The term moral injury popped into the conversation about physician burnout back in 2018, when an article was published entitled “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.” I have learned more about what moral injury looks and feels like in the last several years, as I have taken a deep dive into the causes and the solutions to my own experience of burnout while working as a physician. When I read about the concept of moral injury, it put into words something I had been sensing but could not yet name. A feeling that would arise in my body from time to time while practicing medicine, a distinct uncomfortableness that was difficult to explain, along with a deep sense that something was off or wrong.
I had a challenging experience at work this week that unsettled me, though in the moment I could not see it for what it was: yet another experience of moral injury. I was taking care of a patient that had an acute neurological change in his cognitive status and he needed a Head CT scan as soon as possible. The fastest way to get this test was to send him to the emergency department, where he would also have access to neurology and neurosurgical consultants. The fastest way to get him care also happened to be the most expensive way, and so I was asked to consider other ways to get him the attention he needed. I did what was right for the patient but continued to get subtle feedback that it was going to be costly for our hospital.
The term moral injury was coined after the Vietnam War to describe a type of post-traumatic stress disorder (PTSD) in returning soldiers that did not fit the usual criteria of PTSD, that of having a continued fear of physical danger. Some soldiers felt they came back from the war with scarred morality. They had been asked by their superiors to participate in something that went against their core beliefs, such as killing civilians when ordered to do so.
Moral injury occurs when someone, whether a solider or a physician, commits, watches, or fails to interrupt an act that goes against a strong moral conviction. In healthcare “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.” In the current pandemic crisis, it’s obvious to see how this can arise: with only so many ventilators and hospital beds available, there is the possibility of letting someone die in order to save another. I believe most moral injury in medicine is not as conspicuous as choosing one patient over another, but rather is more insidious, slowly creeping into our day to day lives as physicians to the point that we are unable to recognize it as moral injury at all.
In healthcare the beacon that guides us all as healthcare workers is the well-being of the patient. It is a promise we solemnly take on the first day of medical school, in the form of the Hippocratic Oath. The original oath’s form included the words: “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over-treatment and therapeutic nihilism.” Other forms of the Hippocratic Oath use the words “Primum non nocere; First, do no harm.” The oath I took at my medical school included the words: “The health of my patients will be my first consideration.”
This oath is not something I needed to say out loud to a room full of fellow medical students, professors, physicians, and family members. It was the reason I went into healthcare in the first place: to take care of others. I had no idea at the time how challenging that one simple promise would be in the current business environment of medicine, where in addition to caring for the patient there are expectations to also think about the broader hospital and healthcare system, insurance companies, electronic medical systems, and productivity metrics.
I never knew how much I would be fighting for my patients to get the care they need. The hours on the phone getting pre-authorizations from insurance companies for the “right” medication to treat a patient’s pain or seizure disorder; the pop-up boxes that have dollar signs next to the imaging test I have ordered, with the unstated question “Can you order a different test that costs less?” Or the emails that give me financial details about how much the hospital is making or losing, how many transfers are made back to the acute hospital, and how much it is costing.
What’s not present in each of these scenarios is the question of what is in the best interest of the patient. And that’s the moral injury that chips away at many of us in healthcare. The need to also take into account what’s in the best interest for the hospital, the clinic, the healthcare system, the insurance companies, the bottom line. Yes, healthcare is a business. And yet this business model creates a painful tension between doing what is right and doing what will make the most and cost the least. I do not have an answer to this predicament. I only know that it exists, that I struggle with it, and that I will still always do what is in the best interest of my patient. It’s what I signed up for.
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