“Burnout” is a term that tends to blame the victim — in this case, healthcare workers — overwhelmed by a system that often puts them at odds with their duty to protect patients. A more accurate term for this condition is “moral injury,” says Wendy Dean, MD, a psychiatrist and senior vice president at the Henry M. Jackson Foundation for the Advancement of Military Medicine in Bethesda, MD.

As lead author of a recently published paper, Dean says “burnout,” as well as the typical solutions to treat it, were drawn from other fields and incorrectly applied to medicine.

“[T]he crisis in healthcare has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out,” Dean and co-authors reported.1

Instead, they find the concept of “moral injury” more fitting — a term first used to describe service members who returned from the Vietnam War.

“This was a different category of psychological injury that required different treatment,” the authors noted. “Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the healthcare context, that deeply held moral belief is the oath each of us took when embarking on our paths as healthcare providers: Put the needs of patients first.”

Hospital Employee Health asked Dean to comment further on this condition in the following interview, which has been edited for length and clarity.

HEH: This concept of moral injury is a fascinating new lens through which to view this problem. Can you comment further on how this is different from burnout?

Dean: From my perspective, burnout implies that the individual is in some way lacking. That they aren’t resilient enough, that they don’t do enough with self-care. That they don’t manage their time well. Moral injury is being put in an untenable situation — a broken system.

HEH: Given this broken system, you note the limitations of common resilience methods, like mindfulness and yoga, to address this problem.

Dean: I think all these activities have benefit, depending on the individual. Different things work well for different people. But none of those strategies do anything about the situations that drive moral injury. What they do is allow the individual to be better prepared to stand up and change those things that are driving moral injury. For lack of a better analogy, it is a high-performance tool. You are tuning the engine, but it is not the case that drives the car.

HEH: In the context of moral injury, do you see healthcare as to some degree dehumanizing clinicians, perhaps accumulating in long-term harms that contribute to toxic work cultures and even suicide rates?

Dean: Absolutely. Since the publication of our [first] article on this in July 2018,2 we have heard from clinicians and family members who have said, “I had a very near miss, and this was the driver.” Or, even worse, “this is what happened to my family member.” I was just talking to a clinician at a big medical center who was effectively saying, “We are being asked to do more and more with less and less.” Nobody is valuing the clinicians who are doing this hard work. [We] can’t ask any more of clinicians. We have to do something different. We have to look at how reimbursement or regulations should change. Or, expectations in some way or another should change, rather than just expecting that the clinicians have an infinitely elastic reserve — that they can go on and absorb anything that we ask them to do. There is a finite level of reserve that clinicians have.

HEH: I realize you are addressing physicians in your paper, but do you see aspects of moral injury that may also affect nurses?

Dean: Yes. We wrote [the 2018 paper] from a physician perspective. But immediately after it was published it became crystal clear to us that everyone across the healthcare spectrum — from first responders, nurses, physical therapists, respiratory therapists, physician assistants — everybody said absolutely “This is my language, too.”

HEH: You have compared moral injury to combat. Is it caused by not only what clinicians are being asked to do, but what they are bearing witness to?

Dean: We take an oath. Everyone who leaves medical school takes an oath to put our patients as a priority. Our patients come before we eat, we sleep — they come before our kids’ birthdays, and anniversary dinners. They come before almost everything. When we are asked by corporatized medicine to take care of something else as a priority over our patients — to tend to the electronic medical record, the insurance company with prior authorization, the hospital’s need for volume by seeing more patients in shorter periods — it strikes at our deeply held beliefs that our patient comes first. The thing that was ingrained in our training for the past decade or more.

The reason why we went into medicine in the first place was to take care of patients. All of those things transgress the deeply held moral belief. When we have to break that promise to our patients, that is a painful thing to do. We are witness to their suffering. We are witness to the fact that they are in pain for another six weeks because their insurance company demanded an X-ray and six weeks of physical therapy before they can get an MRI for their back pain. A patient has stage 3 cancer and we know a particular medication is best for that, but they have to wait, or they have to go through a trial of another drug, and that drug has to fail them before they can get what we wanted to give them first.

HEH: You note that addressing moral injury should be a financial priority, and even made a metric to assess hospital administration. Can you comment further on the business case for addressing moral injury?

Dean: On average, replacing one clinician in a healthcare system costs $1 million. That is because of the lost revenue when the clinician leaves and before you can onboard the new one. It is the cost of recruiting, the cost of salary. When there are huge levels of burnout in a healthcare system, the physician turnover is about 21%. When there are low levels of clinician burnout it is less than half that. That is a substantial cost difference. There also is some suggestion that patient safety is an issue. If you add in those costs, not treating clinicians well, not valuing them for what they do, and trying to make sure that very expensive machine you have is running as well as it can, is probably somewhat misguided.

REFERENCES

  1. Dean W, Talbot S, Dean A. Reframing clinician distress: Moral injury not burnout. Fed Pract 2019;36:400-402.
  2. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT, Jul 26, 2018. Available at: https://bit.ly/398pG5V.