The systemic nature of the problems means they are not amenable to easy solutions. Nevertheless, it is essential to begin making inroads into the crisis of moral distress. The first step is to recognize the untenable conflict for physicians imposed by multiple competing allegiances in order to begin establishing boundaries around those obligations. Being caught in the double- and triple-binds of serving opposing masters is a major contributor to moral distress.
And while resilience is important for any high-intensity career, the solution in this case is not simply to train physicians to be more resilient to a system that disempowers them but to create a system in which the physician is enabled, empowered, and encouraged to do the job of taking care of the patient above all else.
In addition, we need health systems led by practicing clinicians who are committed to improving clinical care. Those leaders understand, on a visceral level, the day-to-day challenges of trying to care for patients. They understand, for example, that accomplishing a single task in an EHR might require clicking through a dozen windows and re-populating fields. They know where the EHR needs to change to improve the user experience and to facilitate care, rather than interfering with it.
Those hospital leaders also have a mandate to communicate to their physicians not just what salary they are worth, but the unique value physicians as a whole, and individuals in particular, bring to the organization. By pushing back against unreasonable insurer requests, unproven requirements of the Joint Commission, regulatory demands, pressure to adopt a retail model of care, which undermines the doctor-patient relationship, and redundant institutional requirements, clinician leaders demonstrate to their physicians that their time and efforts matter, and that they are an asset worth protecting.
Medicine also needs a robust process for identifying young physicians with leadership potential and investing in developing those skills. The military has done this for decades, largely successfully. While we are not advocating a “military” style of training, there are lessons we can learn about how to spot those with leadership talent, when and how much to invest in developing them, and what are the skills one needs to hone in order to lead effectively.
Finally, we must refuse to accept competing allegiances, nonsensical responsibilities and any solutions that erode relationships with our patients. Only by saying “no” to some of what is now asked of physicians can we begin to break the binds that tie us to moral distress and injury.
Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Dean is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine.