Moral injury occurs when the basic elements of the medical profession are eroded, say Simon G Talbot and Wendy Dean

In July 2018, we wrote an article that reframed clinician distress as moral injury, rather than burnout. In our view, “burnout” suggests a lack of resilience on the part of clinicians, implying that better self-care will resolve our distress, whereas “moral injury” more accurately locates the source of distress in a conflict ridden healthcare system.

We believe that distress is a clinician’s response to multiple competing allegiances—when they are forced to make a choice that transgresses a long standing, deeply held commitment to healing. Doctors today are caught in a double bind between making patients’ needs the top priority (thereby upholding our Hippocratic Oath) and giving precedence to the business and financial frameworks of the healthcare system (insurance, hospital, and health system mandates). 

Since our initial publication, we have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. Reconfiguring the healthcare system to focus on healing patients, rebuilding a sense of community and respect among doctors, and demonstrating the alignment of doctors’ goals with those of our patients may be the best way to address the crisis of distress and, potentially, find a way to prevent burnout. But how do we focus the restructuring this involves?

“Moral injury” has been widely adopted by doctors as a description for their distress, as evidenced by its use on social media and in non-academic publications. But what is at the heart of it? We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.*

Autonomy is a fundamental component of medical training. We are taught to think independently when considering diagnoses and to guard against the competing influences of pharmaceutical companies, device manufacturers, or any others who may try to sway our treatment decisions away from our patients’ best interests. However, in many facets of our work, we are required to forfeit our autonomy and allow other interests to sway our decisions about care—most commonly for financial reasons.

In the US, we are obliged to abide by insurer constraints, prior authorizations, billing optimization, and revenue quotas. We must keep patient satisfaction scores high, maximize hospital census numbers, and ensure the use of ancillary services. Administrators, regulators, and legislators tell us we must follow clinical practice guidelines and treat our patients according to statistics, instead of tailoring an individual treatment plan to each patient. In many circumstances, doctors today do not have the autonomy to treat our patients optimally, because we are no longer the ones designing treatment options. 

As the speed of information dissemination has accelerated and litigiousness expanded, doctors’ mastery of medicine—one’s sense of a comprehensive command of the fundamental principles of medicine—has constricted. In the face of an explosion of data, and constantly evolving evidence upon which to base treatment decisions, it is increasingly hard to maintain command over a subset of medical knowledge. And the litigious nature of the work causes clinicians to double check their conclusions and overtest in an abundance of caution. In the US, institutions benefit from the revenue stream generated by cautious physicians, making it unlikely to change in the near future.

The title of doctor used to suggest that its holder deserved the utmost professional respect. Other people recognised the sacrifices we made to train, the devotion we demonstrated by working endless hours, the deep repositories of confidences we kept, and the unique skillset and vast fund of knowledge we embodied. Practicing medicine still entails intense sacrifice and long hours, but it is no longer as emotionally rewarding as it once was. Our patients still see us as the healers we want to be, but they lose respect for us when business constraints limit the way we treat them. 

Within the hospital structure, doctors’ diagnostic and therapeutic decisions drive the vast majority of revenue generation, but too often it feels that respect is proportional to our performance metrics. Worst of all, doctors have ceased to respect one another in the scramble for limited resources. We compete with one another for coveted residencies and jobs. We collectively diminish the importance of our own wellbeing for the sake of expedience, so as not to be seen as difficult, and to preserve our share of ever scarcer resources. We cannot demand healthcare reform that benefits us and our patients, while simultaneously perpetuating a culture of quiet, individual physician distress. In order to organize and move together toward better healthcare practice, we must rebuild a sense of community and mutual respect among ourselves.

Doctors are still, to our cores, driven by the personally fulfilling experience of providing excellent care to a patient in need, and in that, our goals are identical to those of our patients. But more and more, the constant skirmishes—sometimes outright battles—with the bureaucracy of care are so exhausting and distracting that the celebration of healing is lost in the fog of the next fight. We barely have the energy to notice when we achieve a victory worth celebrating.

The most disorienting subsidence has been around the language of healing, the organizing purpose of clinician work. As medicine has evolved into a business, and hospitals and health systems employ business professionals instead of clinicians in leadership roles, the clinician’s voice in management conversations has been quieted and, in some places, silenced. Without doctors present to articulate their deep experience with clinical care, louder voices speaking the language of money and metrics have dominated the conversation.

At the end of the day, as our purpose deviates from the patient-centric path we believed we were following to a revenue-centric path, from a relationship to a transaction, we likewise deviate from the caregivers our patients expect us to be—or that we imagined we would be.  

Doctors are struggling with dramatic changes in our work environment. The business and financial frameworks of medicine inflict moral injury on clinicians by competing for our attention and pulling focus from the patients who need our care. Reclaiming our autonomy; reestablishing mastery; focusing on the relationships with our colleagues and patients, which offer fulfillment and a sense of purpose; and explicitly articulating that our goals align with those of our patients are the necessary first steps in addressing the crisis of clinician distress. 

*This characterization draws from and expands on Daniel Pink’s theory of motivation from his 2009 book Drive: The Surprising Truth About What Motivates Us.

Simon G Talbot is an associate professor of surgery at Harvard Medical School and attending surgeon in the Division of Plastic Surgery at Brigham and Women’s Hospital (BWH), Boston, Massachusetts.

Wendy Dean is a psychiatrist, problem solver, ally, and executive. She trained at the Dartmouth Hitchcock Medical Center in general surgery and psychiatry. She has practiced as an emergency room physician and a psychiatrist in Vermont, New Hampshire, and Pennsylvania.

Competing interests: WD and ST are founders of a non-profit organisation aimed at raising awareness and investigating moral injury in healthcare. They also consult in this area with organisations wishing to confront organisational drivers of moral injury and how these can be mitigated.