Moral Injury, Burnout, & Resiliency
by Edgar LeClaire
The burnout epidemic has reached critical levels among physicians, and studies have objectively verified its negative impacts on providers and their patients alike. Interest in promoting physician resiliency has increased in an effort to reduce burnout. However, recent evidence points to a more complex relationship: resiliency scores remain high even among burned out providers.
Moral injury may be a hidden variable that can explain this unexpected discrepancy. Whether a separate construct or a predisposing risk factor, moral injury’s relationship to burnout and resiliency has not been investigated experimentally. Furthermore, while moral injury has received robust educational attention within military training domains, it has not yet received such scholarly consideration in academic medicine. Given potential implications for physician well-being and positive patient outcomes, educational interventions will be needed to identify and prevent moral harm.
Physician burnout, a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment, is endemic and now viewed as a public health risk [1]. Studies of both attending and trainee physicians have measured prevalence near or exceeding 50% nationally [2]. Alarmingly, the devastating impacts of burnout are not limited to the suffering practitioner [3]. Burned out providers are more likely to commit errors, be impaired, or leave practice, all of which are costly to the healthcare system [4]. Thus, interest in resilience, the collection of qualities that enable persons to effectively adapt and maintain well-being as they face and ‘bounce back’ from adversity or stress, has increased dramatically [4]. A growing number of national and global institutions, especially physician organizations, are promoting physician resiliency with increased urgency. Indeed, in 2017, the World Medical Association General Assembly voted unanimously to amend the Declaration of Geneva, considered the “Modern Hippocratic Oath,” to better reflect this emerging priority by adding the words: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard” [5]. However, the link between resiliency and burnout is deceptively complex. Recent evidence indicates that physicians show a high prevalence of burnout while also exhibiting high levels of resiliency [6].
A third, hidden variable may deepen our understanding and clarify the burnout-resiliency relationship: moral injury. Broadly defined as “a character wound” resulting from a coerced or self-inflicted violation of an individual’s moral obligation, the concept of moral injury (MI) arose from research on war veterans [7]. It is a concept that delineates measurable injuries that arise from “moral harm” occasioned by work in life-and-death situations. Such injuries include the symptoms of burnout outlined above. Though much is understood about identifying and addressing MI among current and former military personnel, there remains a large gap in what is known about the occurrence of MI among physicians and other healthcare workers who must often work long hours in “high-stakes situations” and persevere through pressures that healthcare systems place on them intentionally or unintentionally [8]. The sources of moral harm can be particularly evident, as during the recent COVID-19 pandemic [9], but can be more insidious as well [10]. In the healthcare context, MI attacks ethical fortitude at its source: “the oath each of us took when embarking on our paths as healthcare providers: Put the needs of patients first” [11].
The Foundations of Moral Obligation curriculum has gained wide acclaim as an effective ‘philosophical toolkit’ for military leaders in training who, all too often, eventually find themselves under the ethical strains of warfare [12, 13]. Could philosophical education be the key component to a successful strategy to overcome the problem of ethical strain and moral injury in the healthcare space? Follow along and join our discussion. Listen to the Resiliency Rounds podcast and get the physician’s perspective as Aneesh and I work through the curriculum.
Listen here: https://podcasts.apple.com/us/podcast/episode-16-the-foundations-of-moral-obligation/id1499292731?i=1000521955023
References:
1. Devi, S., Doctors in distress. Lancet, 2011. 377(9764): p. 454-5.
2. West, C.P., et al., Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet, 2016. 388(10057): p. 2272-2281.
3. Dewa, C.S., et al., The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review. BMJ Open, 2017. 7(6): p. e015141.
4. Epstein, R.M. and M.S. Krasner, Physician resilience: what it means, why it matters, and how to promote it. Acad Med, 2013. 88(3): p. 301-3.
5. Parsa-Parsi, R.W., The Revised Declaration of Geneva: A Modern-Day Physician's Pledge. Jama, 2017. 318(20): p. 1971-1972.
6. West, C.P., et al., Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open, 2020. 3(7): p. e209385.
7. Shay, J., Casualties. Daedalus, 2011. 140(3): p. 179-88.
8. Mantri, S., et al., Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP. J Relig Health, 2020. 59(5): p. 2323-2340.
9. Zhizhong, W., et al., Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic. BMC Psychiatry, 2020. 20(1): p. 556.
10. Wiinikka-Lydon, J., Mapping Moral Injury: Comparing Discourses of Moral Harm. J Med Philos, 2019. 44(2): p. 175-191.
11. Dean, W., S. Talbot, and A. Dean, Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract, 2019. 36(9): p. 400-402.
12. Gibbons, T.J., "Foundations of Moral Obligation: After 40 Years". Naval War College Review, 2017. 70(Number 3).
13. Cullen, J.G., Moral Recovery and Ethical Leadership. J Bus Ethics, 2020: p. 1-13.