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This week I hosted a special conversation at WBUR's CitySpace with some leading thinkers on “moral injury” in health care. If you’ve never heard the term, it refers to the deep anguish felt by anyone who has had to compromise their values because of external forces. The term has been used, for example, to describe the anguish of veterans.
Here are some highlights from the event, lightly edited for clarity.
Wendy Dean, psychiatrist, co-founder of the nonprofit Moral Injury Of Health Care and author of a recent CommonHealth post, The Real Epidemic: Not Burnout But 'Moral Injury' Of Doctors Unable To Do Right By Patients:
When I talked to friends who were at the tops of their field across the country, I would hear them say, I love my job. I love my patients and doing that work, but everything around it is just wearing me to a nub. I hear a lot about burnout, but when I talk to my friends, they would say, 'I'm not burned out. I'm tired of all of the sort of housekeeping things I have to do, and I'm tired of the wedges that are between me and my patient. But I still love my work.’
The problem for us is that we took an oath, we made a promise to our patients that we would put them as a priority, always. They came before our need to eat or sleep. And then as we as we got more and more into practice, we realized that oftentimes we have to choose. We have to take care of health insurance paperwork and roadblocks so that our patients can get an MRI. We have to refer within a hospital system. And so that's where the the idea for moral injury came in, that we take an oath and every day our hands are tied from doing what we really know is right.
When my husband got ill, I saw it from the family side. And what I saw was that there were practitioners who just couldn't see their way clear around the barriers that their hospitals and their health care system had put up.
It was a very near miss for us. And we're a two-physician family. And in fact, he worked for one of the hospitals, the original hospital that he was at. And if we couldn't figure out how to get the care that he needed, what was going to happen to my former neighbor who didn't have that ability to advocate, who didn't know what risk management was?
So that really gave me the push to start focusing more on how do we fix the system so that patients aren't hurt and clinicians aren't hurt and we can all come together to make this better?
Simon Talbot, transplant surgeon at Brigham and Women’s Hospital:
I came about this from a very different end of the spectrum. I'm a busy clinician, a busy plastic surgeon and a hand surgeon. I also have a large research lab and have the privilege of working overseas and doing some volunteer work as well. My wife is a pathologist, so I'm fairly well embedded in the medical system.
About three or four years ago, the hospitals were looking at clinician distress and saying, 'We know we've got a lot of burned out clinicians, but let's survey them. Let's see what the real story is.' And I sat at my computer and I filled out the checkboxes about burnout, which is a constellation of exhaustion, cynicism and lack of accomplishment. And I started to realize that I had all the symptoms.
I was pretty cynical. I was exhausted all the time. And although I knew objectively that I was achieving a lot, I just felt like I wasn't making progress. So I did what any good clinician-scientist does: I read everything I could about it. And I thought, 'I will teach myself how to fix this problem.'
I had a coach come to my office every Monday evening. I bought a little fridge that fitted under my desk so that I could put good food and water in it and I could eat more healthily. I started running on the beach, and even borrowed a friend’s dog to come with me.
Like any scientist, I revisited the issue about six to 12 months later and said, 'How am I doing? So I went online and I filled out the boxes, and I realized none of the things were actually fixing the problem.
And it became apparent that the thing that was deep down inside causing my symptoms of burnout, my exhaustion, my depersonalization, my lack of accomplishment were about the things that were getting between me and my patients.
It was trying to take really good care of someone but knowing that I really don't have as much time as I want to spend with that person, or knowing they need an MRI scan but their insurance company is going to make me jump through a whole bunch of hoops to get that MRI scan. It was those little wedges that get between you and your patient, and it's the fact that so frequently in health care today, you have time and time again little things that prevent you doing what you know to be the exactly the best thing for your patient.
Elizabeth O'Connor, legislative fellow on the Right on Healthcare team at Texas Public Policy Foundation:
My story is actually about my mother. This time last year, after beating stage four colon cancer, her insurance company allowed her to get genetic testing to see what else potentially could come up in her future due to her family history and also with her age. Everything came back clear, except she did test positive for the BRCA gene.
She and my dad decided that she should go through a preventive double mastectomy and hysterectomy. Unfortunately, within four weeks the stitches opened up. As she was waking up from the surgery to fix her stitches, she found out that her employer-sponsored insurance company denied her a machine that she was required to go home with, to hold both sides of the stitches together like a suction cups, so they wouldn't open again.
Then came a four-day battle with her insurance company. So she's stuck in the hospital for four days, and the visit ends up costing way more than the machine would have to begin with.
Thankfully, it all worked out. But at the end of the day, she was so disheartened by her insurance company. The doctor was getting frustrated at the system, just so angry he couldn't send her home.
Stuart Pollack, medical director at Brigham and Women's Advanced Primary Care Associates:
I don't actually believe there's some evil conspiracy against the relationship between doctor and patient. I just think there's a lot of really good things that are squeezing it out. So, you know, when you come into my office, we ask you if you're depressed, if you're a victim of domestic violence, if you have a substance use problem. We have to do your medicines. There's a lot of boxes to check for billing.
What matters is getting to know the patient as a human being and their values. And we're just sort of running out of time. And so I tend to think of this as death by a thousand cuts. It's not that I'm making some horrible decision about whether you can have the drug or not. It's that every visit I ask: Do I stop looking at the computer and stop clicking and pay attention? Because this is a key moment. And I really need to be very actively listening.
Watch the the conversation above for more, including responses to these questions and comments:
- Why aren't you accompanied by masses of health care staffers and patients all calling for this type of change?
- How do you know this is in fact moral injury and not other emotions?
- How does moral injury translate politically?
- What is to be done?
- Should medical schools be preparing future physicians to cope with moral injury?
- How can you get health care organizations to make needed changes?
- What about nurses and moral injury?
- Is it time for physicians to unionize?
- Should administrators be rated on how their medical staffs feel?
- Do doctors face retaliation for speaking out on these issues, and if so, how?
- How do you get patients to join you in this struggle?
Also, don't miss the comment by Samuel Shem, author of the classic "The House of God," who argues that the issue boils down to "money and screens." And below is an impassioned video by popular medical rapper ZDoggMD (with profanity bleeped out.)
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