Is All Burnout, Moral Injury? Not Necessarily. Does it Matter? It Might.
The right diagnosis is critical to choosing the right intervention. Fully understanding a problem is critical to finding the right solution. The same is true when it comes to the challenges facing physicians. Solutions to the burnout epidemic need to be tailored to each physician’s unique situation.
Physicians will be “well” when organizations appreciate and demonstrate how much they are valued; when they commit sufficient resources to help physicians provide outstanding care; when they alleviate unnecessary workload; and when they provide every physician with support, tools and a plan for a sustainable, rewarding career.
We’ve been discussing the issue of burnout and moral injury with our team, our Advisory Board, and our clients. The J3P team consists of physicians, psychologists and consultants who’ve been providing coaching, operational, business, legal, and career guidance to physicians for decades. Our Advisory Board is made up of leaders in academic medicine and organizational psychology.
Recently, we’ve noticed a trend in the literature and social media arguing that burnout is NOT the right label for what many physicians are facing - that they are really facing “moral injury.” Is burnout the same thing as moral injury? When we talk to physicians and evaluate their frustrations and challenges, are they, indeed, dealing with moral injury?
Certainly, the term moral injury raises the stakes and calls more attention to the problem. Perhaps though, in taking this approach, we are hampering our ability to address the problem and effectively help physicians – because if they are different conditions, then it’s possible they require different interventions.
This doesn’t lessen the seriousness of the problem – but it does point us, potentially, toward a different set of solutions.
In our opinion, some physicians are, indeed,in situations that are causing moral injury. Many other physicians, though, are facing situations that fall under the definition of burnout. This doesn’t lessen the seriousness of the problem – but it does point us, potentially, toward a different set of solutions.
Burnout
Quite simply, burnout occurs when demands outstrip the resources needed to meet those demands. Freudenberger is credited with bringing the term “burnout” into the research lexicon in 1974, defining it as the loss of motivation, growing sense of emotional depletion, and cynicism he observed among volunteers working at a free clinic in New York City. The cardinal symptoms include exhaustion, depersonalization (“compassion fatigue”) and alack of efficacy, and sense of personal accomplishment or purpose.
The term burnout does not specify whether the problem is the demand, the individual resources to meet the demand, or both. The problem is that many physicians, rightly, perceive that organizations frequently imply that the nature of the problem is, indeed, the individual. They only offer solutions targeting the individual and refuse to address the underlying organizational and system deficiencies.
Moral Injury
Moral injury,on the other hand, is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.
The term “moral injury” is thought to have originated in the writings of Vietnam War veteran and peace activist Camillo “Mac” Bica (Brock & Lettini, 2012; Bica, 1999, 2014), and Jonathan Shay (Achilles in Vietnam: Combat Trauma and the Undoing of Character, 1994) as the aftermath of war zone trauma.
Identifying the nature of the problem is critical in order to examine potential interventions. Labeling every situation as moral injury may not be helpful.
Moral Injury in Medicine is Real
Are physicians suffering from burnout, or moral injury,or both? Does the difference matter?
We’ve worked with physicians who are forced to practice in situations that transgress their moral beliefs, values or ethical codes of conduct. Examples:
Physicians working with insufficient organizational resources - causing unacceptably poor quality of care. The problem is compounded when administration appears unwilling to appreciate the situation or to address the deficiencies.
Physicians expected to meet productivity standards, including administrative tasks, that force them to provide a level of care that falls below their standards.
Physicians forced to make decisions on a regular basis where they must balance the needs of patients with the demands of the organization, to a level that it violates their ethical code so consistently that it causes serious emotional harm.
In these situations, the physician faces, on a daily basis, a crisis of conscious and morality that harms her moral compass. These are extreme situations and there are no easy solutions. Rarely is the physician in a position to rectify the underlying conditions. The physician is often left with the choice between staying and suffering the emotional damage, or leaving – possibly suffering from a feeling of failure, career crisis, and abandoning patients in need.
Burnout Does Not by Definition, Blame the Individual
Many of the physicians we work with are in challenging situations that they would not categorize as moral injury. They would not describe their situation as challenging their ethical code or causing moral injury. They are, indeed, frustrated and angry, but,the workload and stress have merely outstripped their capacity to manage them. They are not facing serious, regular ethical dilemmas or damage to their moral compass.
This does NOT mean they aren’t facing burnout or that the system isn’t broken. This does NOT mean that organizations don’t need to take ownership over unacceptable situations and demands. Some physicians are burned out but still able to provide outstanding care. It just takes too much physical and emotional energy, and is not sustainable. Interestingly, that same workload might be tolerable for someone else.
This is not uncommon - One physician can handle a particular workload. A colleague in the same situation, however, might quickly reach a stage of burnout. Why? The second physician may struggle adapting to change, managing his schedule effectively, or be facing challenges outside of work. He may not handle conflict well,meaning otherwise manageable situations quickly become frustrating and overwhelming.
Burnout does NOT, by definition blame the individual. Burnout merely means that “demands outpace capacity.” The problem could be on the demand side of that equation or the capacity side. What is, rightly, frustrating is that organizational “solutions” to burnout all target the individual!
What is, rightly, frustrating is that organizational “solutions” to burnout all target the individual!
When we work with a struggling physician, we examine both sides of the equation. Often, we CAN lessen the demand, to some extent. We can address scheduling issues, staffing issues, process changes, give physicians more of a voice, and establish reasonable performance goals. What we remind physicians, though, is that the system is not going to change quickly so we need to do what we can to better equip them to survive and, hopefully, thrive.
Our discussion on this topic included Karen Weiner, M.D., M.M.M., CPE Chief Executive Officer of Oregon Medical Group, an independent, physician‐owned multi specialty medical organization in the Northwest. Dr. Weiner is also on the Board of Directors for the American Medical Group Association.
Her thoughts on the issue:
"I see moral injury as an extreme form of personal values being violated in the workplace. We know from the original research on burnout by Maslach and Leiter that “ability to honor ones core values” is one of the six identified domains of work-life that either contribute to, or protect against, burnout. (The other five being workload, community, control, fairness and rewards.)
Karen Weiner, M.D., M.M.M, CPE
CEO Oregon Medical Group
For some physicians, experiencing their “core values being violated” in the workplace is responsible for their experience of emotional exhaustion, cynicism and a loss of sense of personal accomplishment (burnout). These concepts are not mutually exclusive but rather intimately related. Core values violation is a known cause of burnout.
The other five domains of work-life are just as important and if we ignore them in pursuit of focusing entirely on “moral injury”, we do ourselves and our physicians a disservice. The challenges could be more related to addressable workload issues, or personal resources such as social support and personal coping mechanisms, etc. If we do not take the time to understand the unique organizational as well as personal contributors, we won’t be able to make a dent."
A Practical Approach
Consistent with Dr. Weiner’s comments, when we work with individual physicians or organizations, we strive to understand the situation and its causes. If a physician is in a situation where her core values are being violated, and she is not in a position to influence change, there may be serious decisions to be made. If it doesn’t rise to that level, it may still be a serious threat to the physician’s emotional well-being and career satisfaction and success.
In these situations, we strive to resolve any operational or workload issues contributing to the problem. Regardless, though, we work to provide physicians with tools, insight, skills, and support to help them better manage the demands and frustration. Examples:
If physicians are in a position to influence change, then we need to give them the communication and influencing skills to be effective change agents.
Physicians leaders need to develop effective leadership skills. Nothing is more frustrating than trying to meet challenges for which you aren’t equipped.
Heightened self-awareness can be the foundation for better relationships with colleagues, administrators and staff. More productive relationships allow the group to resolve issues with less frustration and stress.
Some physicians, merely, need to develop better planning and organizing skills. There are brilliant clinicians who suffer great stress because they are ineffective at managing time – particularly when it is so hard to balance the demands of practicing medicine today, with a life at home.
Physicians need to stay focused on compassion because research shows that those who are effective at using compassion to engage patients, find their work more rewarding and are less likely to be burned out.
Finally, you may notice we’ve not talked about wellness program staples - yoga, mindfulness training, diet and exercise, or amenity services like dry-cleaning, child-care, etc. This doesn’t mean these can’t be part of the equation. Anyone can benefit from better self-care skills. We’ve worked with physicians who will admit that a combination of improving their health, and adding meditation to their life, made them far better equipped to handle their professional and personal stress and avoid burnout – with no change on the “demand” side of the equation. But again, we offend physicians when we propose that these approaches will solve the problem on large scale.
The Take-Aways?
Moral Injury is real.
Not all burnout is caused by moral injury but moral injury (a violation of core values) can lead to burnout.
Identifying the nature of the problem is critical in order to examine potential interventions. Labeling every situation as moral injury may not be helpful.
The situation, the factors, and the solutions are unique to the individual. There is no single mix of solutions that will solve the problem for every physician.
Physicians will be “well” when organizations appreciate and demonstrate how much they are valued; when they commit sufficient resources to help physicians provide outstanding care; when they alleviate unnecessary workload; and when they provide every physician with support, tools and a plan for a sustainable, rewarding career.
To learn more about J3P supports physician, and physician leader, success, visit us at j3p.health.
