BEHAVIORAL HEALTH Physician Moral Distress

Physician Moral Distress A reckoning with unmet needs

BY TIMOTHY J. USSET, MDIV, MPH, MIKE KOOPMEINERS, MD AND JOSHUA T. MORRIS, PHD, BCC

Systemic 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.

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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

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

in guilt/shame responses that has been studied extensively and has yielded Another method is to gather a small group (3-4) of peers that you trust coping techniques that present options for physicians. Specifically, there are and schedule a time-share about what is most stressful in your practice right practices that have been integrated into new wave interventions to facilitate now. This should be in a semi-structured environment that allows everyone those who have experienced moral injury. to speak briefly, then receive and offer feedback to others in the group. A Moral injury can arise from the challenges recommended outline could include: of treating patients in the resource-constrained Step 1: 30 seconds to share something environment of the pandemic. The way in which distressing in your practice physicians are taught to and value practicing medicine has been challenged by the utilitarian Step 2: 15 seconds of silence processes that were implemented to manage scarce The reality of the pandemic Step 3: 3 minutes for feedback from other resources. For some physicians, these dilemmas moves beyond burnout. members of the group create a sense of guilt over “not having done enough” for their patients. This is a prime example Step 4: 1 minute to respond to the feedback of moral injury and there are several effective from the person that originally share techniques to process this experience. One method Repeat steps 1-4 for each person present. is the practice of writing brief letters to a present or The purpose of this group isn’t to solve all of the deceased compassionate person. This should be a person you trust to act with problems in medicine or our healthcare system, but to connect with and receive compassion toward you. The purpose of the letter is to briefly share what feedback from other professionals. The outline above could be completed in you are finding distressing in your practice and what you would like to do as little as 15-20 minutes for meetings of three to four people. Hearing from differently about it. If the letter is written to someone that is deceased (i.e. a others can help identify other perspectives and moral contexts that can foster trusted grandparent, sibling, parent or friend), the next part of the process your “capacity to resist” the pull of shame, despair, or bitterness. In addition is imagining how that individual might respond to you in a compassionate to providing insight on guilt or shame, the above practices work to address way. If the letter is written to someone still living, you can setup a time to loneliness and isolation. By connecting with trusted individuals in or outside share it with them to receive their feedback. If you would prefer not to share it, you can imagine that person’s compassionate response to you. Physician Moral Distress to page 224

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of the profession you can tend to your ability to practice compassion toward staff are not available, EAP programs are another option for seeking shortyourself and others. term support. Physicians Serving Physicians has been providing support to When/Where to seek more formal support? physicians experiencing substance use concerns When it comes to seeking support from peers since 1981. The Physicians Wellness Collaborative or professionals, what we call the various (PWC) was created in 2020 as a program of PSP stresses and challenges of medical practice to reflect the expansion of PSP’s services to include is less important than noticing their impact. Physicians need to have an active sense of what their equilibrium looks like in their practice. This includes everything related to professional It is important for physicians to remember and maintain their agency. physician mental health and wellness. The PWC offers peer support and mental health services to physicians (at no cost to them) that prefer to work with resources outside of their employer. In practice and also time spent with family and these unique times it is important for physicians other life-giving activities. What changes have to remember and maintain their agency, ability to been especially noticeable during the pandemic? make meaning, and practice whole-heartedly in Less time with family? Drinking more? Spending the midst of incredibly challenging circumstances. more time in the EHR? Changes in equilibrium are not in and of themselves problematic, but unrecognized changes can lead to new work/ Timothy J. Usset, MDiv, MPH, is the Executive Director of Physicians Wellness life equilibriums that are at odds with one’s values. On the more serious Collaborative https://psp-mn.com/ side they could result in medical errors, adverse patient outcomes, and negatively impact relationships with family and friends. Mike Koopmeiners, MD, is the Medical Director of Physicians Wellness

Though stigma around seeking help for behavioral concerns is still alive Collaborative. and well, even among clinical disciplines, this should never discourage any or chaplains that are available to support clinicians. In the event internal physician to take those steps, or to recommend them to a colleague who they Joshua T. Morris, PhD, BCC, is the Chaplain at Children’s Mercy Hospital, may know is suffering. Many systems have internal behavioral health staff Kansas City.

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David Schultz, MD Chief Executive Officer Nura Pain Clinics Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers

Our thoughts on chronic pain…

1. Chronic pain doesn’t take holidays.

Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

2. Opioids are a problem.

They can also be part of the solution.

According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

3. There is no silver bullet.

One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn off their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we offer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.