One of the accepted drivers of moral injury in doctors is their inability to give the best care possible due to pressure of work. While assessing a patient with unstable angina the bleep goes off three times. A decision must be made – do I leave this man with only the immediately life-threatening aspects of his condition treated, or do I stay here and finish the job properly? Do I focus entirely on the patient in front of me, for as long as it takes, until I am fully satisfied that they are safe, or do I heed the call to see another? We have all been there. The answer is usually to do the minimum required here, then run over there. Later, there may be time to return and ask how the man with angina is feeling, or to speak to the family. It may be possible to explain, reassure, hand-hold… to be more than the safe doctor, but to be the good or excellent doctor. But that is rare, for life trundles on and the front door is never closed.
When I worked at this level on the wards, we called it fire-fighting. And I found it satisfying. I would look back on a night of fire-fighting and feel good that none (well maybe a few) of the smoldering pathophysiological fires had grown into conflagrations. With a chest drain here and a judicious prescription of antibiotic or thrombolytic there, I played my part in arresting many downward trajectories. The war-zone analogy was bandied about. Those who survived the long nights and triple bleeps were proud. But were we good doctors? And did we notice those colleagues who failed to thrive in that environment?
Numerically, yes, I was a good doctor. I ran upstairs and along corridors, I sustained my own circulation with the odd diet coke or over-concentrated instant coffee; I managed. Colleagues could trust me to see the night through. I delivered my histories and plans to the fresh-faced consultant on the post take round. Damned good fire-fighter, I thought.
But was I really a good doctor?
I mean – would any of those patients remember me a person, or just as a decision-making spectre who materialised from the shadows and passed judgment on their ECG, the sound of their lungs or the strength of their limbs? I mean – did I ever hold their hand (literally or spiritually) while leading their bodies back onto the right path? The kind of doctor Rana Awdish wishes we all could be, as described in her book In Shock, where she (a criticial care consultant herself) recounts her recovery from a ruptured liver adenoma and multiple organ failure. The kind of doctor Kate Granger wished we all should be, in her book The Other Side. The doctor with time.
Quality vs quantity
To simplify the question further – is the good doctor one who gives the best care to the patient before them, or one who flits superficially from patient to patient doing what is needed for the many? The former will do more to improve the health of the patient he or she sees. The latter will treat more patients, and if you could measure it, may do more to improve the health of the population as a whole. But they may not be remembered as a good doctor; they may be remembered as a functional and rushed doctor. In an over-pressurised service we all trend towards the latter profile. The system demands it.
To simplify again – do we want quality or quantity?
Moral injury, I believe, comes from a tension between these two factors. Unfortunately, quality is hard to measure, while quantity measures itself: total patients clerked, total patients discharged, average length of stay, clinic profiles, procedures per annum. While we do try hard to assess quality, through patient experience surveys, through the absence of complaints, through summary hospital-level mortality indicators, they are nebulous and difficult to synthesise. Quantities sit solidly on the page and cannot be quibbled over.
Imagine a ward doctor, Jayne. She cannot find a way to leave one patient in order to rush to the next safely. She has tried colleagues; one is doing a lumbar puncture, the other won’t answer, probably for a good reason. Jayne spends the necessary extra twenty minutes with the patient here, then runs there. But already the second patient, an elderly man, has deteriorated, and is semi-conscious in advanced respiratory failure. Soon after, he stops breathing. The crash team are called. Jayne feels awful. The ward sister reassures her that his condition was probably irreversible. But Jayne walks away morally injured. She could have done something. The first moral wound has been inflicted. There was too much to do.
What were Jayne’s options, both in the moment and longer term?
In the moment, she could have made a decision to prioritise the elderly man, given what she had been told about him over the phone. She could have rushed off leaving the first patient under-treated. But didn’t the first patient deserve to be sorted out properly? She wanted to finish what she had started. The old man wasn’t yet hers, in a manner of speaking. Jayne had never set eyes on him. The patient in front of her was the overriding priority. Her main duty of care was to that person. This is bordering on naïve, because an awareness of competing duties is one of the requisite skills of a doctor. Duty of care has to be modulated according to the circumstances, for you also have a duty of care to the others in the queue. You are employed, after all, to keep the wards safe, not just the first person you are called to see.
So no help there then.
Jayne could have escalated to the consultant, maybe via the site manager. To do so would be saying, ‘I need help’. Some would interpret in another way – ‘I’m not coping.’ And anyway, the consultant would not usually be in a position to rush to the ward.
What is the answer?
The GMC recently put out a message via Twitter that encapsulates this dilemma. It was in response to a question about what to do if a department appears dangerously understaffed:
This ‘official’ response makes it clear that within a resource poor area, there is a duty to stay (that’s fine), to escalate (more later), and to make the best of what you have. To provide the ‘safest care’. Echoing this, in late 2019, doctors in a Norwich hospital were asked to use the ‘least unsafe’ decisions when managing patients during a period of acute pressure.
These are pragmatic responses. Regarding escalation, it is unlikely that any who follow the GMC’s advice will see changes made to staffing or resources in their short career with a Trust. Escalating concerns, which always requires bravery, also requires a degree of altruism, for the benefits are likely to be felt by the next cohort of doctors. The recent innovation of exception reporting has helped shorten the circuit between the recognition of over-pressurised clinical areas and subsequent action. Yet there are barriers to escalation. Robert Francis’ report ‘Freedom To Speak Up’ (2015) explored how fear (of adverse consequences)and a sense of futility (‘nothing’s going to be done anyway…’) can put people off. Francis also touched on the push-back that can occur: ‘I [..] heard it suggested that some people raise concerns for dubious motives, such as avoiding legitimate action to address poor performance.’ The case of Chris Day comes to mind; who really fancies four years of accusations about your clinical competence, career-arrest and adversarial tribunals?
A larger duty
How we react to the tension between quality and quantity probably determines how predisposed we are to moral injury/burnout. In the early years, the duty to the individual appears paramount. But seniority in the NHS brings with it a changing perspective. When or if you become involved in service management, you realise that there is a broader duty of care. This duty is to ensure that as many people can access the service as possible. It is a duty to the population, or catchment area. This duty demands that the ‘greater good’ is served, even if this means hurrying people out of hospital to create bed spaces, or raising the bar of clinical concern to reduce the number of admissions. Taking risks. Increasing flow. The classic argument goes thus:
Doctor: The man in bed 8 should go home, he’s medically fit…
Nurse: But his package of care isn’t activated until tomorrow…
Doctor: Can’t a relative help out tonight, until the morning; we’re completely rammed in the ED, and there are patients waiting in ambulances.
The needs of the patient on the ward are explicitly balanced against the needs of those waiting outside. There appears to be a moral imperative to discharge the ward patient, even though it is not ideal. This ‘zero sum’ scenario does not allow for ideal solutions – only pragmatic ones. The nurse who ends up persuading the relative to take the ward patient home may well suffer a degree of moral injury here. He or she knows it isn’t quite ‘right’, but it is necessary. And it has been condoned by senior people.
Patients are aware of this tension, and articulate it. I have heard several say ‘I know you need this bed doctor…’ To which I have often replied, ‘No, this is your bed now, don’t worry about anybody else.’ So faced with an individual, and aware that beds are indeed needed, I immediately revert to the most basic duty – to the one in front of me.
The worst example
A very dramatic (perhaps over-dramatic) version of this tension was shown in the recent Channel 4 programme ‘The Cure’, which portrayed conditions in Mid-Staffs. In this, well-intentioned nurses are harangued by officious (yes, clipboard bearing) seniors. Staff are made to move unstable patients along before their 4 hours are up, and even to fiddle the figures.
It is not hard to understand the hierarchy of motives that resulted in such moral injury for the visibly distressed nurses. The ward manager’s agenda was to keep up the flow and ensure the 4-hour target was met, thus keeping the operations manager happy. The operations manager had to provide assurances to the CEO that the acute service was running efficiently. The CEO needed to prove to the strategic health authority that the Trust as a whole was in fit shape to be granted Foundation Trust status – the theoretical end result of this process being, we assume, financial autonomy, freedom to design services that suited the local population, improved quality, better access to care… the greatest good for the largest number. Yet, this irresistible logic was clearly wrong. Patients and families suffered. The needs of the one were missed for the less tangible needs of the many. Many saw this, but were not empowered to change it. Deviance (from the values that doctors and nurses were trained to expect) was normalised. The end did not justify the means.
Bentham vs Kant
Some of you may have thought – hang on, aren’t we talking about utilitarianism here. I don’t want to go too far into serious bioethics, but yes, Bentham’s philosophy of maximising overall utility (‘…that principle which approves or disapproves of every action whatsoever according to the tendency it appears to have to augment or diminish the happiness of the party whose interest is in question’) must be invoked. Karl Popper’s negative interpretation may be of more relevance to medicine. He wrote ‘Instead of the greatest happiness for the greatest number, one should demand, more modestly, the least amount of avoidable suffering for all…’
The struggling doctor is caught between utilitarianism on one side, and a Kantian deontological, or ‘duty based’, philosophy on the other. While the strict utilitarian would condone the quality of care being compromised for an individual in order to maximise overall benefit, Kant would judge the doctor’s action according to the individual’s outcome, for that is where the duty lies. The deontological tradition protects the patient-doctor relationship; patients need to know that we have their best interests at heart and are not compromising their care. Yet, we do. We share the resource that is our time.
For policy makers, utility in healthcare must be quantified. The National Institute for Health and Care Excellence (NICE), in rejecting a new and expensive drug for metastatic cancer or cystic fibrosis, is relegating the needs of the few (each of whom will have a vivid and tragic story) to the needs of the many. The committee in question may well have used quality adjusted life years (QUALYs) to underpin the decision. In this way, utility becomes measurable, and the needs of the many can be balanced against the needs of the few. Thus, rationing is an activity that takes place far, far away from the bedside. Utilitarianism becomes manageable, and can be presented on a spreadsheet.
Meanwhile, the oncologist who cannot prescribe the expensive new drug feels frustrated that their duty to the one cannot be fulfilled. However, a higher decision has been made. There should be no associated feeling of guilt or moral injury in this setting. Perhaps doctors juggling competing demands (the resources in question being time and energy) should similarly be protected from feelings of frustration/moral injury if higher decisions have resulted in circumstances that encourage competing demands.
Life in the NHS is not always like this. The days are not always grim. Being busy, being in demand, rushing from one patient to another can be highly innervating. Over ninety percent of the time, I would say, the combination of pressure, human interest and intellectual engagement leads to high job satisfaction. But occasionally this pressure hits a point where the tensions described above become palpable.
The reflections in this post are intended to provide different perspectives to the young doctor who finds themselves in the ‘one vs many’ bind. They are meant to demonstrate that compromises are not failures, but adjustments. One of the skills required to function and thrive in such a system is, I feel, learning how to provide the best care possible without becoming burdened by guilt that you are unable to provide ideal care. This may mean adjusting personal standards and interpreting ‘best practice’ according to local or current conditions. Each day, the path of duty between the one and the many must be uncovered anew.
There is a danger here. Although compromise may be required, strong and clear values are required in each individual to protect their patients from unacceptable or persistent reductions in quality (be that related to deficiencies in kindness, dignity or safety). In hard times, the good doctor must somehow uphold the duty of care to the ones before them, while maintaining an awareness of the needs of the many, and observing the system for weaknesses that should be repaired. It isn’t always easy, but, believe it or not, they will be surrounded by people who are trying to achieve the same ends – quantity and quality.