Our words matter. As with making an accurate diagnosis, using accurate language to describe a situation is the necessary first step in describing its resolution. Labeling the current surfeit of physician distress as “burnout” inaccurately describes the condition and, therefore, misdirects potential solutions. We need the right words to describe the condition, which will allow for development of the right solutions.

Burnout has been the language of physician distress for the last decade. It implies an individual failing and consequently an individual solution, such as improved resilience and wellness. The focus has been on burnout for several reasons: the fixes are clearly circumscribed and used successfully in other professions; the locus of control is internal to the physician, leaving no question as to who is responsible for the outcome; and it leaves the much more difficult questions of systemic prescriptions untouched. But despite ten years of treating “burnout,” the crisis is worsening.1,2

We believe the reason treating “burnout” has failed to reverse this trend is because physicians are not burned out. They are suffering moral injury. Moral injury is “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”3 And the multiple competing agendas requiring physicians to consider demands other than the needs of their patients—those of insurers, institutional business practices, and economic realities—are causing it. Consequently, unlike burnout, moral injury locates the source of distress external to the physician. It occurs at the intersection between the physician, the patient, and the business of medicine, when physicians must negotiate outcomes for each party in the course of treatment planning. The environment for moral injury is exemplified in the evolution from a relational model of care, focused on a mutually satisfying physician–patient relationship built on trust, to a transactional interaction built on a retail model of interchangeable team members, punctuated by productivity metrics, time-based accounting, relative value units, electronic health records, insurance prior authorizations, online reviews, and a multitude of stressors that create irreconcilable double- or triple-binds for physicians.4 Addressing moral injury, an inherently systems-based challenge, requires a more complex approach than is required to treat burnout. Most of the solutions will require engagement from multiple areas of the healthcare delivery system and, hence, are not amenable to “quick fixes.” Those that might offer more immediate improvement are likely to be met with resistance from both physicians and administrators, as they require a change in current practices.

 

Step 1: Use the Right Language

Just as depression is not traumatic brain injury, and vice versa, burnout and moral injury share some symptoms and characteristics, but the causes, impacts, and solutions are distinct.5,6 In order to find the right solutions, we need to have the right diagnosis and use the right language to describe the condition.

 

Step 2: Act Locally

Big changes need to occur in medicine to mitigate the factors driving moral injury. It will take years to fully change the culture, but there is no reason for individual physicians and institutions to wait to start making whatever changes are within their sphere of influence.

Throughout college, medical school, and residency, physicians-to-be are continually reminded that they are ultimately responsible for what happens in their careers and with their patients. Hyper-responsibility is expected and rewarded, while any deviation evokes shame and guilt. It is drilled into physicians that they will do whatever it takes to get their patients the care they need, without considering the cost to themselves. But it is time physicians begin taking stock of whether the demands are reasonable. Ignoring this will further worsen endemic physician distress, and ultimately, this cost will be borne by our patients. The expectation of the physician should be excellent patient care. Should the innumerable administrative burdens and metrics to measure productivity even be part of physicians’ responsibilities? Is the personal toll of such demands affordable?7,8

Physician–patient encounters are the keystones of healthcare. These encounters are where diagnoses are made and treatment plans decided and where patients develop the relationship that determines whether they stay in the system or go elsewhere, adhere to the treatment plan or don’t, and become a medicolegal liability or champions of the institution. Physicians need the freedom to care for patients as they believe best. Evidence-based guidelines, measurement of quality metrics, and medicolegal oversight have a place in modern medical practice but not at the expense of commonsense care. Unfortunately, systems and workflow are frequently not being designed to prioritize the patient–physician encounter. Well-designed electronic medical records should optimize and facilitate the interaction between the patient and the physician. All other facets of this technology (billing, tracking, metrics) should be secondary.

Physician leaders who have not forsaken their roots in clinical care can be a voice in the boardroom in defense of relational care. They can also provide forums that make it easier for doctors to speak up. We are fortunate that many hospitals are still led by physicians; but it is critical that these leaders do not take on these roles to escape the frustrations of clinical medicine and embrace the tenets of corporate healthcare, but rather to improve and strengthen the role of the clinician.9

Unfortunately, in the current healthcare environment, most physicians are not in positions of power relative to institutional leadership, and the culture of medicine does not lend itself to group action. While it is hard, in that position, to speak out for ourselves, we will be granted much greater leeway to speak out on behalf of others—particularly our patients.


Step 3: Think More Globally

Over the long term, it will be critical for physicians to be active in policy and legislation. Changes to our system of payment and provision of care are inevitable. Having a seat at the table during discussions of those changes—on both a state and national level, to voice concerns from the perspective of a patient-centered, clinically active physician—is essential to improving the way we provide care.

Physician distress—the moral injury of healthcare—is on an untenable trajectory. Current approaches to addressing that distress are ineffective because they are treatments for the wrong diagnosis. When physicians have the right language to describe their distress—and the tools, resources, support, and agency they need to take the best care of their patients—the crisis of moral injury masquerading as “burnout” will resolve.

References

  1. Alexander AG, Ballou KA. Work-life balance, burnout, and the electronic health record. Am J Med. 2018 Aug;131(8):857-858.
  2. Peckham, C. (2018, January 17). Medscape national physician burnout and depression report 2018. Retrieved from https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235.
  3. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009 Dec;29(8):695-706.
  4. Hoff, TJ. (2017). Next in line. New York, NY: Oxford University Press.
  5. Talbot SG, Dean W. (2018, July 26). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Retrieved from https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury.
  6. Morris-Singer A, Pollack S, Lewis M. (2018, August 21). Healing the ‘moral injury’ of clinicians will take a village. Retrieved from: https://www.statnews.com/2018/08/21/moral-injury-clinicians-healing.
  7. Berg, S. (2017, September 11). Family doctors spend 86 minutes of “pajama time” with EHRs nightly. Retrieved from: https://www.ama-assn.org/practice-management/digital/family-doctors-spend-86-minutes-pajama-time-ehrs-nightly.
  8. Casalino LP, Gans D, Weber R, Cea M, Tuchovsky A, Bishop TF, Miranda Y, Frankel BA, Ziehler KB, Wong MM, Evenson TB. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff (Millwood). 2016 Mar;35(3):401-6.
  9. Lown B. (1999) The lost are of healing: practicing compassion in medicine. New York, NY: The Random House Publishing Group.