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Burnout = a symptom of something larger: our broken health care system.

The moral injury of health care is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people.

Preventions of delivering good patient care:

- Electronic health records: distract from patient encounters and fragment care, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions.

- The constant specter of litigation (practice of settling a dispute) drives physicians to over-test, over-read, and over-react to results.

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hysicians on the front lines of health care today are sometimes described as going to battle. It's an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it's portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

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We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers' highly conflicted allegiances - to patients, to self, and to employers - and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.

The term "moral injury" was first used to describe soldiers' responses to their actions in war. It represents "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations." Journalist Diane Silver describes it as "a deep soul wound that pierces a person's identity, sense of morality, and relationship to society."

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one's goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one's patients. Failing to consistently meet patients' needs has a profound impact on physician wellbeing - this is the crux of consequent moral injury.

In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients' best interests when deciding on treatment. Financial considerations - of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself - lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results - at times actively harming patients to avoid lawsuits.

Patient satisfaction scores and provider rating and review sites can give patients more information about choosing a physician, a hospital, or a health care system. But they can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied. Business practices may drive providers to refer patients within their own systems, even knowing that doing so will delay care or that their equipment or staffing is sub-optimal.

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of "death by a thousand cuts." Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay - wounded, disengaged, and increasingly hopeless.

In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won't solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses "information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water" in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the "disaster zones" where they work are the everyday operations in many of the country's major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.

We need leaders who recognize that caring for their physicians results in thoughtful, compassionate care for patients, which ultimately is good business. Senior doctors whose knowledge and skills transcend the next business cycle should be treated with loyalty and not as a replaceable, depreciating asset.

We also need patients to ask what is best for their care and then to demand that their insurer or hospital or health care system provide it - the digital mammogram, the experienced surgeon, the timely transfer, the visit without the distraction of the electronic health record - without the best interest of the business entity (insurer, hospital, health care system, or physician) overriding what is best for the patient.

A truly free market of insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care. These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of health care.
Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women's Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, M.D., is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.

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Physicians aren't 'burning out.' They're suffering from moral injury - STAT

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hysicians on the front lines of health care today are sometimes described as going to battle. It's an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury. Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it's portrayed as burnout.

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PROFIT > CARE

The underlying issues / consequences behind profit-oriented care (e.g. negatively impacting patients and the quality of treatment they receive)

HCWs are being overworked due to HCW shortage, and as a result is neither beneficial for the mental health of practitioners or the care of patients

Many doctors have resigned, not because they are burnt out, but rather the moral injury they are suffering from. In today’s society, many practitioners are demanded to focus less on patient care, which is what most physicians enter into medicine for, rather than inputting data.

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Dehumanization: Prioritizing profit over care can lead to the dehumanization of patients. When financial considerations take precedence, patients may be viewed more as sources of revenue than individuals with actual healthcare needs.

Erosion of Ethical Values: The symbolic violence lies in the erosion of the ethical values that underpin healthcare. The shift towards profit-centric models can compromise the fundamental principles of medical ethics, such as prioritizing patient welfare and the doctor-patient relationship.

Disempowerment of HCWs: Healthcare workers may feel disempowered when profit becomes the primary focus. Instead of being advocates for their patients, they may find themselves constrained by profit-driven policies that limit their ability to provide optimal care.

Data-Driven Focus Over Patient-Centered Care: When healthcare becomes more about meeting metrics and less about addressing individual patient needs, it undermines the core purpose of medical practice.

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Overworked Healthcare Workers: The shortage of healthcare workers creates a structural issue where existing staff are overworked to compensate for the deficit. This can lead to burnout, fatigue, and a decline in the quality of care provided.

Moral Injury: The pressure to prioritize profit can result in moral injury for healthcare practitioners. Moral injury occurs when individuals are put in situations that violate their moral and ethical principles. In the context of healthcare, this can happen when practitioners are forced to compromise patient care for financial goals.

Demoralization: The phenomenon of doctors resigning due to moral injury highlights a structural problem within healthcare systems. When healthcare professionals are demoralized and feel their commitment to patient care is compromised, it has significant implications for the overall quality of healthcare delivery.

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Modern medicine has morphed from a healing profession into a business where the primacy of profit takes precedence over greater human needs.

The survey findings indicate that Americans are uncertain about care options as they age and are reluctant to discuss their personal needs with a healthcare system they do not generally trust

There is still profit to be made maintaining the status quo. However dismal the health care situation has become for individuals and families, the for-profit health care industry still churns out billions in profits.

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By JOANNA GARRITANO
GUEST COLUMNIST
Seattle Post-Intelligencer

Though elected officials and experts alike are perplexed about how to solve the current health care crisis, it isn't difficult to recognize the health care problems facing Americans. The 47 million Americans without health care coverage are not the only ones who confront tremendous barriers to health in this country. Businesses, families, workers and people of all ages are finding U.S. health care too expensive and unresponsive to their needs.

Why is this happening?

Modern medicine has morphed from a healing profession into a business where the primacy of profit takes precedence over greater human needs. Trusting relationships with medical professionals have taken a back seat to efficiency standards as patients are rushed through doctors' offices.

With just enough time to peer into a few orifices and change a prescription or two, doctors race to keep up with market demands. Market-driven medicine tears at our moral fabric as people are seen as commodities - mere bodies to insure rather than complex individuals with diverse human needs. Sharp market strategies, though suitable when shopping for goods, will always fall short in defining the value of health, or the value of life, for that matter.

With the resources and ingenuity of the American people, we certainly can do better. Yet, we are fooled into believing that more expensive means better care. The truth is that we spend twice the cost per capita compared with other developed nations, yet are ranked 37th in overall quality, according to the World Health Organization. Americans face higher infant and maternal mortality rates and a shorter life span than our counterparts in other industrialized nations that offer comprehensive health coverage for all their residents.

Why do we tolerate this unstable and unjust situation?

The answer: There is still profit to be made maintaining the status quo. However dismal the health care situation has become for individuals and families, the for-profit health care industry still churns out billions in profits. In a democratic nation founded on principles of "liberty and justice for all," the health and well-being of the many should not come second to the financial benefit for the few.

Close to home, Gov. Chris Gregoire has recognized the disastrous effects that the current health care system is having on Washington residents. In 2006 she charged a team of state officials, the Blue Ribbon Commission on Health Care Costs and Access, to seek solutions at the state level. The recommendations from the BRC will influence legislation in 2007 and direct health care changes in the years to come.

Though the commission should be acknowledged for attempting to address cost and monitor quality, its recommendations fall far short of offering any tangible solutions to the most pressing issue - how to provide affordable high-quality health care for everyone.

It is incumbent upon us all to demonstrate the political will to fundamentally challenge the system in which administrative waste and profiteering are allowed to stand in the way of human health and well-being. Single-payer publicly funded health insurance with privately delivered health care may just be the solution we are looking for.
Joanna Garritano, M.D., is an emergency department physician at Virginia Mason Medical Center, Seattle, and chairwoman of Physicians for a National Health Program, Western Washington.

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U.S. health care puts profit over people - PNHP

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By JOANNA GARRITANO GUEST COLUMNIST Seattle Post-Intelligencer Though elected officials and experts alike are perplexed about how to solve the current health care crisis, it isn't difficult to recognize the health care problems facing Americans. The 47 million Americans without health care coverage are not the only ones who confront tremendous barriers to health in this country.

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Encourage policymakers to prioritize the development and implementation of healthcare policies that emphasize ethical principles, patient-centered care, and the well-being of healthcare workers.

Advocate for transparency in healthcare systems, including financial practices. Patients, healthcare workers, and the public should have access to clear information about how financial decisions impact patient care.

Call for increased support to address shortages and prevent overworking of HCWs. Advocate for better working conditions, competitive salaries, and better health support services.

Encourage and support research that examines the impact of profit-driven models on healthcare outcomes. This research can provide evidence to inform policy changes and support the case for patient-centered care.

Call on healthcare institutions to adopt and prioritize ethical guidelines that emphasize the importance of patient-centered care and the well-being of healthcare workers.

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For more than a decade, the term burnout has been used to describe clinician distress. 1, 2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population. 3 Massive information technology investments, which promised efficiency for health care providers, 4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers, 5 diverted the time and attention of those already engaged in patient care, 6 and done little to improve patient outcomes. 7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day. 8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise. 9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.

Freudenberger defined burnout in 1975 as a constellation of symptoms-malaise, fatigue, frustration, cynicism, and inefficacy-that arise from "making excessive demands on energy, strength, or resources" in the workplace. 10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.

In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care. 11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation. 12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.

Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders-the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security-before the needs of our patients. Every time we are forced to make a decision that contravenes our patients' best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.

The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual's responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation. 13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.

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, on the other hand, 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 is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.

The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients' best interests first.

Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone. The following are our recommendations for how you can bring change both locally and on a broader scale.

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Reframing Clinician Distress: Moral Injury Not Burnout

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For more than a decade, the term burnout has been used to describe clinician distress. 1, 2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration.

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The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.

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Background that has created structural violence

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Background that has created structural violence

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Profit models:

Data-driven focus

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dehumanization

erosion of ethical values

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Disempowerment

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Major section 1 Burnout

Major section 2 Moral injury

Major Section 3 Demoralization