Combating Physician Moral Injury Requires a Change in Healthcare Governance

One of our associate editors, Mike Gotway, emailed me an editorial titled “Burnout versus Moral Injury and the Importance of Distinguishing Them” from Radiographics authored by Sara Sheikhbahaei and colleagues (1). It is well worth reading the full text. However, since Radiographics is not an open access journal and the full text is not available to everyone, I will do my best to summarize Sheikhbahaei’s editorial and expand where appropriate. Nearly every journal (including the SWJPCCS) has published an article and/or editorial on physician burnout. Sheikhbahaei (1) points out that physician burnout is different than moral injury. She uses Talbot and Dean’s (2) definition of burnout as “a pattern of exhaustion, cynicism, and decreased productivity often accompanied by anxiety, cognitive impairment, and diminished functional capacity”. Her editorial points out that “the consequences of burnout are serious and include depression, stress, increased risk of substance abuse, poor self-image, lack of motivation, decreased productivity, poor employee retention, and loss of reputation for the institution”. However, she is also quick to point out that there are corrective measures available, and burnout is generally reversible.

Like post-traumatic stress disorder (PTSD), moral injury was first described in post-war veterans but is now being expanded to non-veterans and non-military situations. Johnathan Shay (3), who introduced the concept of moral injury as a distinct syndrome differing from PTSD, defined moral injury as occurring when: (a) there has been a betrayal of what is morally right, (b) by someone who holds legitimate authority and (c) in a high-stakes situation. Shay went on to describe moral injury creation as "leadership malpractice".

What distinguishes moral injury from burnout is that it is generally irreversible (1). “The most grievous consequences of moral injury are (a) loss of institutional loyalty (or worse, loss of loyalty to medicine in general), and (b) detachment from the noble ideas that attracted one to medicine in the first place. Such heavy soul wounds leave permanent scars and can cause lifelong feelings of betrayal by the institution. Corrective measures (e.g., changing jobs, increasing vacation time or remuneration, providing psychologic support) may mitigate burnout but cannot heal the permanent wounds of moral injury” (1).

The Radiographics editorial points out that in academic medicine ethical standards are violated by the very entity that instilled them in the first place — academic medicine (1). The tripartite mission of academic medicine (patient care, teaching, and research) has been increasingly supplanted by institutional priorities that focus on control of the clinical practice of physicians; the production and distribution of medicine; and the redistribution of its financial productivity away from the original objectives (1). Academic medicine had been a calling for professionals willing to sacrifice financial gain while seeking fulfillment in research and teaching. This has changed, not because the physicians changed, but because academic medicine changed.

Institutional priorities have diverged from those of physicians and are nearly exclusively molded by financial considerations (1). Countless metrics of dubious relevance, measurement of physician worth by clerical skills and other myopic administrative efforts detract from academic medicine’s true calling of providing the best patient care, education  and research. Health care administration has pursued a business culture to cement administration’s fiscal goals. Worse than simply wasting resources, administration punishes physicians who rebel against their financial structure. To avoid this losing conflict, physicians may impose self-censorship, settle on a daily routine of doing the minimum required to get by, or simply resign. The coup de grace is the feeling of deep betrayal that becomes permanently fixed. It is the physicians’ training at these very institutions that etched the primary moral creed of serving the patient. Now, these same institutions demand that physicians devalue this deeply held moral belief and toe the line for institutional financial gain. 

It is the administration of the institution, and the bureaucracy that results, that causes, defends, grows, and perpetuates physician moral injury. The growth of the administrative bureaucracy is staggering. Between 1975 and 2010, the number of physicians in the United States grew by 150%, but the number of health care administrators grew by 3200% (4). In 2019, Sahini (5) estimated that the United States spent nearly 25% or $1 trillion directly on healthcare administration with some believing that adding the indirect costs makes the true costs closer to 40% (6). These numbers are the source of the old joke from a couple of decades ago that in the future not everyone will have a doctor or nurse but everyone will have an administrator. Unfortunately, that time has arrived.

Sheikhbahaei (1) states that institutions should educate administrators away from emphasizing financial gain to emphasizing excellence in patient care by facilitating clinical practice. Some administrators do, others do not. Resources should be redirected from bureaucratic efforts of little value toward improving health care quality and accessibility, reversing a long-standing trend in the other direction. Those who deliver health care should be shielded from unnecessary tasks. According to Sheikhbahaei this can be achieved by delegating to clinicians some oversight of the medical bureaucracy (1). Although I agree with the sentiment, I disagree with the lack of action. Merely pointing out that there is a problem is not likely to solve it, especially when the beneficiaries of the present system, the administrators, are charged with fixing it. We need to do more than identify and study areas of administrative complexity that add costs to healthcare but do not improve value or accessibility. Administrators have taken the money and run, squandering their chance to deliver quality care at lower prices. Prior to the 1980’s physicians were mostly in charge and did better — they can do better again. However, first they need control. Physicians should demand that regulatory organizations such as the Joint Commission, Centers for Medicare and Medicaid, ACGME, etc. remove administrators from control of healthcare. Regulators need to address policies that add costs without patient benefit or improvement in education and research. Leaving healthcare administrators in charge without oversight and accountability will preserve the present system of substandard healthcare, poor accessibility, deficient education, second-rate research, high prices, and “leadership malpractice”.

Richard A. Robbins, MD

Editor, SWJPCCS

References

1. Sheikhbahaei S, Garg T, Georgiades C. Physician Burnout versus Moral Injury and the Importance of Distinguishing Them. Radiographics. 2023 Feb;43(2):e220182. [CrossRef] [PubMed]
2. Talbot SG, Dean W. Physicians are not “burning out”. They are suffering from
3. moral injury. STAT. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/ (accessed 2/14/23). 
4. Shay J, Munroe J. Group and Milieu Therapy for Veterans with Complex Posttraumatic Stress Disorder. In: Saigh, PA, Bremner JD, eds. Posttraumatic Stress Disorder: A Comprehensive Text. Boston: Allyn & Bacon; 1998:391-413.
5. Cantlupe J. Expert Forum: The rise (and rise) of the healthcare administrator. November 7, 2017. Available at: https://www.athenahealth.com/knowledge-hub/practice-management/expert-forum-rise-and-rise-healthcare-administrator (accessed February 6, 2023).
6. Sahni NR, Mishra P, Carrus B, Cutler DM. Administrative Simplification: How to Save a Quarter-Trillion Dollars in US Healthcare. McKinsey & Company. October 20, 2021. Available at: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/administrative-simplification-how-to-save-a-quarter-trillion-dollars-in-US-healthcare (accessed 2/6/23).
7. Robbins RA, Natt B. Medical image of the week: Medical administrative growth. Southwest J Pulm Crit Care. 2018;17(1):35. [CrossRef]

Cite as: Robbins RA. Combating Physician Moral Injury Requires a Change in Healthcare Governance. Southwest J Pulm Crit Care Sleep. 2023;26(3):34-6. doi: https://doi.org/10.13175/swjpccs008-23 PDF

Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines

One of my former fellows emailed me an article from Stat+ titled “Hospitals Have Been Financially Propping Up Medical Schools, But Now It’s Squeezing Their Bottom Lines”. The article reports that hospitals have been financially supporting medical schools and are feeling their bottom line squeezed (1). An example cited is the purchase of the University of Arizona Medical Center in Tucson by Banner Health and an agreement by Banner to help both of Arizona’s financially struggling medical schools. Financial statements show that Banner has dedicated roughly $2 billion to the schools and a faculty medical group it bought as part of the 2015 deal. Banner is blaming these expenses for shrinking its operating margin from 5% before the deal to 1% today (1). The businessmen who purchased the academic medical centers initially embraced these mergers but now are facing the financial reality of managing a medical school (1). It seems likely that there will be increasing friction between hospitals and their affiliated medical schools competing for funds. These editorial points out the other side of coin, i.e., that the medical schools are financially shoring up academic medical centers.

Count me as one who is not overly sympathetic to businessmen in charge of academic medical centers. They now collect the pro fees from physicians, paying themselves first. Banner is a good example where the CEO made in excess of $25 million in 2017 compared to the average $155,212 earned by physicians (2). This means the CEO earned more in 2 days than the average physician earned in a year or about $164 for every $1 earned by a physician. As medical education has become more expensive, medical schools now find themselves increasingly reliant on the money they get from their faculty seeing patients and less able to count on other revenue sources, like federal research funding or tuition (Figure 1).

Figure 1. Source of medical school income (1). Click here to view Figure 1 in a new enlarged window.

Furthermore, many physicians, especially pulmonary and critical care physicians, worked above and beyond during the COVID-19 pandemic (3). The pandemic’s resulting disruptions affected academic and educational pursuits such as research productivity, access to mentoring, professional development and networking and personal wellness (3). These disruptions were compounded for faculty at high COVID-19–volume medical centers where clinical responsibilities were necessarily prioritized. Many recognize that it is important to prepare for a postpandemic accelerated burnout syndrome that disproportionately affects early-career physician-scientists at high-volume centers. However, rewards for service have largely been unfulfilled (3).

One quick comment on the validity of hospital ledgers. Physicians are usually shown the finances that businessmen want them to see. The accounting can be prepared to justify further physicians sacrifice of even more time and money. Hospitals tend to see the money generated by physicians, nurses and other healthcare providers as “their” money (1). They see a revenue stream going to a medical school as robbing them of “their” profit and want to know what they get for it (1).

All the above stems from the “hyperfinancialization” of medicine and applying a corporate structure to institutions which should be not-for-profit other than in name only. It is hard to pinpoint an inflection point in medicine, the point in which the direction changed and the mission changed. Maybe it is because in reality the inflection point is not a point but a large blotch, a series of smaller dots in coalesce into a bigger stain brought on by greed. I worry that the core of medicine has been forever damaged; that the doctor patient bond has been replaced with institute/provider - patient service. This model has proven to be more costly, less rewarding and associated with higher burnout. Yet, we continue to move forward with this model. Mergers between community-based physicians and hospitals which are supposed to bridge the gap between evidenced-based care and practice-based care has only served to devalue the intangibles in medicine further, always looking for what can be standardized and more importantly… billable. A corporate structure with a board, CEO, and a variety of vice presidents and other corporate titles has not served the public well. Physicians make less, administrators make more and hospital services have declined or not improved (4). One needs to only look at outcomes such as life expectancy and costs as a percent of GNP (gross National product) to recognize there is a problem (5).

Many, including myself, remain skeptical of the intrusion of business interests into medical education. The oversight of academic medical centers provided by organizations such as the Accreditation Council for Graduate Medical Education (ACGME) that protects the public’s interests remain inadequate. Presently only a written statement must be provided every 5 years that “documents the Sponsoring Institution’s commitment to education by providing the necessary financial support for administrative, educational, and clinical resources, including personnel.” This is to be reviewed, dated, and signed by the designated institutional official (DIO), a representative of the Sponsoring Institution’s senior administration, and a representative of the Governing Body (6). It seems unlikely that review every 5 years by a DIO and other officials employed and dependent on medical center support is likely sufficient.

To provide oversight I recommend that a system be developed to hold medical center administrators accountable for decisions that lead to a decline in efficiency at both in the medical center and their affiliated medical schools (4). If they are in charge of medical care as they seem to think they are, then deficiencies need to be laid at their feet - the same for medical education and research. After all they now credential the healthcare providers and any deficiencies would seem to have resulted from a poor work environment or  poor administrative judgment in credentialing. It is time that administrators are held to the same standard. Physicians are required to have continued medical education, board certifications, etc. for credentialling. Present hospital systems where a board elects its own members with the nomination and blessing by the hospital CEO need to end. The chief of staff should be elected by the hospital staff and the majority of members of a hospital board need to be independent of the CEO and knowledgeable about the practice of medicine at that medical center (7). If administrators are not acting in a manner that promotes the doctor patient bond, increases the access to care, promoting cost containment in a transparent manner, and promote physician well-being, then it is time for them to go. 

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Bannow T. Hospitals have been financially propping up medical schools, but now it’s squeezing their bottom lines. Stat+. April 14, 2022. Available at: https://www.statnews.com/2022/04/14/hospitals-medical-schools-financial-relationship-tension-squeezing-bottom-line/ (requires subscription).
2. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
3. Kliment CR, Barbash IJ, Brenner JS, Chandra D, Courtright K, Gauthier MC, Robinson KM, Scheunemann LP, Shah FA, Christie JD, Morris A. COVID-19 and the Early-Career Physician-Scientist. Fostering Resilience beyond the Pandemic. ATS Sch. 2020 Oct 23;2(1):19-28. [CrossRef] [PubMed]
4. Jeurissen PPT, Kruse FM, Busse R, Himmelstein DU, Mossialos E, Woolhandler S. For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study. Int J Health Serv. 2021 Jan;51(1):67-89. [CrossRef] [PubMed]
5. Cohen J. Dismal U.S. Life Expectancy Trend Reflects Disconnect Between Dollars Spent On Healthcare And Value Produced. Forbes. Nov 1, 2020. Available at: https://www.forbes.com/sites/joshuacohen/2020/11/01/dismal-us-life-expectancy-trend-reflects-disconnect-between-dollars-spent-on-healthcare-and-value-produced/?sh=3657f353847e (accessed 5/2/22).
6. Accreditation Council for Graduate Medical Education. Institutional Requirements. Available at: https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements2022.pdf (accessed 5/2/22).
7. Robbins RA. Time for a Change in Hospital Governance. Southwest J Pulm Crit Care Sleep. 2022;24(3):43-5. [CrossRef]

Cite as: Robbins RA. Medical School Faculty Have Been Propping Up Academic Medical Centers, But Now Its Squeezing Their Education and Research Bottom Lines. Southwest J Pulm Crit Care Sleep. 2022;24(5):78-80. doi: https://doi.org/10.13175/swjpccs023-22 PDF