Are We Causing Moral Injury in our Physician Workforce?

By Carolyn C. Meltzer

Image courtesy of Carolyn C. Meltzer, "Stark Reality"
Burnout – characterized by feelings of disengagement and depersonalization – has become a national epidemic among healthcare workers, particularly with physicians. Contributing variables cited include loss of autonomy in an era of increasing market consolidation and corporatization of healthcare organizations, growing volumes of work, less-than-user-friendly electronic health record systems, sleep deprivation, and lack of work-life integration or stress reduction strategies (Jha et al. 2018). Burnout has been further associated with patient safety concerns, medical errors, and indices of rising physician turnover and suicide (Montgomery et al. 2019).

The term moral injury was coined by psychiatrist Jonathan Shay, MD PhD, who, while working at a Veterans Affairs hospital, noted that moral injury is present when 1) there is a betrayal of what is considered morally correct, 2) by someone who holds legitimate authority (conceptualized by Shay as “leadership malpractice”), and 3) in a high-stakes situation (Shay and Monroe 1998). Nash and Little (2013) went on to propose a model that identified the types of war-zone events that contributed to moral injury as witnessing events that are morally wrong (or strongly contradicted one’s own moral code), acting in ways that violate moral values, or feeling betrayed by those who were once trusted. In a fascinating study using the Moral Injury Event Scale and resting-state functional magnetic resonance imaging (fMRI), Sun and colleagues (2019) were able to discern a distinct pattern of altered functional neural connectivity in soldiers exposed to morally injurious events. In fact, functional connectivity between the left inferior parietal lobule and bilateral precuneus was positively related with the soldiers’ post-traumatic stress disorder (PTSD) symptoms and negatively related with scores on the Moral Injury Event Scale.

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Moral injury has been recently applied as a construct for physician burnout. Those who argue for this framework propose that structural and cultural factors have contributed to physician burden by undervaluing physicians and over-relying on financial metrics (such as relative value units, RVUs) as the primary surrogate of physician productivity (Nurok and Gewertz 2019). Turner (2019) recently compared the military experience to that of physician providers. While one may draw similarities between the front line of healthcare delivery and that experienced by soldiers, Turner argues that a fundamental tenet of military leadership - that leaders eat last – provides effective support for the health of the workforce. In increasingly large healthcare organizations managed by administrators who may be distant from the front line and reliant on metrics of productivity, the necessary sense of empathy and support from leadership can seem lacking.

The interplay of variables contributing to the burnout crisis is complex and not well understood. National health care thought leader Donald Berwick, MD, has described changes in how the public perceives of physicians as a contributing factor. Berwick (2016) describes the ascendancy of the medical profession as embracing the norms of being “noble,” “beneficent,” and “self-regulating,” and thus worthy of “privilege most other work groups do not get: the authority to judge the quality of its own work.” This idealism was undermined by large unexplained medical errors, social inequity of access and outcomes, and rapidly rising costs. As a result, healthcare became increasingly characterized by burdensome, metric-driven accountability with incentives and punitive actions that are often not well linked to the quality of patient care delivered; market-driven health care management; and rising consumerism. In a New York Times editorial published on June 8, 2019, Dr. Danielle Ofri makes the case that while “health care has become corporatized to an almost unrecognizable degree,” physicians and nurses remain driven by the ethics of caring for their patients above all, regardless of the personal sacrifice. Thus growing workloads, workforce shortages, burgeoning compliance burden, and clumsy electronic health record systems leave exhausted caregivers struggling to both maintain psychological well-being and keep up with their patients’ needs.

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Shanafelt and colleagues (2019) further reinforce the incongruence between deeply held assumptions within the overarching culture of the profession of medicine and modern health care system management. From my own medical training, I understand how deeply embedded are the ideals of the physician as self-sacrificing, perfectionistic, and heroic. Self-care is shunned and poor patient outcomes are interpreted as personal failures regardless of the cause. The persistence of this culture was recently highlighted at an international medical society meeting at which physician wellness was a featured topic on the program. At a traditional evening awards dinner ceremony, a gold medal was bestowed on a giant of the field. The colleague who proudly introduced the beaming awardee spoke of him as a “workaholic” who arrived at his office daily by 5 am, left for dinner at 7pm, and returned to work afterwards. The honoree was further described as a role model for his faculty, who knew that if they wished to meet with their department chair they had better schedule a 6 am appointment. This tribute struck me as emblematic of the persistence of the negative attributes of the culture of academic medicine, characterized by revering stoicism, self-sacrifice, hierarchy, and individual resilience that is beyond that of mere mortals.

While the term moral injury may be a helpful framing concept to describe the epidemic of burnout among clinicians, it suggests that the injurious agent is solely externally imposed. Yet, it may be more useful to consider a bidirectional, multivariate construct in which rapidly changing, systemic approaches to address health care costs, access, and population health needs of our communities are clashing with the remnants of an increasingly unhealthy professional culture – to the detriment of caregivers and patients alike. Perhaps carefully designed functional neuroimaging studies, like the one developed by Sun and colleagues (2019) in soldiers, could be adapted to evaluate the neurobiological correlates of burnout in clinicians. If the functional connectivity pattern was similar to that seen in veterans exposed to moral injury, and that pattern was distinct from that observed in depression, this could help us to address the causative and mitigating factors contributing to the burnout epidemic.
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Carolyn C. Meltzer is the William P. Timmie Professor and Chair of the department of Radiology and Imaging Sciences and Executive Associate Dean for Faculty Academic Advancement, Leadership and Inclusion at the Emory University School of Medicine.

Dr. Meltzer is a neuroradiologist and nuclear medicine physician whose translational research has focused on brain structure-function relationships in normal aging, dementia, and other late-life neuropsychiatric disorders. Her work in imaging technologies includes oversight of the clinical evaluation of the world’s first combined PET/CT scanner. Dr. Meltzer has held numerous leadership roles in national professional societies and advisory boards, including the Advisory Council for the National Institute for Biomedical Imaging and Bioengineering, and has authored approximately 200 publications. 

References
  1. Berwick, D. M. (2016). Era 3 for Medicine and Health Care. JAMA, 315, 1329.
  2. Jha, A. K., Iliff, A. R., Chaoui, A. A., Defossez, S., Bombaugh, M. C., Miller, Y. R. (2018). A Crisis in Healthcare: A Call to Action on Physician Burnout. Massachusetts Medical Society. Retrieved on September 7, 2019, from http://www.massmed.org/news-and-publications/mms-news-releases/physician-burnout-report-2018/ 
  3. Montgomery, A., Panagopoulou, E., Esmail, A., Richards, T., Maslach, C. (2019). Burnout in healthcare: the case for organizational change. British Medical Journal, 366, l4774. doi: 10.1136/bmj.l4774 
  4. Nash, W. P., Litz, B. T. (2013). Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Member. Clin Child Fam Psychol Rev, 16, 365–375.
  5. Nurok, M., Gewertz, B. (2019). Relative Value Units and the Measurement of Physician Performance. JAMA. Retrieved on August 14, 2019, from  https://jamanetwork.com 
  6. Ofri, D. (2019). The Business of Health Care Depends on Exploiting Doctors and Nurses. New York Times. Retrieved on September 7, 2019, from https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html 
  7. Shanafelt, T. D., Schein, E., Minor, L. B., Trockel, M., Schein, P., Kirsch, D. (2019). Healing the Professional Culture of Medicine. Mayo Clin Proc. https://doi.org/10.1016/j.mayocp.2019.03.026 
  8. Shay, J., Munroe, J. (1998). "Group and Milieu Therapy for Veterans with Complex Posttraumatic Stress Disorder." In Saigh, P. A. & Bremner, J. D. (Eds.), Posttraumatic Stress Disorder: A Comprehensive Text (pp. 391-413). Boston: Allyn & Bacon.
  9. Sun, D., Philips, R. D., Mulready, H.L., Zablonski, S. T., Turner, J. A., McClymond, K., Nieuwsma, J. A., Morey, R. A. Resting-state brain fluctuation and functional connectivity dissociate moral injury from posttraumatic stress disorder. Depress Anxiety, 36(5), 442–452.
  10. Turner, J. (2019). Do hospital administrators eat last? Kevin MD Blog. Retrieved on August 23, 2019, from  https://www.kevinmd.com/blog/2019/08/do-hospital-administrators-eat-last.html 

Want to cite this post?

Meltzer, C.C. (2019). Are We Causing Moral Injury in our Physician Workforce? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2019/11/are-we-causing-moral-injury-in-our.html

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