Many physicians are in turmoil. And many physicians are in turmoil about what that turmoil actually is. Much of it may have been fueled by the transition from the practice of medicine to the business of medicine to participation in the healthcare industry.
Many experts say that physicians are experiencing burnout, which is characterized by emotional exhaustion, depersonalization, and a sense of reduced accomplishment. In fact, burnout is reported in 40 to 80 percent of physicians and residents. Many causes for burnout have been offered, including hours worked, loss of autonomy, and the EHR.
One indication of the turmoil is the proliferation of articles and discussions about burnout among physicians. The term “burnout” is credited to Herbert Freudenberger in his 1975 article “The staff burn-out syndrome in alternative institutions.” The term “physician burnout,”related to residents, and physicians, first appeared as early as 1981 in the American Medical News. Many more articles about burnout in medicine appeared in the 1990’s starting with descriptions of burnout related to the practice of oncology. The sustained number of recent physician-burnout related articles attests to the ubiquity and urgency of the topic. But the validity, nature, and usefulness of the burnout concept is being questioned. Several articles have suggested that “moral injury,” not burnout, is the essence of current physician distress.
The origins of moral injury
Moral injury is characterized as the result of being forced to engage in actions contrary to one’s moral values. In healthcare, moral injury is cast as the result of problems with healthcare systems that force physicians to provide care that is compromised and thus conflicts with their values of quality care. This perspective blames stresses from the systems for physician distress and emphatically states that their distress is not due to a lack of resilience, which the term burnout implies.This application of moral injury echoes, but is different from the related concept of “moral distress” (also called “moral regret” and “moral residue”) in nursing, which occurs when a nurse knows the morally correct action but is constrained from doing that action.
The term moral injury, however, has been appropriated from the military, with special emphasis on currently returning veterans. The origin of the concept is attributed to psychiatrist Jonathan Shay who spent over twenty years working in the Veterans’ Administration.
It should be easy to understand how the requirements, brutality, and devastation of modern war can create moral dilemmas for soldiers. It is reported that 28 percent of service members have acknowledged that they faced ethical situations in which they did not know how to respond.
It is not clear, however, why there is a sudden interest in “moral injury” as a replacement for “burnout” in the medical literature. Perhaps it is a sincere attempt to clarify the turmoil physicians have been experiencing as medicine continues to change. Perhaps it is a dramatic phrase to draw greater attention to physician concerns. Perhaps it is more complimentary and ego-syntonic than a diagnosis of burnout or depression. Perhaps it stems from a need to publish something new in this area and burnout is old news. Perhaps it is something to do and to write about in the face of limited potency to find solutions that can move powerful financial interests and political complexities.
Whatever the reason, the use of this term and the importation of this concept from the military should be done with caution and humility, if at all. There are several reasons for this hesitancy.
Concerns over replacing burnout with moral injury
First, while the existence, nature, and impact of burnout has been thoroughly researched, methods to accurately and objectively define and assess moral injury in healthcare and, as a result, data on its prevalence, seem absent. A recent study attempted to delineate moral injury in medical students, but, while well-intentioned, it consisted of a qualitative analysis of thematic overlap from a focus group methodology with a total of five students. Even the military is continuing to devise measures of moral injury and determine the exact prevalence.