#100 Moral Injury: The Unseen Struggle of Healthcare Professionals
Its Making Them Miserable
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I precociously proclaimed that I wanted to be a doctor while I was in high school.
I volunteered as a candy striper. I went to a fine university and medical school. Pennies were pinched to make tuition payments. I gave up the trips to the beach and the family vacations. Along the way, I learned the classic methods of conducting a history and physical exam. I bought the fancy stethoscope. I learned to poke, prod, start the IV lines, and insert all the tubes.
I completed four years of post-graduate training in emergency medicine, which included hundreds of sleepless nights on call. I finally landed my first job as an emergency medicine attending physician in a large community hospital in Virginia.
Why on earth was I so miserable in the profession I had struggled and worked so hard to obtain?
I wish I had an easy answer to that question.
I do have a few thoughts. I knew that I was not the only one. Many doctors and nurses are struggling, and the problem has gotten worse over the last decade. The American Medical Association surveyed 20,000 physicians in 2021 and found that one in five was planning to exit the practice of medicine within two years.
At Austin’s Ascension Seton Hospital, 900 nurses went out on strike to bring attention to intolerable conditions.
The Texas Tribune reports, “The nurses union says its members are responsible for too many patients at a time, resulting in delays in care for patients and more exhaustion among nurses.”
Healthcare workers at hundreds of Kaiser Permanente hospitals and medical facilities across the U.S. walked off the job in October of 2023 to bring pressure on their employers to fix staffing shortages.
Medical staff members must contend with violence in the workplace and exposure to diseases. ABC News reported that 3600 health workers died of Covid during the first year of the pandemic.
There are vast systemic problems of understaffing, overscheduling, and under-supply of equipment. Physicians must spend hours pleading with insurance company medical directors to approve medications or procedures that have been summarily denied. Some insurance companies are using automated systems to churn out denials even more quickly.
Medications we prescribe are scarce or back ordered. Inpatient beds are not available, so patients waiting for beds to become available are “boarded” in the emergency department while the staff is still expected to take care of all the sick and injured people coming in through the door. Boarded patients in the emergency department just do not get the level of attention or care that they deserve.
Overcrowded psychiatric care facilities cannot take the people who urgently need care. Some of those folks get boarded in the emergency department for days or weeks. Many are sent home. Just forget about the availability and scheduling of anything when the ill or injured person has no medical insurance.
The System is a Mess
The doctors and nurses know that the system is wrong and unjust. Most are employees of hospitals and large corporations who feel endangered when they speak up or blow the whistle. They know that the system is broken for many. They are suffering from moral injury.
Moral injury is defined as the social, psychological, and spiritual harm that arises from a betrayal of one’s core values, such as justice, fairness, and loyalty. We know it should not be this way! Working in the current environment makes us feel terrible.
Physicians and nurses feel exhaustion and cynicism and start to question why they even chose to enter the medical field. This constellation of symptoms comprises the condition of burnout. Relative newcomers are experiencing burnout and looking to exit the field of clinical practice.
More than one physician or medical student per day dies by suicide in our country. Physicians are employed in a system that frowns upon seeking mental health care for its own hurting members.
I have a lot of thoughts on the matter. So much more is expected of our students in training than just a decade or two before. Some medicines and procedures are so time-sensitive that pressures and fines are levied against hospitals for conditions that are missed or treatments that are not started on time. We must get those antibiotics hung or those heart attacks to the cardiac cath lab within an hour!
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New imaging technologies are available that physicians need to learn. We used to call for an ultrasound. Now medical students get pocket ultrasound devices to use at the bedside. Nurses use ultrasound to find intravenous line sites at the bedside too.
Newer and more advanced medications are developed every year. The doctors and nurses need to learn about them and how to give them. It’s not enough to greet a sick person and hold his hand.
We have performance metrics to meet!
My strong suspicion is that our young people have built up a lovely fantasy of what they thought the practice of medicine or nursing would be. They would introduce themselves to some grateful patient who would treat them with respect and value their recommendations. The patients would get the imaging studies, wear the splints, take the medicines, and follow up in the correct way. They would get well, then shower smiles and gratitude on their hardworking medical professionals.
But no
Patients are impatient, unrealistic, and non-adherent to the plan. They post critical reviews online or with our supervisors. Some patients or their families become argumentative, angry, and violent towards us. When we make mistakes, there are terrible consequences. Even when everything is done “correctly,” patients still have bad outcomes, and as much as we resist this fact: everyone will die.
What can we do?
There are no easy answers to the multi-factorial problem of moral injury and burn-out. As a society, we need to address the systemic issues, but what can individuals do now? As a family member of someone suffering or a professional yourself, there are some things one can do.
Treatment for true mental health issues should begin through a primary care provider, with consultations made as needed. Employers should be encouraging mental health treatment among their healthcare staff.
Another useful approach is to work with a life or career coach. Good life coaches help their clients parse out the facts of a circumstance from the thoughts that the client has about them. Physicians have a lot of judgmental ideas about how things should be and how patients, families, and administrators should act.
We tend to resist reality: Things shouldn’t be this way! We also personalize: This bad outcome is all my fault! These are examples of unhelpful thoughts that physicians and nurses have about situations in the hospital and with their patients.
A life coach can help a struggling professional recognize thoughts that do not serve them and work to change the thoughts. Accepting reality when bad things happen, without personalizing, can give people more peace around some unfortunate circumstances.
We want to be sad when folks die and be outraged when a person is abused. Frustration around “non-compliant” patients is an expected and understandable human response. Most patients and their families try their hardest to follow the plan.
My spouse, who is a gastroenterologist, frequently comes home grumbling about patients who cancel procedures at the last minute, do not take their colonoscopy preps, or cannot get through to schedulers. When he feels frustrated, all he can see are the ways things are not working.
I try to remind him about all the parts that are going well. He prevented that lady from needing surgery for colon cancer! He works with lovely and dedicated nurses. He gets a solid paycheck and feeds the retirement account.
The good stuff in medical practice is still there; our attention must be directed towards it.
In his wonderful book, On Becoming a Healer, Dr. Saul Weiner advises engaging with patients more fully when we find out that they are missing dialysis or not getting a study we have ordered. There is usually a reason for “non-compliance” that we can work on with our patients.
Turning away from our computer screens and toward the human in front of them is a challenge that can lead to more rewarding interactions with better results.
I’ve written a book where I address the problem.
In my book Changing How we Think about Difficult Patients: A guide for Physicians and Healthcare Professionals, I address the problem of interactions with families and patients that go poorly. Even though infrequent, these interactions can torpedo an otherwise good day at the hospital or clinic. I discuss some unhelpful thoughts on both sides and introduce ways to change how we think. If we accept reality and avoid judgment, we can have more peace around difficult patient interactions.
Artwork from American Association for Physician Leadership
In her book, Real Self-Care (Crystals, Cleanses, and Bubble Baths Not Included,) Dr. Pooja Lakshmin outlines the changes in thinking that people must go through to integrate better choices to serve themselves. Doctors and nurses would do well to follow her definition and advice about setting boundaries. The creep of messages and information into minds and homes on a 24/7 basis contributes mightily to feelings of burnout.
Any of these books would make thoughtful holiday and graduation gifts. Additionally, since doctors notoriously have little time to read, they are available in audio additions that a person can listen to while commuting in the car or on the go.
Suffering doctors or nurses need a chance to express their emotions and to feel them. We witness some of the most sad and gut-wrenching scenes imaginable. Grief, frustration, and sorrow are perfectly normal responses in the workday or night of a medical professional. It helps to have a good cry. Holding their hand, listening, sharing a cup of tea or hot cocoa, and being present will help immensely.
Let them take the time to feel miserable. It is an integral part of the human experience of being a healthcare professional. If they need to step away for a while, that is alright too. They might need to recharge and re-evaluate.
The sun will come up tomorrow.
