Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.
Doctors are dissatisfied and demoralized with how they are required to practice today, and as a result physician burnout is taking a huge toll on medicine. Innumerable surveys show that more than 50 percent admit to at least one symptom of burnout and that many are relocating in hopes of finding a better practice climate, or exiting clinical practice through early retirement, moving to administration, or simply leaving medicine altogether. But we contend burnout is an inaccurate diagnosis for the condition and instead, that physicians are experiencing moral injury.
Moral injury is generally defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” This concept better describes the untenable double- and triple-binds that physicians are finding themselves in, whereby the countless roles they are expected to undertake often place them in conflict with their primary moral imperative: taking care of the patient.
The underlying problem is, we are being pulled in too many directions. We took oaths to put the needs of our patients above all else, but over time that priority has eroded in the face of economic drivers in healthcare and competitive realities. Too often now, physicians must choose between the needs of their patients and the demands imposed by their employers, productivity metrics, insurance companies, mandates to reduce “leakage,” and satisfaction surveys. The patients’ needs cannot always win—and often don’t.
Physicians are not taught when, why or how to set boundaries, nor are we often encouraged or empowered to do so. In fact, much of a physician’s training contravenes establishing boundaries of reasonableness or responsibility. Lacking comfort and experience in refusing requests or setting limits, physicians fail to demand or negotiate acceptable expectations regarding tasks, responsibilities, allegiance and priority.
When asked to assume responsibility for some aspect of patient care, no matter how thin the thread tying them to that burden, physicians are usually loathe to refuse it. As a result, physicians have gradually taken on the job of data entry clerks, insurance go-betweens, educators in healthcare literacy, coders/billers, and chiefs of customer service.
As the list of responsibilities grows, doctors have not negotiated sufficient off-loads. While other providers such as nurse practitioners, physician assistants and registered nurses have assumed some patient care tasks, the ultimate responsibility for that care typically still resides with the physician. We are a hyper-responsible, control-freakish lot because legislation requires it and everything in our preparation and training has conditioned us to be so.
Not surprisingly, physicians incur moral injury in the face of these competing allegiances and, among other consequences, it is driving the physician suicide rate to more than twice that in the general population. Yet despite a decade of recognition and a rapidly proliferating industry to promote wellness, studies indicate the problem has only grown worse.
Any physician whose treatment for a patient failed so profoundly would reconsider whether the diagnosis was accurate and the treatment strategies well-aligned. In this case, the problem is that moral injury, rather than being an individual challenge with individual solutions, is actually a symptom of underlying dysfunction in the healthcare system, a dysfunction that results in doctors being torn between competing allegiances.