IN THE NEWS
Moral Injury: The Emotional Impact of Complications By MONICA J. SMITH
NASHVILLE, TENN.—Many who read General Surgery News will be familiar with this quote attributed to René Leriche: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray.” Meditative, elegiac and also incomplete. “The latter half is, ‘a place of bitterness and regret, where he must look for an explanation for his failures,’” said Sunil Geevarghese, MD, a hepatobiliary and transplant surgeon and an associate professor of surgery at Vanderbilt University Medical Center, in Nashville, Tenn., speaking at the 2022 Southeastern Surgical Congress. Dr. Geevarghese continued: “I think he was talking about moral injury in 1955.” First documented in Vietnam War veterans who described unsettling symptoms that differed from classic posttraumatic stress disorder (PTSD), moral injury occurs when individuals witness or fail to intervene in a situation that goes against their moral beliefs. “Moral injury is a little different from an ethical dilemma because with moral injury, we know the correct ethical action but feel powerless to do it. An example would be that we know a patient needs surgery and would benefit from it, but a delay occurs, which leads to worse oncologic outcomes and patient distress and our own distress,” said Toan T. Nguyen, MD, a breast surgeon and the director of breast oncology at Lakeland Regional Health, in Florida, speaking at the 2022 annual meeting of the American Society of Breast Surgeons. Moral injury is different from burnout, although it can lead to the latter, Dr. Geevarghese said. It is “like acute kidney injury is not end-stage renal disease.” Although Leriche’s possible description of moral injury more than 65 years ago suggests it has long been part of the cost of being a surgeon, recent research shows that the COVID-19 pandemic has exacerbated matters, according to Dr. Nguyen (J Gen Intern Med 2022;37:2033-2040). “This work—which was broadcast on national headline news—showed that healthcare workers, many of us physicians, experience moral injury comparable to veterans. About 50% of us have trouble with moral injury because of someone else’s immoral behavior due to COVID19, and 20% of us have actually had to violate our own morals and values because of pandemic-related restrictions. This led to more PTSD, depression, lower quality of life and burnout,” Dr. Nguyen said.
How Surgeons Experience Moral Injury Preparing for a talk on moral injury,
Dr. Geevarghese came across a paper that described the experience of a neurosurgeon who, after a major complication, yearned for the next case that would have a happy ending. “I think all of us, the morning after a major event, just want to get past it. In reality, it’s really complicated,” he said. Although moral injury affects physicians across all fields of practice, Dr. Geevarghese thinks it hits surgeons a little differently. As described in a paper
that investigated the emotional impact of complications, surgeons progress through four phases after an adverse event (Med Educ 2012;46[12]:1179-1188). The kick: a visceral blow to the core. “I think everyone can attest to how that feels; it’s accompanied by feelings of failure, self-doubt and unworthiness,” Dr. Geevarghese said. The fall: a sense of spiraling out of control. “If a patient develops a complication, even if it wasn’t your fault,
The Surgeon Orients in the OR for More Accurate Margin Analysis MarginMarker™ Sterile six-color ink kit; the surgeon applies ink to designate each margin for pathology.
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CorrectClips™ Sterile radiographic clips; the surgeon applies clips to orient specimen on the image.
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Request a Sample | VectorSurgical.com | +1 (262) 798-7970 Vector Surgical, the Vector Surgical Logo, MarginMarker and CorrectClips are trademarks of Vector Surgical LLC. Reg U.S. Pat & TM Off | © 2022 Vector Surgical LLC | References (1) Molina MA, Snell S, Franceshchi, D, et al. Breast specimen orientation. Ann Surg Oncol. 2009; 16:285-288. (2) Altman AM, Nguyen DD, Johnson B, et al. Intraoperative inking is superior to suture marking for specimen orientation in breast cancer. Breast J. 2019;00:1-7. (3) Singh M, Singh G, Hogan KT, Atkins KA, Schroen AT. The effect of intraoperative specimen inking on lumpectomy re-excision rates. World J Surg Oncol. 2010;8-4. (4) Van Den Bruele AB, Jasra B, Smotherman C, et al. Cost-effectiveness of surgeon performed intraoperative specimen ink in breast conservation surgery. Journal Surgical Research. 208;441-447 | MMCC SPREAD GSN SUMMER 2022
