On Moral Injury vs Burnout in Medicine
Sometimes I feel like I’m burnt out from hearing about burnout. Lectures on the topic usually involve giving some definition of burnout, then we hear about examples of burnout along with a laundry list of strategies like “talk it out with colleagues” or “give yourself a break.”
The cynic in me thinks all that can be said about burnout has been said, and that devoting what precious little time we have to attending lectures on burnout can drive us to….burn out.
Lately, a new psychological phenomenon has taken center stage, and there is much to be learned about it. It’s called “moral injury,” and no doubt, in the busy life of hospital work, whether or not you ascribed this particular name to it, you’ve suffered from it. Here’s what to know about the difference between the two.
The stoic in me is much more optimistic about moral injury vs burnout. After all, identifying that you’re experiencing the former rather than the latter can lead to strategies you can use to rise above it.
You can ensure that you’re practicing medicine in line with your values, and be a more resilient and esteemed clinician, if you can understand what you’re feeling and experiencing.
Of course, this requires us to identify what moral injury is, and how it can be distinguished from the all too familiar topic of burnout. Let’s begin by having a look at the difference between the two concepts.
Moral Injury vs Burnout: What’s the Difference?
We’ve all heard about burnout from our relative wellness representatives. No matter what phase of training you’re in, you’ve almost certainly been visited by a student/resident/medical staff wellness speaker who told you that burnout is the feeling of emotional exhaustion, depersonalization, and a decreased sense of accomplishment.
Moral injury, on the other hand, is defined as actions (or inactions) that betray one’s deeply held values and ethical principles.
A simple example of moral injury be the idealistic intern, who got into the field of medicine because they felt like patients weren’t being listened to, and instead were being treated like lists of problems instead of human patients who were navigating important medical issues.
The bright-eyed intern was going to make a difference, and give patients his ear for as long as the patient wanted to talk. He was going to make his patients feel heard and empowered, even if it meant staying late at the hospital.
But then, the realities of intern life broke through. While trying to give patients his undivided attention, the phone just keeps ringing. Nurse A needs orders changed. The pharmacy calls and wants a QT interval checked before releasing the Haldol. The resident texts him to say that they’re going to be a little late, due to an employee health visit. There’s still 12 patients to pre-round on, the phlebotomist was unable to get labs on two of them, and the resident is counting on the intern to give today’s morning report on hypercalcemia.
Despite his values and earnest intentions, the intern cannot give the patient the undivided listening he was intent on giving them. His values are being compromised because of the demands of work.
I imagine that anyone working in the clinic where 10 hours of visits are scheduled in eight hours of office time experiences the same injury. Dr. X was going to be the primary care doc who gave patients their due time, instead of truncated 15-minute visits. But with office building rent to pay, a staff that needs support, and decreasing Medicare reimbursements, Dr. X has no choice but to double book, short change patients with the easier problems, and hope to make it through the day without causing harm or unintentional error.
All in all, it’s enough to make anyone…burn out.
Some Examples From an Anesthesiologist
As an anesthesiologist, not a day goes by without production pressure. It’s part and parcel with the territory. I have surgeons tell me, “Don’t do a nerve block for this patient.” I ask them why, and am told, “Because it takes longer.” Yet, the patient wants the block and I want them to experience the benefits of it!
Despite the pressure, it’s up to me to fight against moral injury and act in concert with my values.
Because of staffing shortages, I often have to beg staff to stay late and handle unforeseen emergency cases. The staff that remain are at greater risk for burning out, working more hours, experiencing more exhaustion, and feeling depersonalized, like a cog in the wheel trying to generate money to keep the hospital system afloat.
In order to get the cases done, I have to stretch every other anesthesiologist to cover four rooms, which means everyone is practicing close to the limits of their ability to know what’s happening at their sites. There’s an irony related to moral injury here as well. Many of us get into anesthesia to focus on one patient at a time, and know every minutiae regarding this single patient’s medical history and current care.
But instead, I’ve got three patients waiting to be pre-oped, four patients in the OR, and two more in the PACU. So much for knowing everything about everyone. And all of that mental burden leads to…burnout.
How to Handle Moral Injury vs Burnout
Yes, both life and medicine can be tough. How can we respond to moral injury? Once you realize your morals and ethics are being compromised, blow the whistle, stop, and think what changes can be made that’ll allow you to practice closer to the way you intended.
See if any creative solutions can be thought up to “make time.” Maybe your medical student can talk to that patient with low health literacy for an extended period of time, and help the patient understand why diabetes is bad.
If you want to do what you think is the right thing for a patient, go ahead and do it, even if it takes longer or requires more effort.
Regarding burnout, that’s a tougher challenge, especially as the demands of medicine and expectations of patients continue to grow. I haven’t any brilliant solutions here, other than what the greats have offered time and time again: take care of yourself so you can take care of your patients, remember why you got into medicine, lean on others when you need to, and ask for help if you need it.
Further Reading
I hope you found this discussion on moral injury vs burnout helpful! Remember, there are simple (though not easy) things you can do to combat moral injury. Try your best to stay true to your ethics even when work makes that hard to do. The bane of burnout has no simple solution, but you’re no doubt familiar with the tried and true tactics used to combat it.
Getting a handle on these two hazards in healthcare will make you a healthier and happier physician. Stay true to yourself, take care of yourself, and reach out if you need assistance!
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