Physicians on the front lines of health care today are sometimes referred to as “fighting.” It’s a good analogy. Physicians, like combat soldiers, are frequently exposed to a serious and underappreciated threat to their health: moral harm.
Moral damage is commonly misunderstood. Post-traumatic stress disorder (PTSD) is the diagnosis for combat veterans, while burnout is the term used by doctors. The wounds will never heal unless the critical difference between burnout and moral harm is understood, and both physicians and patients will continue to suffer the repercussions.
Syndrome of emotional exhaustion is defined by tiredness, cynicism, and diminished productivity. At least one of these is reported by more than half of physicians. However, physicians dislike the concept of burnout because it implies a lack of resourcefulness and resilience, qualities that most physicians have finely refined during decades of hard training and demanding job. One-third of physicians at the Mayo Clinic, which has been tracking, analyzing, and resolving burnout for more than a decade, report symptoms.
Burnout, we feel, is a symptom of a greater problem: our failing healthcare system. The increasingly complicated web of providers’ deeply conflicted allegiances — to patients, self, and employers — and the resulting moral harm may be driving the health care ecosystem to a tipping point and precipitating resilience collapse.
The phrase “moral damage” was coined to describe soldiers’ reactions to their wartime activities. It refers to “acting out, failing to prevent, witnessing, or learning about acts that contradict deeply held moral beliefs and expectations.” It’s “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society,” according to journalist Diane Silver.
The moral impropriety of providing health care is not the same as killing another human being in the course of a war. In the context of health care, it is the inability to deliver high-quality care and healing.
Most physicians are drawn to medicine by a calling rather than a career route. They enter the field intending to assist others. Many people approach it with a fanatical zeal, sacrificing sleep, missed years of adolescence, significant opportunity costs, family stress, financial instability, disrespect for personal health, and a slew of other issues. Each stumbling block teaches perseverance in the pursuit of one’s aim, which, beginning in the third year of medical school, is laser-focused on providing the greatest possible care to one’s patients. Failure to meet patients’ requirements consistently has a significant influence on physician well-being – this is the crux of the moral harm that results.
Physicians are intelligent, tough, long-lasting, and resourceful individuals. They would have done it already if there was a way to MacGyver their way out of this dilemma by working harder, smarter, or in a better way.
Physicians must consider a variety of variables other than their patients’ best interests when deciding on treatment in an increasingly business-oriented and profit-driven healthcare system. Conflicts of interest arise as a result of financial concerns involving hospitals, healthcare systems, insurers, patients, and occasionally the physician himself. Electronic health records, which divert attention away from patient visits and fragment care but are extremely useful for analyzing productivity and other business metrics, overburden busy physicians with chores unrelated to providing excellent face-to-face interactions. The constant threat of lawsuits drives physicians to over-test, over-read, and overreact to results, sometimes to the point of harming patients.
Patients can learn more about a physician, a hospital, or a health care system by looking at patient satisfaction scores and provider rating and review sites. However, they have the potential to prevent physicians from giving necessary but unwelcome advice to patients, as well as to lead to overtreatment in order to keep some patients happy. Providers may be compelled by business practices to refer patients within their systems, even if they are aware that doing so will delay care or that their equipment or staffing is inadequate.
It’s emotionally and morally draining to try to find an ethical path among so many competing forces. Constantly balancing the Hippocratic oath, a decade of training, and the realities of profiting from people at their sickest and most vulnerable is an untenable and unreasonable demand. Experiencing the pain, anguish, and loss of not being able to provide the care that patients require regularly is excruciating. The “death by a thousand cuts” is exemplified by these routine, ongoing betrayals of patient care and trust. Any one of them, if given alone, has the potential to heal. However, when they are repeated daily, they add up to the moral injury of health care.
Physicians are intelligent, tough, long-lasting, and resourceful individuals. They would have done it already if there was a way to MacGyver their way out of this situation by working harder, smarter, or in a different way. Many doctors consider leaving medicine entirely, but most do not for a variety of reasons, including a lack of cross-training for alternative careers, debt, and a commitment to their calling. As a result, they remain wounded, disengaged, and increasingly despondent.
Executives in the healthcare system must recognize and then acknowledge that this is not physician burnout in order to ensure that compassionate, engaged, and highly skilled physicians are leading patient care. Physicians are the canaries in the healthcare coalmine, and they’re killing themselves at alarming rates (twice as many as active-duty military personnel), indicating that something is seriously wrong with the system.
The problem will not be solved by establishing physician wellness programs or hiring corporate wellness officers. Pushing the solution onto providers by converting them to team-based care, creating flexible schedules, and float pools for provider emergencies will not solve the problem; encouraging physicians to engage in mindfulness, meditation, and relaxation techniques, as well as cognitive-behavioral therapy and resilience training. In the event of an emotional distress crisis, we don’t need a Code Lavender team that provides “information on preventive and ongoing support and hands out things like aromatherapy inhalers, healthy snacks, and water.” These teams provide the same assistance that first responders do in disaster zones, but the “disaster zones” where they work are many of the country’s major medical centers’ daily operations. None of these policies are designed to alter the institutional patterns that cause moral harm.
We need leaders who are willing to acknowledge the human costs and moral harm caused by multiple competing allegiances. We need leaders who are willing to face and balance competing demands. Physicians must be treated with dignity, autonomy, and the power to make rational, safe, evidence-based, and fiscally responsible decisions.
We need leaders who understand that taking care of their doctors leads to thoughtful, compassionate care for patients, which is good for business. Senior doctors should be treated with loyalty rather than as replaceable, depreciating assets because their knowledge and skills transcend the next business cycle.
Self-regulation and patient-driven care would be possible in a truly free market of insurers and providers, with no financial obligations imposed on providers. These objectives should aim to create a win-win situation in which patient well-being is linked to provider well-being. In this way, we can avoid the ongoing moral harm caused by the healthcare industry.
Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, M.D., is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.