‘Moral injury’ is now the preferred term for burnout. And burnout is not going away. A recent GMC burnout survey found that over 60% of trainee respondents felt it ‘somewhat’, ‘to a high degree’ or a ‘very high degree’. Professor Andrew Goddard, President of the Royal College of Physicians, headlined with the term at this year’s RCP annual conference. Picking up on this, the BMJ explained the new term in its ‘Sixty seconds…’ slot. High profile medical YouTubers such as ZDogg MD have spoken on the subject.
From my reading, it appears to have come from Simon Talbot (a plastic surgeon) and Wendy Dean (a psychiatrist), who recently applied observations relating to the stress experienced by soldiers to that experienced by medical staff. The theory is, doctors are torn, and therefore morally injured, by competing ‘binds’ that cannot be resolved without compromising their values. Just as soldiers who cannot resolve the effects of morally repugnant acts that they have undertaken or witnessed, may go on to develop PTSD, so doctors who cannot do their job to a reasonable standard suffer an equivalent syndrome.
Just as the soldier is impelled by duty and discipline to kill (and is morally absolved by their nation’s perception of the greater good), he or she still has to overcome the feeling that it is ‘not right’. In the same way, just as the ‘system’ demands that a junior doctor in a poorly staffed hospital may have to leave a deteriorating patient for three hours while they tend to even sicker individuals on another ward, they know it is not right and are injured by the knowledge that the first patient may have suffered needlessly. Yet the greater good is still served. Neither the soldier nor doctor has the power to change the system; they cannot end the war or flood the hospital with extra doctors. They are employed to do their duty, are naturally a ‘hyper-responsible, control-freakish lot’, and will always try to make the best of a bad situation.
My question in this article is – are there sufficient similarities between medical and military situations to adopt the term ‘moral injury’ in place of burnout? Is the frontline of battle anything like the frontline of healthcare? These questions are important, for if we are to accept the term ‘moral injury’ we must run with the parallels and make very sure that our doctors can be protected, or at least treated.
Doctors as victims
The term moral injury adds to the impression that doctors are victims. Is this true? Is this healthy? Recently, the BMJ ran a strong editorial criticising the term ‘2nd victim’ i.e. the idea that the psychological suffering experienced by HCW who are involved in patient safety incidents are deep enough to put them in the same league as the injured patients and families. Melissa Clarkson and colleagues wrote that being seen as a victim diminishes a sense of responsibility for one’s actions, thereby reducing the drive to improve.
Perhaps accepting that doctors are being morally injured will engender a similar feeling, one of passivity, victimhood, powerlessness. However, supporters of the shift to moral injury would say that this is exactly the change of emphasis that is required. Burnout suggests the doctor has failed, and that the response is due to personal factors, maybe weakness or vocational misjudgment, whereas injury suggests that is harm as come from the environment, and is not doctor specific. This puts the onus on organisations to improve the environment, not on doctors to dig deeper into their mental resources.
Proximity to suffering
In a recent Sunday Times article Adam Kay, the author of ‘This Is Going To Hurt’ (a deep if often flippant study of moral injury) wrote:
‘If you want to be a pilot, they’ll make you speak to a psychologist. If you want to drive a train, they check you can cope if the worst happens and someone jumps if front of your train…[ ]… but if you want to be a doctor, nothing.’
Put like this, it is striking. Doctors are dropped into scenes of suffering, yet no provision is made for the injuries that are bound to be sustained to their psyche. Why?
Then Kay writes ‘..by the very nature of the job, bad days at work outnumber the good.’
This is interesting. Is it a bad day, in medicine, when people get ill and die despite our best efforts? Or is that just ‘a day’. After all, in entering medicine we willingly enter a world of suffering and death. Perhaps it is necessary, before adopting the term moral injury, to agree on what separates the ‘everyday stress’ encountered in an important but high-stakes job from definite injuries. Should we expect doctors (again in the words of Kay), ‘to bloody get on with it.’ Are those who fall, even temporarily, ‘histrionic’? (a term applied to Kay after his exit from medicine).
Consider this recent distressing, Tweet from a doctor:
This horrible experience, and its damaging effect, did not result from competing binds or a heartless organisational culture. It occurred because of disease and the doctors proximity to its tragic end-stage. Unrecognised, the psychological effect could well contribute to burnout or PTSD type symptoms. So, I would argue that moral injury does not apply here. Of course, a caring system would make available the appropriate psychological support. An excellent system might not wait for the doctor to present him- or herself, but take note of the distressing event and offer support pro-actively.
Who will make the distinction between everyday professional ‘stress’ and ‘distress’, and true ‘moral injury’? Is it dependent on the situation, or the psychological robustness of the individual? Just as one soldier will be unaffected by carnage (‘this is the job…’), and another will be appalled, so one doctor will thrive in the semi-chaos of a busy shift (‘it’s a war zone there… you’re fighting fires all night… fix one up, move on to the next… I love it) and another will leave in tears, knowing that they could not deliver the quality of care that they were taught to provide. It is doctor dependent, we all know that. But this does not make the injury, if we choose to use that term, any less deep.
The forces tearing at doctors are not those you would expect. Talbot and Dean, in their July 2918 STAT news article, hone in on the electronic patient record, which ‘distract[s] from patient encounters and fragment[s] care…’, on patient satisfaction scores that ‘silence physicians from providing unwelcome but necessary advice’, and on commercial forces that ‘drive providers to refer patients within their own systems, even knowing that doing so will delay care…’. These sound like American problems, but similar issues can be identified in the NHS.
The capacity of the NHS is always behind the demand for its services. It serves best those who with potentially mortal problems who are taken on an express route straight to its technologically impressive and highly focussed heart. Those who may have cancer are similarly mainlined through its bureaucracy into clinics, scanners and operating theatres. Others, with benign disease, less visible psychological issues or social needs, may find themselves struggling to get a look in. Doctors and health care workers trying to apply guidelines and protocols that are written to a high standard may find themselves unable to provide ‘excellent’ care in a timely manner. A sense of perpetual ‘sub-optimalism’ may set in. The gap between the ideal and achievable becomes established. They stop fighting for the best. They sigh, and take paths of least resistance. This is burnout. Or if not full-blown burnout, then a kind of smoulder. It is not failure. It is adaptation to a service that can only spend so much. I’m not sure ‘moral injury’ describes this situation.
Variability and vulnerability
We all see doctors who are knocked this way and that by misfortune, complications, ‘bad outcomes’, but who carry on, apparently metal jacketed, who turn up and treat the next patient and the next. Are they different? Are they stronger? Are they better? Are they just hiding their injuries?
We have to accept variability without making judgements. This is more difficult than it sounds.
People like me, 40-something and older, may have become so used to seeing colleagues disappearing into coffee rooms and crying that we were no longer surprised by it. I often wondered, as a trainee, if lawyers, engineers, dentists etc. at a similar career stage witnessed such distress in the workplace on a weekly basis. Of course not. But such was the regularity, it was easy to shrug and think, ‘Well, that’s medicine’.
The recent focus on mental health, and its de-stigmatisation, are encouraging developments, but we are still a long way from normalising the articulation of psychological distress. It would take a particularly brave F2 to come to a ward round and say to his or her team, ‘I’m taking myself down to the Occupational Health 24/7 service, I’m not coping well at the moment…’ Can you imagine the looks, the quiet comments in the corridor later on? This sounds facetious, but trust me, as a consultant who tries hard to empathise, I would still find it difficult to process this. Of course the doctor’s distress would be taken seriously and sympathetically, but the courage required of the F2 would be great, and I’m not sure the systems are yet in place for young doctors to voluntarily take themselves off and reveal their injuries.
So do I support this term ‘moral injury’? I see where it comes from, but I am uneasy about its derivation and its applicability to all forms of mental exhaustion in doctors. Medicine is not a battlefield, and its practitioners are not employed to harm, degrade or kill the enemy. The opposite, in fact. The moral binds are between competing positive actions, not destructive ones. A term derived from the military arena carries with it many connotations, the flavour of battle, of wounding, or doctors facing patients and their relatives across the lines – when in fact the enemy is not them, but inefficiencies and bureaucracies, and yes maybe the electronic health record.
Should sixteen year olds who are choosing their A-levels be made aware that being a doctor is now felt to have parallels with going to war? Does the NHS have the ability to support its injured? Or to back-fill the fallen so that those who are left to shuffle along and fill the gap in the front line do not put themselves in even greater danger? If not, why on earth would a keen and clever student volunteer to join up?
If we take on the term moral injury, we’d better be prepared to look beneath the Kevlar (woven from conscientiousness, role-modelling, fear of failure and bravado) and treat it without putting others at risk.