Reframing Clinician Distress: Moral Injury Not Burnout

To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.¹ Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.

Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.

These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.

The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.

Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.

Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”² Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment. ³ Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.⁴ However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.

Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multi-pronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.

A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.

It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.

We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.

An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.