Why we need to separate burnout from moral injury in health care

By Wendy DeanJune 7, 2023

In the new book "If I Betray These Words," I tell the story, with Simon Talbot, of Rita Gallardo (a pseudonym):

Deployed in the desert Middle East, confined to a military base ringed by Hesco barriers and razor wire, Dr. Rita Gallardo's only escape from the horrors of the combat-shattered bodies of young service members was dreaming of the life she might build later. She imagined a husband equally enamored of country living, a sprawling farm, and a small-town medical practice caring for patients as she would care for her own family. But in the span of five years, Rita left two jobs when she struggled to get her patients the care they deserved, with the specialists she thought were best for their situation, all in the interests of corporate profits. She struck out on her own and set up a direct primary care practice where there is no one to come between her and her patients. But she's paid a high personal cost for this freedom. Less than a year into this new venture, she sold the farm of her desert dreams, and her future remains uncertain. But at least for now, she's healing from her moral injury by healing her community according to the values she's long lived by.

Rita learned about moral injury while serving in the Army. That training heightened her awareness of the betrayal she experienced in civilian medicine and sharpened the personal sacrifices she eventually made to live with professional integrity.

Rita's is just one of hundreds of personal accounts of moral injury Simon and I received after we wrote a thought experiment in First Opinion arguing that the medical industry needed to expand the characterization of distress in health care to add moral injury alongside the decades-old construct of burnout.

In the years since, it has become an improbable movement, a nonprofit organization, a podcast, a book, and a deeply resonant way of framing distress in health care for clinicians. The moment the article went live we began fielding responses, many using strikingly similar words: "This is the language that finally describes my experience." Or, "I’ve been looking for this language for decades." It spread first through health care circles before finding its way to people in education, law, and veterinary medicine.

That viral nature was not about our cleverness, but about the clamor for a new way to think about a well-worn topic.

In retrospect, however, we could have been clearer about what we meant by "this is not physician burnout," and we’ve been fighting assumptions ever since. Stated more clearly, we identified elements of distress that seemed distinct from "burnout." Those novel elements were the frustration, anger, and disorientation associated with existential threats to our professional identity as corporate interests undermined the oaths we swore to put our patients’ needs first when we embarked on this path. As we wrote in "If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First," "The covenant we make is not simply about how we will do a job, it is also about who we will be when we don the mantel of ‘physician.’ It prescribes our conduct, calibrates our moral compass, and entwines both with our identity."

We did not intend to subvert the concept of burnout, but to consider what might be missing, carefully parsing the completeness of a diagnosis in the face of an incomplete treatment response, as any well-trained clinician would do.

Research — both published and preliminary — confirms our hypothesis that burnout and moral injury are distinct experiences, though they often co-occur. Moreover, they may influence each other. For example, short staffing is the type of demand-resource mismatch that can drive burnout. But when repeated requests to increase staffing to safe levels fails to elicit a response, clinicians may perceive that as a betrayal, increasing their risk for moral injury. And, morally injurious situations that are inescapable may lead to the learned helplessness, cynicism, and detachment of burnout.

Many challenged the need for new language, arguing that we have a half-century of research on burnout. Surely, they said, that must encapsulate this experience we identified. But clinicians’ responses said otherwise. In my practice as a psychiatrist, providing an accurate diagnosis often flooded patients with a profound sense of relief. They finally felt deeply understood and no longer alone, even if the diagnosis was uncomfortable. A diagnosis of attention deficit or bipolar disorder could help organize what they had long worried was simply a lack of discipline. They shed the shame of pejorative labels, like "lazy" or "unmotivated," and had a clearer path to healing. That language changed how my patients thought about themselves and how others thought about them, too. It is the same with the language of distress. One therapist told me that talking with clinician clients about moral injury let them "shed the shame of individual responsibility for the systems dysfunction driving their ‘burnout.’"

Separating burnout from moral injury also could provide a useful approach to developing solutions. The demand-resource mismatches of burnout, the operational drivers, are substantial and must be addressed: clumsy electronic medical records, understaffing, and administrative overburden, among others. But it is equally essential to address the relational ruptures, the betrayal, at the heart of moral injury by recommitting to a just workplace, which encourages workers to speak up; a learning culture; and the restorative justice principles of accepting responsibility for harm (even if unintentional), self-reflection, introspection, and making amends.

In our 2018 piece for STAT on moral injury we wrote that "the increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point. …" That has never been truer than it is today. Correctly identifying drivers in ways that resonate with the workforce and developing targeted solutions could be the answer to retaining and sustaining a robust healthcare workforce. Adding new language alongside an existing concept seems easy enough if it helps make such necessary change.

Wendy Dean is president and co-founder of the nonprofit organization Moral Injury of Healthcare, and with Simon Talbot is the author of "If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Clinicians to Put Patients First."

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