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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.
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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,
—Toan T. Nguyen, MD
wondering if you shouldn’t have offered them surgery. What would their life had been like if they hadn’t had an operation?”
The recovery: “Almost all surgeons admitted it just took time.”
The long-term impact: “This can be major. Again, in the words of a surgeon, ‘a piece of me felt taken away with every complication.’”
No surgeon is immune from moral injury. Junior faculty, representing the lauded institutions where they trained while transitioning to new positions, are vulnerable. So are surgeons more advanced in their careers, whose partners and administrators expect more of them as they gain experience.
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The Impact of Surgical Culture On Moral Injury, and How to Change It
A recent paper exploring the effect on surgeons of postoperative complications found that their emotional responses may harm their well-being and, if left unaddressed, could represent a threat to the profession (Ann Surg 2022;275:e124-e131).
Calling for a shift in the surgical culture, the authors suggested their readers accept their humanity, destigmatize selfdoubt, “and encourage seeking help when dealing with the burdensome accumulation of a lifetime of complications.”
Part of this shift toward a kinder surgical culture might entail a willingness to mentor junior colleagues in a way that sets them up for success early on. Dr. Geevarghese described some tips that his colleague, Kamran Idrees, MD, the chief of surgical oncology and endocrine surgery at Vanderbilt Health, in Nashville, Tenn., has for mentoring early-career surgeons.
“He gave away his 7:30 a.m. block time. Dr. Idrees rationalized that if he gave them that OR time, he’d be on the second and third case; if they get into trouble, he can be available. And it’s during daylight hours instead of getting the scraps at 5 p.m., and trying not to be bumped by trauma,” Dr. Geevarghese said.
In an email to General Surgery News, Dr. Idrees noted that historically, new junior faculty cases are scheduled as “addons”—often starting long, complex cases later in the afternoon with random nursing teams, “which is not setting them up for success,” he said.
Dr. Idrees also calls on junior partners to help him out in the OR, stressing that he needs their assistance. “He runs cases by them, rather than just expecting them to run cases by him. This abolishes that stigma of weakness to call for help by making it natural. If my chair is asking me for help, then it’s no big deal if I, as the junior person, ask for help. And he safeguards them by always being available.”
For surgeons at all points in their careers, Dr. Nguyen advises taking steps to alleviate moral injury the way they would address any other emotional or psychological problem. “Identify the problem, gather appropriate facts, turn to each other and build support networks. We find colleagues who share our interests and concerns and share ideas, and it reduces factors leading to moral injury and distress.”
Dr. Nguyen also suggests trying to focus on changing the work environment instead of attempting to fix specific patient factors. “For example, when my patient told me she couldn’t get an MRI for six weeks, I called the radiologist and said I’d send her somewhere else. Sure enough, 48 hours later, she got her MRI,” he said. ■
