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

Combating Morale Injury Caused by the COVID-19 Pandemic

Healthcare burnout is on the rise during the great COVID-19 pandemic. Healthcare burnout is emotional exhaustion, cynicism and depersonalization, reduced professional efficacy and personal accomplishment caused by work-related stress. Numerous factors cause healthcare burnout: long work hours, lack of respect, difficult patients, feeling of helplessness, lack of healthcare worker safety and leadership seemingly disconnected from the universal goal of all healthcare workers—saving people’s lives. Morale injury occurs when hands are tied from giving each and every patient the very best care, he/she deserves. Healthcare workers experience disappointment from doing a great job when saving lives. Hearing negative feedback about inconsequential small details and lack of praise for their great deeds can understandably lead to depression, anxiety and fear about the future. In order to combat negative feelings built up over time, it is important to fight back with positive feelings. This requires active positive thinking and not negative thoughts that can consume you. Throughout the day and night all kinds of thoughts flow through our mind. This cannot be controlled but you can counter negative thoughts by thinking of positive thoughts. There are things to be grateful for everyday in life: 1) life itself; 2) family; 3) purpose; 4) belonging to something greater than yourself; 5) the weather; and 6) all of the boundless opportunities that lay ahead. According to Gautama Buddha (1),

“to enjoy good health, to bring true happiness to one’s family, to bring peace to all, one must first discipline and control one’s own mind. If a man can control his mind, he can find the way to Enlightenment, and all wisdom and virtue will naturally come to him”.

Healthcare workers expend so much of their time and energy helping others, they themselves can end up in a void. Therefore, it is important that healthcare workers set aside a time for rejuvenation. (I personally find exercise as a great way to recover and let my mind clear after a long day in the hospital). Anything that gives you joy will suffice such as listening to music, singing, reading, laughing, playing with your children or having a funny conversation with your friends and family. Even something as simple as smiling at a stranger walking by and saying good morning will not only make you feel better, but it will also make the other person feel better. I say hello to everyone I pass in the hospital hallway and it makes me feel good.

It is always life or death in the intensive care unit (ICU). Working as an Intensivist, I am exposed to extraordinary situations every day. Thus, prior to walking into the ICU, I make it a point to think of something positive and smile because once those doors open up all Hell can break lose. Lack of personal protective equipment (PPE) because of the COVID-19 pandemic and staff isolation has demoralized everyone. I try my best to provide some encouragement in this very high mortality setting. It is important to let the staff know about those patients that survived so they know they are truly making a difference and see there is light at the end of the tunnel (2).

As Friedrich Nietzsche said, “that which does not kill us, makes us stronger” (1). That saying can be true for some but not all. You have to have a particular mindset in order to learn from these terrible situations and rise above like a phoenix from the ashes. “These life experiences have been called ‘crucibles’, severe test or trial that is unplanned, intense and often traumatic” (3). Unfortunately, not all of us can handle such diversity and may develop post-traumatic stress from such life experiences and never recover. That is why it is important to try and look at such profound life altering events as lessons. There is always something to be learned from every situation. Even negative events can be turned into positive experiences that build on a person’s character. For example, immediately after a COVID-19 surge descended on one hospital I was working at, I immediately learned to question the reliability of the estimated oxygen saturation measured by pulse oximetry (SpO₂) and to intubate as quickly and as safely as I could in order to avoid exposing staff to the SARS-CoV-2 virus as well as preventing cardiac arrest during intubation of those critically ill patients. It was a Sunday, the day before Doctor’s day 2020 in America when all of a sudden, the flood gates opened from the wards and literally five patients within minutes all required immediate intubation because all of them had critical oxygen levels despite maximal high-flow therapy. One after another the patients arrived in succession into the ICU and I went from bed-to-bed intubating all of them. This kicked off many months of treating very high numbers of critically ill patients two to three times the volume I was used to treating. Instead of being overwhelmed by the pressure, I focused on each patient and discovered the best treatment options all the while making sure that I did not add to the depressing morale by complaining about how difficult the working conditions were in order to keep the ICU team motivated. As Winston Churchill repeated during the daily bombardment of England by the Germans in WWII—keep calm and carry on (4).

I had never seen the need for so many arterial blood gas draws (ABG) and neither had the laboratory staff. One evening around midnight I needed around 20 ABGs. Instead of shrinking from the challenge, two laboratory technicians stepped up and brought the machine that processes the ABGs to the ICU and enthusiastically ran all of the tests. This made a huge difference in patients’ outcomes because what I was seeing was a big discrepancy between the continuous patient SpO₂ monitoring and the actual partial pressure oxygen (PaO₂). The true measurement of PaO₂ derived from the ABG helped confirm my suspicion that many patients were actually hypoxic despite having normal readings on the pulse oximeter, allowing me to adjust the ventilator appropriately and preventing death. I praised the laboratory workers in person and let their supervisors know what a terrific job had been done. They never complained despite being understaffed (some of their colleagues quit and never showed up for work that day). The lesson I learned from all of that was that as long as I kept pushing myself, I could save those patients despite the large volume and lack of supplies which gave me a great feeling of accomplishment. I then travelled to other hospitals facing similar situations and was able to continue this way for over a year.

Now I realize that not everyone can handle the pressure that follows a crucible event. I, myself, struggle as well and I have to remind myself to carry on and stay positive, which is not always an easy task. I definitely have not mastered this strategy yet, but I am trying. Marcus Aurelius said “you have the power over your mind – not (on) outside events. Realize this, and you will find strength” (1). Throughout our lives we will encounter hardships but as we get through one and then the other encounter, we realize that we can handle it. Know that the next life event is just another challenge. From the 2^nd century BCE Epicurus reminds us that “a person will never be happy if they are anxious about what they do not have” (1). Use that incredible focus and discipline you summoned from deep within during decades of study to train your mind into thinking positively. “Our life is shaped by our mind; we become what we think. Joy follows a pure thought like a shadow that never leaves,” Gautama Buddha (1). Remain altruistic and continue to take care of those in need and you will live a happy and joyous life.

Evan D. Schmitz, MD

La Jolla, CA USA

References

1. Robledo, IC. 365 Quotes to Live Your Life By. Powerful, Inspiring, & Life-Changing Words of Wisdom to Brighten Up Your Days. Published by I. C. Robledo, 2019.
2. https://www.goodreads.com/quotes/521459-there-is-a-light-at-the-end-of-everytunnel#:~:text=Quotes%20%3E%20Quotable%20Quote,%E2%80%9CThere%20is%20a%20light%20at%20the%20end%20of%20every%20tunnel,to%20be%20longer%20than%20others.%E2%80%9D
3. Warren G. Bennis and Robert J. Thomas. Crucibles of Leadership. 2002. Harvard Business Review.
4. https://london.ac.uk/about-us/history-university-london/story-behind-keep-calm-and-carry.

Cite as: Schmitz ED. Combating Morale Injury Caused by the COVID-19 Pandemic. Southwest J Pulm Crit Care. 2021;22(5):106-8. doi: https://doi.org/10.13175/swjpcc015-21 PDF