Physician Burnout: Why It Is Really Moral Injury

By John Shufeldt
physician

Compassion fatigue, burnout, PTSD, and moral distress are terms we physicians use to describe the result of prolonged stress in the line of duty. It’s important to understand these terms properly because then we will understand the current war cry of those working in healthcare today—it’s not simply being tired or burned-out, it’s moral injury.

The term “burnout” was coined by German psychologist Herbert Freudenberger in 1975, who identified it as the presence of symptoms like malaise, fatigue, frustration, cynicism, and inefficacy that emerge when the workplace makes excessive demands on energy, strength, or resources of workers.

This definition suggests that the problem lies with the worker, who doesn’t have enough inner resources to cope in a particular work situation. Therefore, it is also the worker’s responsibility to find a solution, to buck up, and to soldier on. This was the medical environment in which physicians of my era grew up.

This was the belief and, frankly the culture, in medicine up until the pandemic. The outbreak of COVID-19 has escalated the problem of physician burnout beyond measure and beyond even a stoic’s endurance.

In their STAT article, Talbot and Dean write that “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.’’ Put bluntly—we can take it. We have for years endured 36-hour shifts, working weeks in a row in high-pressure environments, not exercising, and eating hospital food.

What we are facing today goes beyond “burnout.” In medicine, moral injury occurs when a nurse, physician, administrator, or other healthcare worker must do something, witnesses an action, or fails to prevent an action that clashes with their deeply held moral beliefs. For us, that North Star is the Hippocratic Oath. To put the needs of patients first.

Moral injury stems from a disconnect between the ideals that people enter the medical field with and the reality they meet when they start working.

For myself, and most doctors and nurses, entering healthcare is not a career, it’s a calling. They enter healthcare with a compassionate heart wanting to be of service. However, at times, those expectations clash with the real world. When that happens, the caregiver is often caught off guard and ultimately deprived of the support and resources to deliver the best possible service.

In modern healthcare, even before the pandemic, health care workers sometimes felt like they were serving a different master, whether it was the hospital’s revenue, the insurance company’s bottom line, the electronic health record, the fear of medical malpractice, and their medical or nursing board. The patient was lost somewhere near the bottom of the hierarchy.

Healthcare has changed dramatically in my professional lifetime. It’s no longer solely focused on providing compassionate care to patients, it’s also now driven by a constellation of motives and agendas beyond the control of the caregiver.

Providers now are forced to wrestle with all the nuances of the various the electronic health record which takes away attention we should be giving to the patient as opposed to the keyboard. Adding to that is the often-conflicting demands and agendas of the healthcare ecosystem—those of the patient, the hospital, government mandates, the insurer, the caregiver, and their hospital department or private office. Taken together, you have an environment that is extremely difficult to navigate day after week after month after year. But we do. Now add COVID and the deluge of patients with comorbid conditions using Facebook for their reference about the vaccine, Ivermectin, and hydroxychloroquine. Regarding the vaccine, “It’s made from aborted fetal tissue,” was a reason to not vaccinate I heard last week from a patient gasping for air and demanding “those antibody things.”

This environment has put health care workers in a position where they constantly have to sacrifice the care they were called to provide in deference to competing agendas. This burden is moral injury, not burn out.

Three ways to help with caregiver burnout are:

  1. Developing Moral Resilience: In an article that appeared in the Journal of Medical Ethics, the authors explain how Communities of Practice (CoP) can help to build the moral resilience of healthcare professionals so they can cope with inevitable moral distress. In healthcare, a CoP can be created as a safe space to share experiences, find solutions in coping with difficult situations, express vulnerability, discuss ethical problems, and more.
  2. Improving Work Culture: Having the right culture can take some time for larger institutions because they may need to completely restructure and retrain several people. It is important that companies take the time to make sure they are inclusive and create a supportive environment.
  3. Entrepreneurship: Many healthcare professionals make great entrepreneurs. In fact, being an entrepreneur can be a great way to combat moral injury for several reasons. For other healthcare entrepreneurs and I, being an entrepreneur allows you to put your creativity towards solving a problem for a larger audience, not just the patient in front of you. To learn more about entrepreneurship, check out my book Entrepreneur Rx.

Overall, at the end of the day, the issue of moral injury is not a new one. Those working in healthcare have been intimately familiar with the condition for years. The pandemic has simply brought it more clearly and more dramatically to the forefront. By understanding that this is not a lack of stoicism or some weakness born of sleep deprivation and constant stress, we can collectively begin to address and correct the problem.