Moral Injury to Medical Students

Medical students are exceptionally well trained to get a job done, no matter the obstacles. Wendy Dean, MD, and Simon Talbot, MD report.

Since high school you have been on a paththat requires exceptional performance, personal sacrifice, and exactingstandards. You have pulled all-nighters since college (maybe since highschool?). You have given up important social events to study for exams. Youhave missed milestones because of rotation schedules. You have learned toignore your own needs - for food, sleep, exercise, self-care - in the serviceof your profession and of your patients. And the reward has been the promise ofadmission to a rarified, honorable profession. Being one of the small cadre ofhealers walking the hospital hallways in the dead of night, who can offerrespite to the desperately ill, is a privilege like no other. Being admittedinto the confidence of a stranger and being trusted with some of their mostabjectly vulnerable moments is a deeply humbling experience replete withmeaning, and purpose, and satisfaction.

But this training also leaves youvulnerable. Because of your powers of self-denial and hyper-responsibility -intensified during internship and residency - you will, often unquestioningly,assume responsibility for whatever is expected of you, whether or not thatresponsibility should be yours and whether or not it is a reasonableexpectation. Expectations of revenue generation, call, administrative burden,and unwaveringly extraordinary performance, all delivered with boundlesspersonal charm, will be heaped on you. Patients will expect you to provide themthe latest, greatest treatment for any given condition, no matter the cost.Insurers will expect you to treat their insureds without incurring any costs.Health systems will want you to keep costs low, reputations high, and “leakage”(yes, it is exactly as ugly as it sounds) nil. And your employer will require thatyou bill enough to justify your salary (and, ironically, theirs).

Where does this leave a hyper-responsible,newly minted physician struggling to make the patient, the insurer, the healthsystem, and the boss happy? You will hear about “physician burnout”. But weargue that it’s NOT burnout that is harming physicians. Burnout implies theproblem resides with the physician, that they have some deficit in copingskills, when in fact responsibility for this issue lies with the system itself.And the system may leave physicians struggling with double, triple or quadruplebinds and well on the way to moral injury.

Moral injury is “perpetrating, failing toprevent, bearing witness to, or learning about acts that transgress deeply heldmoral beliefs and expectations”. The term was first used to describe thepsychic wound sustained by service members committing what were, to them,morally reprehensible acts in the context of war. The moral injury of healthcare, though, is not sustained through overt reprehensible acts. Rather, it isincurred over time, through repeated instances of knowing what is required toproperly care for a patient and being unable to provide it. As health care hasgrown into a massive, multi-billion dollar business, physicians have been caughtin a moral vice of multiple allegiances - to self, employer and patient. Thatmoral vice of competing allegiances, which are often mutually exclusive, andthe attendant moral injury may be driving physicians to a tipping point andcausing the collapse of resilience.

Finding ways to thread an ethical paththrough these intensely competing allegiances is emotionally and morallyexhausting. Routinely witnessing the suffering, anguish, and loss perpetratedupon patients and their families when physicians are unable to deliver the carepatients need is deeply painful. The physician-patient relationship is built ontrust: that the patient will provide fully truthful disclosure, knowing it willbe held in confidence, and used in the service of delivering optimal treatment.Patient trust is also rooted in an unspoken contract that the vulnerabilityattendant to such disclosures will not be exploited. But each time a physicianknows what treatment is best and cannot provide it, because of insuranceconstraints or the business model of the organization or for some other reasonwith a locus outside of the patient, patient trust is eroded. Those dailybetrayals of patient care and trust are examples of ‘death by a thousand cuts’.Those cuts, amassed over days and months and years, result in the moral injuryof healthcare.

Currently, nearly all institutionsresponding to the ‘crisis’ of burnout do so by pushing the solutions ontoproviders. The solutions include adopting flexible schedules, tighter teamsupport, and strengthening individual strategies that inoculate against stress:mindfulness, meditation, relaxation, cognitive-behavior therapy, and resiliencetraining. And without question, these are good skills and practices to have formanaging individual responses in any high tempo, high-risk career. But thesesolutions are wedged into the crevices of precious and limited personal timeand none of them is geared to address the organizational double bindsinflicting moral injury, but simply to teach strategies for enduring yet moredistress.

The challenge for most physicians inpractice is that they are the proverbial frog boiling slowly. Expectationsevolved gradually but inexorably over the last decade. Physicians voiceddistress, but were too burdened to mount an effective objection. In fact, untilthe STAT article, many did not have the language to describe their pain:burnout never resonated; moral injury does. The challenge now is to respondeffectively to the myriad forces exerting pressure.

What are the best ways to maintainequipoise in the current health care environment?

1. Accept that these challenges exist and that, no matter your practice environment, you will face many of them.
2. Understand the pressures being shifted to you and what your own personal response is to such pressures:
3. Administrative burdens (EHR demands, primarily)
4. Insurance constraints
5. Patient expectations
6. Marketing pressures with billing implications (i.e., patient satisfaction surveys)
7. Employer quotas
8. Follow the money. Physicians are not trained to fully understand and manipulate the economic drivers in health care. Most decisions are driven by the bottom line and understanding how you are tied to that is important to addressing your work environment.
9. Follow the metrics. Know how your organization evaluates itself, and evaluates you as a physician, because metrics are tightly tied to money and therefore, are closely linked to executive decisions, which will eventually impact you.
10. Curiosity is a stealth weapon. The more you understand a system, the better prepared you are to change it. You have your entire residency and about five years at the beginning of your career to be innocently, relentlessly curious. Use every one of them exhaustively.
11. Gather nationally. Physicians all across this country are facing the same crisis. Join together to amplify your voice.
12. Act locally. Speaking as a unified voice across the country is important, but the real work - and the real progress - gets done in your organization, through your actions. Even small steps mean progress. Let the rest of us know how you have succeeded and how we can help.
13. Understand policy and how government works. There are precious few physicians with a government policy background. MD-JD and MD-MBA combined degrees have been popular over the last few decades, and are still necessary. But it is also time more focus is directed at Masters of Health Administration/Health Policy dual graduates. Physicians who are deeply knowledgeable about both policy and medicine MUST inform national conversations about the direction of healthcare. And those physicians must speak as advocates of patient care, not business principles.
14. Prepare for a marathon, not a sprint. These changes evolved over years and they will diminish over years. Do not go all out in the first stretch. Husband your resources of energy, time, and attention.
15. Keep in touch. We are in this for the long haul; please join

us

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Wendy Dean. MD. Image Credit: The Moral Injury of Healthcare, LLC.

About the Authors

The Moral Injury of Healthcare, LLC wascofounded by Wendy Dean and Simon Talbot. Through this nonprofit, Dr. Dean andDr. Talbot work to bring resources and education about moral injury tophysicians across the spectrum of healthcare.

A psychiatrist by training, Dr. Deanpracticed for 15 years in academic, rural, and direct patient care settings.She is currently a senior executive for a large, international nonprofitsupporting the advancement of military medical research. Dr. Dean left clinicalmedicine when generating revenue crowded out the patient-centered priorities inher practice. Her focus since has been on finding innovative ways to makemedicine better for both patients and physicians: technologically, ethically,and systemically.

Dr. Talbot is a reconstructive plasticsurgeon who routinely sees the most challenging clinical cases requiring acombination of surgical skill, judgment, and a strong doctor-patientrelationship. He is regularly confronted with obstacles to providing the bestcare for patients and recognizes the consequent moral injury of healthcare.

Originally published in  Issue 4, 2018 of MT Magazine.