We need to address moral injury in healthcare — for ourselves and our institutions

“As physicians we so often feel we aren’t enough. We’ve seen too much. We know the disease is stronger than the cure, we feel the deck is stacked and that we can’t possibly win. We frame our losses and successes in terms of the disease, which is a mistake. The language alone implies a battle and a clear outcome, a victor and a loser.” — Rana Awdish, In Shock

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From the National Academy of Medicine https://nam.edu/initiatives/clinician-resilience-and-well-being/

From a recent Medscape survey: “About two thirds of US physicians (64%) said that burnout had intensified during the crisis (70% of female physicians and 61% of male physicians said it had).” A recent single center survey by Gomez et al of 481 critical care professionals at the University of Pennsylvania revealed that burnout and professional fulfillment went from 35% and 58%, respectively, pre-pandemic (prior to March 2020), to 57% and 38%, respectively during the pandemic. And we have seen numerous narrative reports, video interviews in the news (see the poignant interview with Joey, a Montana nurse at this link. The New York Times story of Dr. Lorna Breen, and emergency physician from New York who took her own life during the pandemic was particularly devastating. Not only is the virus taking lives — including those of over 1700 healthcare workers — but the impact of the virus has led to talented physicians taking their own lives.

Not physician burnout, but moral injury

Burnout is a long term stress response, characterized by emotional exhaustion, depersonalization, and reduced sense of effectiveness and personal accomplishment. It leads to many downstream issues, from depression to increased medical errors, to physician turnover at medical practices, and, as noted above, even suicide. This term “burnout,” is problematic, as it places the burden of this issue on the physician him/herself. Solutions become centered on the individual: get sleep, do yoga, meditate, and exercise, and you’ll get yourself better. And while these are good advice, and in fact, essential, they ignore the fundamental issue that we face. The system and external circumstances beyond our control that are contributing to this situation.

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From Dean W et al. Federal Practioner 2019.

A more apt term has been coined for this, that of “moral injury.” In the words of Dr. Wendy Dean and colleagues, “moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” The challenges that healthcare workers have faced for years include conflicts between focusing on the patient, the hospital, the insurer, the EMR, the system, and our productivity metrics. And now in the midst of the pandemic, healthcare workers responded to the crisis of high numbers of critically ill patients, lack of PPE, lack of a unified public health strategy in the USA, battling misinformation propagated by the current occupant of the White House and shared rampantly on social media, and moving into crisis mode, and Dr. Wendy Dean describes what happens on a podcast with zdoggmd.com. We are forced to compartmentalize the overwhelm, bottle up our emotions around it, so that we can take care of our patients in a crisis situation in the mission critical moments. In the interview she also describes how when the dust settles just a little bit, it is then that healthcare workers will be hit by their feelings of overwhelm, and processing all the emotional trauma that we have experienced. It is in the downtime, when one is out of the fray that these emotions can sneak up on you.

Moral injury is real

I’ve seen the manifestations of moral injury in my friends and colleagues, and I’ve felt it in myself. I came back from New York City with this desire to make a difference, start impactful research to make a difference in COVID-19. I secured funding from a donor for a project, a lifeline to work on something meaningful in addition to clinic, but let myself be stymied by senseless bureaucratic barriers to enact this project. Furthermore, while trying to do this our non-COVID clinic and service got busy again, and we all struggled with losing some of our longstanding, and long-loved patients, and these losses hit me on an emotional level for which I was not prepared. It was decimating. During my two separate weeks of vacation I used the time to catch up on writing and emails just to get back to the water’s surface (because I had had no energy to do this on nights and weekends while dealing moment to moment with taking care of patients). There was no break. I did not take real time to recharge. Because of that, for the past two months have been just trying to take the best care of patients, meet my RVU expectations, and just get through each and every day. I struggle with exercising regularly. I’ve lost a little piece of myself that once was a part of how I expressed my love for life: riding my bike. I keep telling myself: Once I get this project done, my life will improve. Just clear out the task bucket or the email inbox, and then I’ll have space again. If I try to dial back a little bit on clinical work to write and get these academic projects completed, I risk that patients will be kept waiting, or referring physicians won’t be able to get their people seen in the short time needed when patients have a progressive disease. So I still struggle with writing my articles and submitting my revisions, because I struggle finding the energy on my mornings and weekends that I once had. These are my own internalized pressures, and my own goals for growing, yet with each day that I do not achieve them it’s another day I feel I don’t make an impact, and thus have felt completely deficient, under-performing every single day. I had a moment several weeks ago where I told my friend how I could understand how physicians get burned out and even seek to escape through suicide. Although I was not contemplating it myself, I felt a sense of empathy around this problem I had not ever felt before, and that feeling in and of itself frightened me.

Some might say, ask for help, ask for more assistance from your colleagues. But what do we do when we see so much of the same fatigue, exhaustion and suffering in our colleagues? How do we ask for help from others when we are all exhausted, and with the social distancing of the pandemic, more isolated from one another.

Moral injury requires institutional change, but right now we must help each other

Ultimately moral injury and the burnout crisis will take fundamental change within instructions. It takes incorporating employee wellness in the mission statements of the practices. Most mission statements for hospitals and clinics are completely patient-focused, and so this culture continues to encourage the sacrifice of the healthcare workers and our health for the good of the patient. It takes adding a wellness officer type position to an institutional adminstrations, and putting these issues front and center for the institution. These are big changes that need to happen, but take time to implement, and again, and like many of our colleagues, the institutions themselves are in crisis mode.

So what can we do for ourselves and each other during this pandemic? What can we do immediately, like today — now? Focus on the things we can change in our own lives, the lives of our friends, and perhaps our smaller circles in hospitals and clinics. We need to check in with our colleagues. In the words of Dr. Awdish from her book, In Shock, she puts it so well:

“If we are honest and allow ourselves to see death for what it is, an inescapable inevitability, then our story can change. In that light we can accept that our greatest gift is not in fact healing, because all healing is transient. Our greatest gift is, in fact, our ability to be absolutely present with suffering. To allow it to transform us, and, by holding the suffering of others, transform it for them as well.”

Perhaps by reaching out to one another we can be present with our suffering. We need to connect with each other and talk about these issues, our difficult cases, share our emotions, and listen to each other with compassion and empathy. And we need to seek ways for our own restoration during these challenging times and guard our time as our most valuable asset. We need to say yes to the things that build our energy and we need to be able to say no to those things we really can’t afford time or energy for right now. We need to stick a flag in the sand of those territories that define our happiness, and protect those territories with ferocity (e.g, time for our loved ones, time for our own passions, time for our own physical, mental, and spiritual health). We need to set up our own personal boundaries between home and work that will let us have that restorative time, and perhaps adjust our own personal expectations during the pandemic, acknowledge that this emotional roller coaster will be real, and is normal, and allow ourselves to know we are doing our best. And we need to support each other, and then continue to ask our leadership to help address systemic challenges that contribute to this moral injury.

Dr. Wendy Dean prescribes a solution in her STAT News blog article, that I think is a good advice for our own emotional healing.

1. Ease up. The work of recovery is hard and highly variable.

2. Check in — and mean it.

3. Provide support. Finding ways to pull staff members together to support each other, and publicly recognizing their value and contributions to the organization, are essential.

4. Listen. Every organization can, and should, expect criticism about its response to Covid-19.

5. Acknowledge that it won’t be business as usual. While the temptation is to get the clinical machine up and humming as fast as before, especially in challenging financial times, acknowledge that there will be need for give and take as physicians need time to rebuild their own resiliency.

And to Dr. Dean’s list of tips I would add the following: When people reach out to you and ask you how you’re doing, be honest, be vulnerable. It’s okay to lean on a friend or family member. I think the way we get through this challenging time is truly by suffering together.

Fellow healthcare workers, how are you getting through this pandemic? How do you restore yourselves? Feel free to share in the comments below.

If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1–800–273–8255 (Español: 1–888–628–9454; deaf and hard of hearing: 1–800–799–4889) or the Crisis Text Line by texting HOME to 741741.

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