All Specialties Struggle With ‘Moral Injury’

Derick Alison
Derick Alison
16 Min Read

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    Emily Hutto is an Associate Video Producer & Editor for MedPage Today. She is based in Manhattan.

In this exclusive Instagram Live clip, Jeremy Faust, MD, editor-in-chief of MedPage Today sits down with Wendy Dean, MD, president and co-founder of Moral Injury of Healthcare, and Adam Brown, MD, MBA, founder of ABIG Health, to discuss moral injury and burnout in healthcare.

The following is a transcript of their remarks:

Faust: Thank you both for joining us on MedPage Today. This session has a long title, but it’s really about moral injury. I just want to tell everybody an example of how I think of what moral injury is.

I’m an ER doctor. I’m talking to a patient’s family about some really bad news, something that’s really hard for everybody involved. I do something that’s quite hard for an ER doc to do: I sit down, I close the door, and I have a conversation with them. Then, I realize that there’s a knock on the door and someone says, “Hey, Dr. Faust, there’s a patient who’s coding in bed 35, you gotta go.”

Now, I have to decide between literally telling this patient — I just told them they have cancer or something that’s really devastatingly bad that I can’t wait to tell them, and now I have to step out of the room and go do something else. I don’t know, it’s [like] no matter what I do, there’s no good answer because it goes against my ethics either way. I can’t stop a conversation, but I can’t also prevent myself from going to help someone in need, and there’s no way out.

So the harm that’s done to me as a physician is another pile-on, in addition to what the patients are experiencing. So that’s my feeling of what this is. I want people to understand what it is we’re talking about, like how we can provide the best care.

Dr. Dean, did I get that right? The vignette that I provided, is that sort of a decent example of moral injury?

Dean: I think it is a good example.

The one thing I would add to that is that we know that there are always difficult decisions to make in medicine. What I would see as primarily driving that moral injury is if you know that you’re understaffed, for example. If that is what’s presenting the challenges where you’re constantly having to make that decision because you don’t have sufficient staffing in the emergency room to manage the patients that come through.

Faust: OK, so the distinction there is, OK, we work in medicine, we don’t always have control over everything in our lives. So there are some things where we just — what are you going to do, right? I mean, you have 10 patients who are crashing and you’ve got to go one at a time. But that’s different than if you have two patients crashing and there are supposed to be two docs and there’s only one because someone’s trying to save money.

So it’s really about whether we process it as something that was an “own goal,” so to speak, something that we created, the system created, rather than just life. Is that the distinction?

Dean: Yeah. Really the crux of moral injury is betrayal. It is that sense of someone is causing you to betray your oath or to repress your oath because of some other need that doesn’t focus on the patient. Right? We make a pledge to take care of our patients to the best of our ability without self-interest, and then we’re constantly asked to put the interest of some other entity before the needs of our patients.

Faust: Yeah. And Dr. Brown, let me have you hop in here. How would you define this term? Would you add anything to that?

Brown: No, I think you really defined it well.

Let’s say you Google on the internet: what’s moral injury? Sometimes people will describe it as this big event that’s a singular type of event [where] you saw something that conflicted with your values or your beliefs.

But as we’ve all talked about, it’s more of an incremental — especially in healthcare — an incremental, continual type of assault that happens to your psyche and to who you are. Then over time, that starts to have — and I’m sure we’ll talk about it more — a significant number of ramifications as we go down the line.

To your earlier point, I think many of us entered into medicine with an idea of what it would be like, but there’s this expectation mismatch between what we expected it to be and what the reality of what we end up seeing in practice.

As I talk with medical students, very few of them recognize the administrative burdens that they will have to undertake to care for a patient. Yes, they may have to document in an EMR [electronic medical record], but very few of them are getting calls from quality or from the coding department or having to sit before peer review because something was missed or facing a lawsuit.

You start to add up those sorts of things, and what ends up happening is it becomes an assault to who you are and to who we have… as physicians, many of us have personalized our profession into our entire being. That’s where you start to get really a true injury to who we are as a person. Then, of course, the ramifications follow.

Faust: Yeah. I actually really like this point about — it’s almost like an original sin. The way medicine looks from the outside or how it’s portrayed on television and how it’s portrayed even in our writing — I read a lot of books by our colleagues — and, yes, people are very open and honest about things, but there’s also some degree of hagiography. Like, “Oh, it’s a great calling.” It’s all the fantasies you have about what it’s like to be a physician, but it starts early, this idea that it’s a calling as opposed to a profession. Well, it could be both, right? I don’t know.

Dr. Dean, do you think in a way it’s almost like we’re setting ourselves up for this or the culture sets us up for this because of how medicine is portrayed to young people?

Dean: I think it’s partly how it’s portrayed, but I also think it’s how we’re trained and the standards to which we’re held. So all of that put together creates this sense that we can do no wrong, that we can’t make mistakes, that we’re not human, and that becomes internalized into part of our identity.

I wrote that it’s who we are when we don the mantle of physician, it prescribes our choices and it becomes entwined with our identity. I do think that there are ways that we could make that less so, so that these ideals of a physician are still noble and in the patient’s best interest, but they don’t so much overtake our identity.

Faust: Yeah, I’m curious to hear both of your perspectives on — let’s use a quasi-hypothetical. It’s not that hypothetical, it’s real, but I’ll just try to explain. For me personally as an ER doc, I am still wearing a N95 mask every time I’m anywhere near a patient, and even almost all the time I’m in the hospital. I mean, I’ll take it down for a few seconds here and there. Because I truly believe that we have spread all kinds of viruses to our patients since time immemorial.

The one thing that we should have learned from this pandemic is that actually, we are much bigger vectors for spread than we realized. So I do this, but now we don’t have to. So a lot of my colleagues are tired of wearing the mask or they wear a flimsy little thing or not at all.

Now I feel like, oh gosh, are we killing patients? And yet I go to work and I have to do this thing. My response to it is to say, “OK, well for me, I’m going to wear the N95, that’s what I’m going to do.” But what am I supposed to do? Am I supposed to cry bloody murder to my admin? This thing, this new policy, goes against what I have come to believe, which is that we need… it flies in the face of that.

So Dr. Brown, what do we do? I don’t want to get fired. I don’t want to be the pain in the ass doc. But I also feel like this is nagging at me.

Brown: Well, I think what you’re highlighting is actually a broader issue that we’re facing on a more macro level. It’s that you’re seeing a problem or an issue, but the societal responses — even to masks or to vaccinations — are so antithetical to what we’ve been taught and what we know to be true, and that in and of itself starts to become an injury to you.

So for example, you were asking before about some of the reasons that we’re seeing this or how you would describe moral injury. Personally, being also a business school professor, I see profitability as one of the biggest drivers of creating problems within the system to create moral injury.

Now granted — there’s no margin, there’s no mission. You have to have a certain level of dollars within the system to make the system work. But when you ask physicians what are some of the drivers and the things that are making them unwell, it’s staffing, it’s the EMR, it’s the prior authorizations. Every single one of those issues ladder back up to a desire for intense profitability on the corporate level.

So when you take your situation as a mask, your frustration in that individual environment, and then you say, “Well, why is this happening?” A lot of the reasons why it’s happening is because on a broader societal level, there is frustration with this virus and we’re just tired of it. When you ask why are things with the EMR happening, it’s a broader societal issue that we believe in profitability as a healthcare system.

So what ends up happening, Jeremy, is you become the frustrated individual who goes and talks to administration and using your own words, then you are perceived as the person that’s the pain in the ass, when really it’s a bigger issue, much more outside of yourself.

The antecedents to moral injury, the antecedents to depression and burnout and all these other things are really much farther removed than sometimes what you’re seeing individually on the ground.

Faust: And Dr. Dean, outside of the ER — because that’s one thing that Dr. Brown and I have in common — it kind of comes up in a different way. I feel like one of them is this administrative fight about prior authorization and not being able to get your patients what they need. But I’d be curious to hear from your perspective on the outpatient side and mental health side some of the major examples of where this is happening.

Dean: I think the understaffing that you feel, the challenges with the EMR, they’re the same across the board. Prior authorization is a big issue, for sure. Scheduling in the outpatient world is a huge issue. Not being able to control how patient flow works in your clinic, even though it’s very different in ob versus orthopedics versus plastic surgery. Those simple things that clinicians should have a handle on and should be able to influence they find are out of their control, because a scheduling program gets put in place and it’s concretized. They can’t change it. So there are innumerable ways that this happens.

Faust: I feel like these are the right specialties — emergency medicine and psychiatry are two of the bigger ones — where you can easily grasp onto where these challenges hurt not just the patients, but the clinicians.

But are there other fields in your experience that are really hurting with this? I mean, obviously all of them have the EMR and the staffing issues, but I’m curious if there are some that are worse than others.

Dean: I honestly haven’t found one that’s not struggling with it. Neurosurgeons, orthopedic surgeons, plastic surgeons, pediatricians, primary care physicians, nurses, physical therapists — it’s across the board.

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