Author cites moral injury, not necessarily burnout, as cause of clinicians' distress

July 2023


While pulling weeds in her garden, Dr. Wendy Dean listened to a news report about moral injury in drone pilots who never actually saw combat.


She had heard of moral injury before — doctor and psychiatrist Jonathan Shay, who had worked with Vietnam veterans suffering with post-traumatic stress disorder, developed the term. It's the feelings of distress and betrayal that happen when someone can't do their job or has to act or witness something against their values or moral beliefs.

Dean, a keynote speaker at CHA's 2023 Catholic Health Assembly, recalled making the connection between drone pilots and what she saw in medicine. "I thought, hang on, if these folks who go from their suburban house to a base, fly their drones and go back home again can experience moral injury, maybe other folks can too, including those in health care," she said.

A psychiatrist by training, Dean is president and co-founder of The Moral Injury of Healthcare, a nonprofit that addresses the crisis of clinician distress. Dean and co-founder Simon Talbot, a plastic surgeon, wrote If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First, published in April.

Finding the right language
She and Talbot talked to numerous colleagues, including a nurse practitioner who retired early because she couldn't stand to keep turning away from her patients to enter data; a doctor who quit two jobs in five years when her hospital told her where she could and could not refer her sick patients with cancer; and a physician who said business imperatives were undermining his medical judgment and "inflicting financial toxicity" on his patients.

Dr. Wendy Dean, a featured speaker at the 2023 Catholic Health Assembly, talks about the research she and another physician have done on moral injury among health care workers. Dean said the health care sector needs new language and new ways of thinking to deal with moral injuries.

"What they all said was, 'I'm struggling, I'm distressed, but burnout doesn't quite fit. It's not quite the right language,'" Dean said.

She and Talbot wrote an article in 2018 for the online publication STAT called "Physicians aren't 'burning out.' They're suffering from moral injury."

Dean learned it was one of the site's most read articles. "And that isn't because we're so clever," she said. "What that said to us was that clinicians were hungry for a new way to describe their distress."

Then came the COVID-19 pandemic.

For the next three years, Dean said, "I fielded variations of this same theme with clinicians saying to me, 'It's not that I can't handle my job. I can't handle being unable to do my job. I know what my patients need, and I can't provide that for them.'"

Rebuilding trust
It's important to address moral injury because when clinicians feel distressed, patients are less likely to feel satisfied with their interactions with them, and they're less likely to follow directions and have good outcomes, she said.

Moral injury is also "wildly expensive," Dean said. She cited a Mayo Clinic article published in February 2022 that estimated that $260 million in excess health care costs come from burnout-related turnover among primary care physicians and $4.6 billion in lost productivity and costs to replace physicians.

To move forward, Dean said hospital leadership and federal agencies need to rebuild trust with health care workers who felt betrayed during the pandemic.

'A unifying purpose'
Dean suggested that clinicians and health care workers "flip the script" and ask administrators what they are doing to help clinicians so they can focus on patient care. She also urged clinicians and administrators to break down imaginary barriers between them and ask how they can help one another.

"In health care, we need to come together as a community to emerge from this pandemic with new language and new ways of thinking about where to go from here," she said. "We won't agree on everything all the time, but we have a unifying purpose."

Copyright © 2023 by the Catholic Health Association of the United States

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