Moral Distress as a Critical Driver of Burnout in Medicine

Abstract

There are many known drivers of burnout and distress among physicians and other healthcare providers. Current conversations have not fully characterized the significant impact of workload increases alongside staffing shortages as drivers of moral distress and subsequent burnout. Together these factors pose a significant systemic threat to the workforce, and a personal threat to the individuals within it. Physicians are at high risk for moral distress because of work ethic and culture. The drive to do the right thing for the patient limits an ability to set boundaries around work. Moral distress is experienced when the needs of patients can’t be met; this drives us to work even harder. Culturally, there has been limited opportunity to acknowledge this distress, so we haven’t been able to deal with it outright. Financial pressures continue pressure health systems to drive productivity. Additional patient encounters drive more after visit work that requires time and attention. Simultaneously, the remaining physicians are further stretched as people burnout and leave. There are few groups of workers more mission-driven than primary care physicians. We are committed to doing the right thing for patients and our teams. If we can acknowledge and talk about moral distress as an indicator that we need to change the way we do things, we can use it as a tool to optimize patient care. The physician voice may help us move beyond the learned helplessness and shift to engagement in solutions. We propose three solutions: 1) acknowledge the presence of routinized stress injury that occurs in healthcare 2) leverage data on physician wellbeing to understand how to optimize care, and 3) foster connection and community. Fundamentally, when our healthcare workers feel seen, heard, and valued, they are healthier themselves, and better able to support the missions of the medical system.

“Days felt like digging out of an avalanche with a teaspoon.”

The post-Covid Great Resignation was a cultural cry for help. Among the many fields deeply affected, medicine buckled during and immediately after COVID in ways that continue to reverberate. One of our authors, who had dedicated 20 years to caring for patients and families in the same family medicine practice, experienced severe burnout during this time. Despite having built meaningful and deep connections with her patients, she found herself overwhelmed. The challenges she faced had been simmering even before the pandemic, but as the crisis worsened and her workload skyrocketed, her burnout intensified. Burnout manifested in several ways: emotional exhaustion, a growing sense of detachment from her patients, and a diminished sense of personal accomplishment. She felt constantly drained, both physically and mentally, and began questioning the value of her work. Most nights, she found herself working until midnight just to catch up, sacrificing her own well-being and personal time. Looking back, this grueling routine was not just about the physical demands but also a reflection of moral injury. The relentless stress led to disillusionment. In retrospect, this pattern was partly a reflection of the moral injury evident in many practices across the globe. ¹

Moral distress is a compromise of moral integrity where there is conflict between what a person feels they should do based on their values but is constrained from doing.^2,3 This conflict can cause an acute negative emotional reaction. If situations continually arise causing moral distress, the impact can build over time. Emotionally distancing from the patient and team can ease distress by limiting the sense of responsibility to others, but can compromise care; if unchecked, burnout (as defined by a combination of emotional exhaustion, depersonalization and reduced sense of accomplishment) can result.^4,5 Furthermore, repeated episodes of moral distress can lead to moral injury defined as psychological and spiritual harm that results from violating or witnessing the violation of one’s core values, a more significant phenomenon with the potential for lasting substantial impact on a person’s mental health.^2,6 Moral injury is more common in extreme situations such as war or natural disaster, but healthcare, since the onset of the COVID pandemic, has faced a surge in both moral distress and, increasingly, moral injury. Both moral distress and injury are associated with burnout but are distinct constructs. ⁷ In the case above, the physician knew the answer was to slow down, take more time to work in community with others, but moral injury occurred when the system failed to provide more time or resources, and the physician was forced to compromise frequently and repeatedly, consistent with the Job Demands-Resource model of burnout. ⁸

The typical primary care physicians sees 20 patients per day. ⁹ Between, or even during these visits, providers manage in baskets which can have up to 100 asynchronous tasks/day including prescription requests and refills, patient questions, prior authorizations, calls to other specialists, patient family concerns, as well as lab and image results that need to be addressed. ¹⁰ Many tasks and interactions pose questions that have no clear answer, or cannot be answered asynchronously or in a reasonable timeframe. This can leave a physician feeling frustrated and helpless. Some scholars call this excessive cognitive load, but it is more than cognitive load alone. This repeated stress can result in injury over time. Our author’s experience was not an isolated experience.

Measures of moral distress such as the MDD-HP can point to common sources of distress, including being required to care for more patients than can be done safely, excessive documentation requirements that compromise care and experiencing compromised patient care due to lack of resources. ¹¹ Examples of the subtle but repeated points of contact currently perpetrating moral distress experienced in a typical day of a primary care physician can look like these experienced by the author:

• • Message from clerical staff: Hi Dr This patient needs to get in to see you, but there aren’t any openings. Where would you like me to put them?

• • Message from patient: Hi Dr This is patient X. I cannot get an appointment to see you until 6-12 weeks from now, but wanted to discuss my dizziness and fatigue with you. Can you please order labs or testing to figure out why I’m feeling the way I am while I wait for my appointment?

• • Message from patient: Hi Dr I am tired of being told you don’t have any openings to see me. I would like to switch to another doctor so that I can get in to see them when I need to.

• • Discharge note from ED visit: Hi Dr This pt is being discharged s/p NSTEMI with anemia thought to be secondary to GI bleed. PCI took precedence so no GI procedure was performed during this hospitalization. We could not get him scheduled with GI, so have asked him to follow up with you instead.

• • Message from support staff: Hi Dr This patient’s insurance does not cover the medication you prescribed, and they cannot afford it. What would you like to do?

• • In person office visit: Hi Dr It’s nice to meet you. I am on these 15 medications which I would like you to refill for me. In addition, I would like to discuss my fatigue and memory difficulties.

At the end of a day full of these small examples of moral distress, providers are frequently left feeling frustration, guilt, helplessness, anger, and decreased satisfaction with the quality of care provided and ultimately begin to experience moral injury. When these issues are not acknowledged, one starts to feel devalued by their employer, viewed as a replaceable cog, and as a source of earning potential rather than as a medical practitioner focused on developing the meaningful relationships with patients which are correlated with high quality care. ¹² Eventually the positive feelings of working in medicine can be overshadowed by the overwhelming negative feelings associated with the inability to provide quality care. Perpetuating this vicious cycle, burnout can result, followed by a decision to prematurely leave the workforce. This, in turn, leaves the remaining team more understaffed and more at risk.

Our co-author, who left her practice in favor of early retirement, actually returned to the work force, once she was able to step back and take the time to assess the issues at play. She initially took a position working in urgent care which was busy, but rewarding. Notes were easily completed within her shift, and there were very few in basket tasks to manage. The feelings of burn out slowly disappeared and a sense of joy in medicine returned as she experienced more of the positive emotions associated with caring for others and a sense of accomplishment of a job well done. Later, joining an academic family medicine program allowed her to pursue multiple interests which proved to be another way to combat burnout. While this individual’s situation improved, moral distress and injury are widespread. ³ In order to keep our work force productive, strong, and able to provide quality care to our communities, we need to seek solutions to the moral distress broadly.

Workforce turnover was impacting medicine prior to the Covid-19 pandemic, ¹³ but the problem escalated during and since. While trying desperately to recruit new workers, clinics remain short-staffed and the remaining healthcare workers are often overwhelmed by the work load. Workforce has become the new buzz-word in healthcare administrative circles, and there is an ever increasing and urgent discussion about what drives the epidemic of burnout in healthcare. We posit that these conversations about workforce and burnout frequently overlook the root cause. Physician burnout is often attributed to tangible issues such as feeling too busy or having to maintain too many records, or carry too large a panel size, and clearly these are concerns, but we posit that more subtle issues are at play related to moral injury and moral distress that are often a root cause. Moral distress pushes physicians to work beyond usual limits while simultaneously the culture within medicine prevents acknowledging and discussing that distress. This culture classically discourages open communication of stress injury specifically considering it a personal weakness. ¹⁴ While we may feel comfortable talking about the workload or staffing, issues that underlie the current climate include moral distress and moral injury are often more difficult to acknowledge and may include:

• • The belief that the patient is first and physicians should not show or talk about their own emotions.

• • Physicians often have an unrealistic sense of duty: I should be able to do everything, I should be able to manage it alone.

• • The belief that working to exhaustion is a badge of honor and that we should take pride in having done so.

• • A feeling of not doing enough, no matter how much time and effort is put in.

• • Clinical uncertainty and difficult outcomes can drive self-doubt.

In this paradigm, physicians work until they can’t take it anymore, trying to meet the needs of the patient above their own as evidenced in this example. The moral distress accumulates, leading to moral injury. Eventually, they may leave their job or even the profession.

If moral distress and the culture of medicine are currently contributing to burnout, and burnout is resulting in individuals leaving healthcare, what are possible solutions? COVID-19 and its aftermath have been a massive disruptor in the way we do business. Almost every aspect of the way we work has been impacted. One silver lining is that disruption is often an ideal time to consider change for the better. We have roadmaps of how to help not only individuals but organizations make sustainable change.^15,16

We need to consider changes at the individual, leadership and organizational levels. ¹⁵ We need to be clear in regards to each person’s roles and responsibilities for success. Considering what we can personally impact can be a good first step. Each of us can work within our locus of control. Individuals can help leaders understand what gets in their way. Leaders can listen and empower individuals and remove barriers to success. ¹⁷ Organizational experts can help structure and guide these efforts. To be successful, we need to consider both articulated drivers: workload, staffing, voice (do you hear and value me) as well as unarticulated drivers (culture and moral distress). By recognizing and discussing the distress of the current system, we can use our voice to change the system.

As we address the culture of medicine that has led us to our current unsustainable reality, there are three priority areas that will help us move forward to a more sustainable future. First, the roadmap to the future starts with an open discussion of the role stress injury and specifically moral injury plays in the practice of medicine. Secondly, we must move toward connection and community which can be intentionally re-enforced. ¹⁸ Thirdly, we must focus on using local data to understand the relationships between moral distress/burnout alongside the outcomes health systems typically track and prioritize such as clinical quality, patient experience and finances. ¹⁹ This data can be used, for example, to address panel sizes, improve box management and allow dedicated time for all types of clinical work, not just those that are directly billable. Using data to understand workplace optimization will help create further agency for change by generating positive feedback loops where physicians see that the organization hears them and understands their needs. It will also allow for a closed feedback loop to enable the rightsizing of work. This work fundamentally serves the missions of a health system by improving the quality of care provided, reduces moral injury and keeps clinics open and operating in a patient centered way. Nationally recognized programs such as the National Academy of Medicine’s National Plan for Healthcare Worker Well-Being, the Institute for Healthcare Improvement’s Framework for Joy in Work, the American Medical Association’s Joy in Medicine Roadmap and the Nursing Magnet Program can serve as practical guides^20-24 (see Table 1). Lastly, a newly evolving intervention, the Moral Distress Consult, has been implemented in some centers.^25,26

Table 1.

Resources for Addressing Burnout and Moral Injury in Healthcare Workers.

Organization	Resource
National Academy of Medicine	National Plan for Health Workforce Well-Being 20
American Medical Association	Steps Forward toolkits 21
	Joy in medicine roadmap 22
American Nurses Association	Magnet recognition program 23
Institute for Healthcare Improvement	Framework for Improving Joy in Work 24

As our formerly burnt-out colleague re-engages in clinical medicine, she has the opportunity to share by example how addressing moral injury head on can change the way we approach burnout. The first step is recognizing and acknowledging that it is happening to you. The next step is to implement change. For our author this included setting boundaries, pursuing opportunities for professional development, and developing connection and community through open communication. Her new employer had processes in place to use data to support the physician experience. Recovering from moral injury is a process that requires time, patience, and a supportive environment. Combining these strategies can help build resilience and foster a sense of well-being, enabling healthcare professionals to continue their essential work with renewed energy and purpose.

ORCID iD

Amy Locke https://orcid.org/0000-0002-6127-5361