Practice Partner

New Language for Clinician Distress

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A physician slumped to the floor in a hallway

Dr. Wendy Dean is changing the language and approach to clinician distress in health care — and it is resonating with physicians. “Whenever I speak to groups of clinicians, they tell me that, finally, they feel as though the root of their anguish has been identified,” Dr. Dean, a U.S. psychiatrist, recently told Dialogue. Dr. Dean and Dr. Simon Talbot, a surgeon, were the first to apply the term “moral injury” to the health care context — a term initially used to explain the psychic wounds suffered by some soldiers returning from Vietnam.

In their 2018 op-ed, they described moral injury as being frequently mischaracterized. “In combat veterans, it is diagnosed as post-traumatic stress; among physicians, it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal, and physicians and patients alike will continue to suffer the consequences,” they wrote.

Dr. Dean defines moral injury as the feeling that one has participated in actions that transgress their deeply held moral beliefs or the sense of being betrayed by an authority figure in a high-stakes situation, preventing one from doing the right thing.

Moral injury, she said, describes the challenge of knowing what care patients need, but being unable to provide it due to constraints beyond one’s control.

“Each time physicians fail to deliver the care their patient needs, it’s an insult to our guiding purpose, which is to care for our patients above all else. If it happens intermittently, you can come to terms with it. No system is perfect. When it happens every day, week after week, month after month, the accumulated residue of those insults amasses into moral injury,” she said.

The term “burnout,” she said, suggests a health professional is at fault for their emotional state: they aren’t resilient enough, they are somehow deficient, and/or they need to learn to recover better. But meditation and weekend yoga retreats are not what physicians need. And, not surprisingly, putting forward those Band-Aid solutions as the cure only serves to alienate clinicians, said Dr. Dean.

“Years of tough education and training have honed physician resilience. Physicians are some of the most resilient people I know. If they don’t know how to fix a situation, it’s because it is almost unfixable,” she said.

Physicians have embraced the use of the term “moral injury” because it acknowledges that something larger is at play, said Dr. Dean.

“Moral injury subtly shifts the responsibility from the individual to the system.” she said. “It locates the source of the distress, appropriately, in system dysfunction. The system is broken, not the individual.” Finding solutions, Dr. Dean said, requires the problem be addressed for what it really is: a challenge inherent in the structure of the health care industry.

The U.S. health care system — with its network of private insurers and the need to consider a patient’s ability to pay — has a number of unique drivers of moral injury. In fact, Dr. Dean left clinical medicine when the pressure to generate revenue threatened to overtake the patient-centred priorities in her practice. But she said the term “moral injury” also applies to the experience of Canadian clinicians as they struggle to make patient referrals or are ground-down by administrative work that keeps them from patient care. Ontario emergency departments’ recent temporary shutdowns due to staffing issues is both a symptom of moral injury (as more health care providers leave their professions), and a driver of moral injury for those who remain in health care and are forced to spread themselves even thinner among patients.

Physicians have embraced the use of the term “moral injury” because it acknowledges that something larger is at play

The number of physicians responding to workplace stress by reducing clinical hours is reason enough for corrective action. Data from the 2021 Canadian Medical Association’s (CMA) National Physician Health Survey suggests half of Canadian physicians are considering reducing clinical work in the next two years.

“While a growing shortage of physicians was certainly an issue pre-pandemic, the cost of increased burnout in the form of early retirements and reduced clinical hours due to the pandemic may be substantial in the coming years,” stated the CMA report. “Considering this, wellness should be considered as a pillar of future health human resource planning.”

But Dr. Dean said moral injury was rampant for years before the emergence of COVID-19. The virus, however, did magnify the issue of physician disenfranchisement. “With the pandemic, we couldn’t look away from it anymore. Here, in the U.S., we continued doing elective surgeries nearly a month into the pandemic, using up the supply of personal protective equipment that clinicians knew were at risk of depletion because of an unreliable supply chain.”

Dr. Dean said it’s her goal to help people better understand the clinician’s perspective and the environment of moral distress that is so widespread within the health care industry. To that end, she and Dr. Talbot co-founded The Moral Injury of Healthcare, a non-profit organization focused on finding innovative ways to make medicine better for both patients and health care professionals — technologically, ethically and systemically.

She recognizes the solution to moral injury won’t be found without better and more engagement. Organizations and policy-makers need to acknowledge the clinician experience and understand how their decisions impact those providing frontline care. For their part, Dr. Dean said, clinicians need to come together and continue to demand what they need to provide quality patient care.