Burnout vs. Moral Injury?

Burnout has been defined as a work-related mental state, with physical and emotional exhaustion, mental distance, impaired emotional control, impaired cognitive control with depressed mood, psychosomatic complaints, and psychological distress.

The Maslach Burnout Inventory concentrates on 3 areas: 

1. Emotional exhaustion,
2. Depersonalization - withdrawal or distancing from work with increasing negativism,
3. Reduced efficacy or self-accomplishment.

Many of us can relate to this, yet many also resist being characterized as burned out because it suggests that the individual lacks the resources or resilience to withstand the rigorous medical environment. I know this is how I felt throughout my personal burnout journey, and the majority of physicians I have spoken to feel the same way; “I love my patients, but I hate my job" – the paperwork, the EMR, the metrics and pay for performance… etc.  "There is nothing wrong with ME – it’s secondary to all the other competing priorities that I can’t handle while trying to provide the excellent patient care that I am used to giving.”

• 6 Categories of Competing Demands placed on Healthcare Staff:
  • Lack of time to provide the excellent care the patient needs and deserves
  • Documentation and other administrative demands with inefficient EMRs; with most clinicians being without the use of a scribe,
  • Regulatory (insurance and value-based reimbursement) requirements
  • Productivity metrics and pressures to see more to keep the business afloat
  • Organizational goals
  • Other Healthcare system dynamics - recruitment and retention issues as of late. 

The compilation of these factors has caused a huge rise in burnout symptoms amongst healthcare workers.  Notice that most of these categories are system issues, which seem very much outside of our ability to control or have influence over.  Because leaders don’t understand (or want to admit) the major distinction between individual and system issues, they place the responsibility on the individual to find and implement their own burnout solutions: yoga, meditation, wellness retreats, or counseling.  While people obviously benefit from these practices, as there is nothing inherently wrong with them, it is disingenuous to believe that these alone will solve the health system problems that are intricately interwoven in the burnout process. System issues are NOT the result of some individual failing!

A better description of what many healthcare professionals are experiencing is Moral Injury, a term which was was coined in 2019 by Dr. Wendy Dean et. al.  
 
“Moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” 

• Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held values, moral beliefs, Hippocratic oath or behavioral expectations.
• It can be the distressing psychological, behavioral, social or spiritual aftermath of:
  • exposure to injustice because of medical or leadership malpractice,
  • shouldering intense burdens and unrealistic expectations, or
  • unanticipated adverse events.

Whether you refer to it as burnout or moral injury, there are many causes; the consequences of which create significant binds in how we deliver care. How do we proportion our limited time: take thorough care of the patient, the hospital, the insurer, the EMR, the health care system, the productivity metrics, ourselves and our families!? The business framework of medicine pressures us to serve all these masters at once – an impossible feat!

• Moral injury appropriately locates the source of distress to a broken system, rather than a broken individual. It allows us to direct our primary strategies at the causes of most distress – the system.   
• Treating moral injury will not be simple, nor will it happen without widespread engagement. Change can begin when clinicians (We) and administrators (They) come together, identify the specific struggles each face and respectfully convey those challenges to the other party.  Both sides need to be willing to listen and work collaboratively; to synergistically build a bridge across this chasm to manage the dilemmas together as a healthy team.  When organizations do that, the culture and outcomes of health care delivery will improve.

How prepared and/or willing are you to take on this challenge?

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