BEHAVIORAL HEALTH
Physician Moral Distress A reckoning with unmet needs BY TIMOTHY J. USSET, MDIV, MPH, MIKE KOOPMEINERS, MD AND JOSHUA T. MORRIS, PHD, BCC
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ystemic change in health care delivery to improve clinician well being, and thereby patient outcomes, has long been overdue. The need for it now has become even more acute. Physicians were experiencing well-documented rates of burnout, as high as 60%, before the pandemic began. New workplace realities have multiplied the complexities of this problem. These factors include caring for individuals who knowingly or unknowingly have COVID-19, concerns they will contract the virus and infect loved ones, wondering whether their institution will provide the necessary PPE, juggling child care, elder care, personal paid time away from work if they get sick, wrestling with furloughs and a struggling economy, and the numerous issues around the COVID19 vaccination. Add to this the pressures that arise leaving work to have conversations in the community with people about the efficacy of masks and shelter-in-place protocols. Physicians and other healthcare professionals, often lauded as “heroes” continue to experience the above stressors in ways that are further complicated by inconsistent political responses and lack of appropriate response from society at large. Day to day decisions people make about mask wearing and social precautions are the front line of the pandemic.
Multivalent Factors At minimum, the reality of the pandemic moves beyond burnout to include the paradigms of moral distress and moral injury, considerations that are being amplified for physicians during the pandemic. Moral distress takes place at the intersection of recognizing the appropriate clinical course of action, but due to internal or external constraints, being unable to take that action. The literature on a complementary term to moral distress; moral injury, defines that in high stakes situations, and from key leadership personnel, there is a betrayal of what’s right or the experience of acting in ways contrary to individual moral value. It is precisely through naming the betrayal of what is right and in acknowledging the moral stress of working in the pandemic that we can affirm what physicians are experiencing. Further, the totality of the stressors physicians and other healthcare professionals are carrying needs a reckoning. This stress leads directly to emotional and physical harm. Many studies aptly identify elements of how our health cares delivery system works that contribute to burnout. Wellmeaning healthcare advocates and administrators encourage workers to practice self-care, take respite, and focus on one’s self in preparation for taking on this virus. Individual practices of centering oneself and self-care are, of course, vital for caregivers however treating a robust systemic failure with individual manners of reliance does not adequately address the issues.
Moving Forward
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DECEMBER 2020 MINNESOTA PHYSICIAN
What is needed, or at least has the potential to move the industry in the right direction, is for the community of physicians to remain tethered in solidarity. There are exceptions, but our health systems will not be making drastic changes overnight to bring about healthier work environments for physicians. The dark irony of how slowly vital issues in our healthcare and political systems are addressed is found in the need for individual and collective practices among physicians to support and sustain one another. Physicians can not fix the problems of burnout, moral distress, or moral injury through just self-care, but can take steps toward maintaining meaning and purpose amid the increased challenges of their work to weather this storm.
Making meaning and valuable practices Resilience may be a protective factor against things such as burnout or moral distress, but it is a not vaccine. High levels of burnout have been found even among “resilient” physicians. In concert with building one’s capacity to thrive, holding and fostering one’s capacity to resist despair and bitterness during incredible adversity is a necessary and possibly more appropriate way of framing resilience during the pandemic. There are practices and interventions that have been found to be effective in addressing the impact of morally challenging events. Service members and veterans frequently experience guilt and/or shame following morally challenging or ambiguous circumstances. Similar to those in the military, physicians may also experience guilt and/or shame following the stress of practicing medicine during the pandemic. Not to conflate or equate military experience with practicing medicine but there is a similarity
