these. And while wellness strategies may address some symptoms of burnout, they won’t solve the problem of moral injury.
Let’s expand the conversation about physician burnout to include specific dysfunction in the health care system. Instead of leaning heavily on “physician, heal thyself,” let’s also discuss ideas about how to protect the physician/patient relationship. (One example is the Academy’s push to end prior–authorization abuses by Medicare Advantage plans.) Working together on a common goal contributes to moral healing.
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1 www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury.
2 Litz BT et al. Clin Psychol Rev. 2009;29(8):695-706.