ETHICS COMMITTEE
Not Burnout: Moral Injury in the ED Melissa Myers, MD FAAEM, Jennifer Gemmil, MD FAAEM, Al O. Giwa, LLB MD MBA FAAEM
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ver the last year, we’ve all read countless articles about “burnout” and “wellness.” These articles fail to address one of the chief causes of this burnout epidemic amongst emergency medicine (EM) physicians, the broken system in which we work. In the chaos of the COVID pandemic, we’ve focused on new problems but the systemic problems that we face in EM still exist. These problems were present before the pandemic and have only been exacerbated by the stress COVID-19 has placed on our healthcare system. In putting the burden on the physician to be “resilient” we ignore the systemic problems which we face every day on shift. Yoga and CrossFit will not fix a dire need for a better healthcare infrastructure and there is a limit to personal resilience, one which I believe many physicians are approaching or have already passed. I believe that at the root of burnout for many emergency physicians lies the moral injury we incur with each shift in the emergency department (ED). In the article “Moral Injury in Emergency Medicine,” recently published in The Journal of Emergency Medicine, the authors describe moral injury as being required to do something which violates our moral code. The causes may differ by practice site or individual circumstances but we are all familiar with the phenomenon even if we call it by different names. Our patients present with preventable diseases which could be managed outpatient by specialists without the damage to their bodies and disruption to their lives that they incur through repeated ED visits. Take the example of a patient I recently saw who presented with diabetic ketoacidosis (DKA), as he had every few weeks for the past year. Treating DKA is straightforward for any EP, just start the insulin drip and call the ICU. But that’s not the real solution to his problem which is that he’s
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uninsured and can’t afford insulin or access to an endocrinologist to manage his condition. He’s accepted this revolving cycle of admission and discharge as being the best he can expect. Providing crisis care without any ability to solve the root problem becomes frustrating. It’s hard to take pride in providing care which provides a short-term solution without solving the patient’s real problem. And therein lies the moral distress. I know I should do more, but the issue is much bigger than I or any one of us individually can fix. We all know what the “right” is but how do we achieve it on a global scale in the current US healthcare system? This year, with the pandemic raging and volumes high, many of us are tired both physically and mentally and may not live up to the high standards we set for ourselves. During a recent shift at a rural facility, I cared for a patient at the end of life who died from COVID pneumonia. Following the declaration of death, I walked into a room where a patient just diagnosed with COVID pneumonia became very frustrated and angry when I declined to give him a shot of ceftriaxone. He didn’t believe me when I tried to explain that his symptoms were from the coronavirus, not a bacterial infection. Normally, I would have sat down with this patient and done my best to explain the difference and to answer
his questions. This time I didn’t. I reiterated that this was viral, not bacterial, advised him to get vaccinated after he recovered, and I left the room. He left the ED angry and I was frustrated with myself for not being the caring, empathic physician I had promised myself I would be at my white coat ceremony. I believe a combination of systemic problems and disappointment in ourselves for failing to live up to an impossible standard is leading to widespread moral injury amongst EPs. We need to accept that we will not always be “right” morally or otherwise, especially when there are circumstances beyond our control. This is not saying that we should stop trying as our patients will always continue to deserve our best efforts. We need to accept, however, that we may not handle every encounter without issues and move on from these without self-deprecating browbeating. We need to remember to take pride in providing the best care we can to those who can’t access it otherwise. Maybe what you do for the patient isn’t the final answer he or she needs, but it’s what they need today and you are the one who can provide that. We can also take steps to address the systemic failures in medicine. As emergency physicians, we have seen some of the difficulties our patients face and can provide them with a voice. We can advocate for our patients through our
YOGA AND CROSSFIT WILL NOT FIX A DIRE NEED FOR A
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BETTER HEALTHCARE INFRASTRUCTURE AND THERE IS A LIMIT TO PERSONAL RESILIENCE, ONE WHICH I BELIEVE MANY PHYSICIANS ARE APPROACHING OR HAVE ALREADY PASSED.”
