I fight, but I am not exhausted. I enjoy taking care of my patients and doing clinical work. It’s all that bothers me that I find intolerable.
Almost all of our colleagues experience some level of distress, but most refuse to call it burnout. They used the term because they had no better way to frame how they felt.
We started talking to doctors, nurses and other healthcare professionals about their experience five years ago. One thing was clear: they resented the idea that they were the problem, that they weren’t resilient, efficient, or resourceful enough to handle their demanding careers.
One study validated their resilience, concluding that even “resilience scores significantly higher than the general employed population in the United States” did not protect physicians from burnout. (JAMA Netw Open. 2020;3:e209385; https://bit.ly/3HFOCnf.)
Decades of research and countless interventions like meditation, sleep, and exercise borrowed from America’s $4 trillion wellness industry have barely budged the burnout statistics. A good physician reconsiders the diagnosis if repeated interventions fail to resolve a patient’s condition. It is time to do the same with the crisis of distress in health care, which has been exacerbated by the pandemic but certainly not caused by it.
what’s really going on
Burnout is a constellation of symptoms that most physicians can probably recite: emotional exhaustion, feelings of ineffectiveness, and depersonalization or detachment. But the term fails to capture the sentiment we’ve heard time and time again: Doctors’ greatest distress stems from their inability to provide their patients with the care they need or, as Ed Yong put it, workers of health “cannot manage to be unable to do one’s job.” (Atlantic. November 16, 2021; https://bit.ly/3HKM9YT.) It’s “the challenge of both knowing what care patients need but not being able to provide it due to constraints beyond our control,” as we pointed out three years ago. (Federal practice. 2019;36:400; https://bit.ly/3N5vRL5.)
Reframing distress as a failure of systems rather than the lack of character implied by the burnout label resonates powerfully with physicians. Individuals risk moral harm when faced with “[p]committing, failing to prevent, witnessing or becoming aware of acts that violate deeply held beliefs and moral expectations. (Clin Psychol Rev. 2009;29:695; https://bit.ly/3b3eIo2.) These deeply held moral beliefs in health care are the oaths physicians take, whether expressed or implied, to always put patients first.
Moral injury in health care is knowing that a patient needs a drug, test or procedure, only to spend hours on the phone trying to get approval and fail. It is the nurse whose unit is regularly understaffed who knows that she will again have to choose between doing an hour of documentation or checking on patients she has not seen for an hour. It is the doctor who must break the news of a cancer diagnosis to a patient, knowing that the time she spends with him is insufficient to allay his fears.
Consumer solutions are attractive because they are quick and simple and require less commitment from already overloaded systems. These are essential supports, but they have failed as stand-alone interventions and will continue to do so. Addressing moral harm will require a long-term commitment to lasting change with interventions at multiple levels almost simultaneously.
Doctors’ distress is reaching crisis levels. Initiatives to support those struggling with acute and overwhelmed difficulties are a no-brainer, but they are band-aids for multiple trauma and insufficient as stand-alone interventions.
Organizations must also recognize the plethora of operational barriers to effective and efficient care and address them methodically. The starting point is to solicit feedback from those who make up the workforce on the challenges they face every day, keeping in mind that asking for feedback and not following change only amplifies the betrayal they already feel.
Treat moral wounds
Organizations are experiencing a strong moment. The workforce is hungry for change and action. They know what health systems can do with the right motivation because they’ve seen field hospitals spring up overnight and telemedicine explode during the pandemic. They are, however, waiting to see if their own well-being will motivate leaders to move towards cultures of psychological and physical safety, where they are valued for their ideas and for speaking out, where their leaders support them and give them superior cover. . .
Health care is complex, and so are the solutions to its challenges. Overwhelmed organizations, however, continue to seek simple approaches with modest operational impact – a weekend course, retreat or e-learning – but repairing the hurt feelings is about each organization’s culture and commitment to dealing with patients as they wish to be treated.
Creating this culture will not happen in an hour, a week, or a month, but when executives and frontline physicians commit to working together. The best starting point for this kind of change is a culture of curiosity (asking doctors what they need to be successful), co-production (creating collaborative solutions), and community (success depends on doctors thriving and executives), where all levels of the organization are committed to building better, in particular:
- The C-suite: Commitment and champions at the highest levels of the organization are the drivers of change and models of culture and behavior for the workforce.
- The connectors : Managers, the liaisons between the C-suite and the frontline physicians at the heart of patient care, are uniquely positioned to recognize patterns and break down silos in the organization.
- Doctors at the forefront: Those who care for patients are hungry for new approaches. Inviting them to propose solutions will mobilize considerable energy within the organization, increase engagement and give them a renewed sense of belonging.
Dr. Deanis a psychiatrist, writer, speaker, podcast host, and president and founder of Moral Injury of Healthcare, a non-profit organization that provides training and counseling to organizations focused on alleviating the distress of their staff. (www.fixmoralinjury.org.) Dr Talbotis an associate professor of surgery at Harvard Medical School and a surgeon in the division of plastic surgery and director of the upper extremity transplant program at Brigham and Women’s Hospital in Boston. He is also one of the founders of Moral Injury of Healthcare. Follow Dr. Dean on Twitter@WDeanMD, Dr Talbot@simontalbotmd, and their organization@fixmoralinjury.