Moral Injury in Medicine: The Frontline

Welcome to the AMA Steps Forward Podcast. Here we explore Physician Developed Solutions to help care teams and their organizations thrive. Empowering Physicians, Transforming Practices. This is AMA Steps Forward. Hello and welcome to this episode in the AMA Steps Forward Podcast Series. I'm your host, Dr. Heather Farley, Group Vice President of Professional Satisfaction and Practice Sustainability here at the AMA. Today, we're diving into the often misunderstood concept of moral injury and how addressing moral injury is essential to bridging the trust gap between the frontline healthcare workforce and health system leadership. This is the first episode of a three-part series. Our guest today is Dr. Wendy Dean. Welcome, Wendy. Oh, thank you. It's so great to be here. Before we get started, would you mind telling our listeners a little bit more about yourself and your background? Sure, absolutely. So I first started my training as a surgery resident, moved to working in emergency rooms in rural Vermont and New Hampshire, and then finally came back and did a residency in psychiatry and practiced for about 10 years, where I realized that I was being challenged in how I could care for my patients in ways that were good for them and sustainable for me. After stepping away and working for the DOD for a few years, I realized this was a bigger problem than just me, and eventually I turned to looking harder at the big picture of clinician distress. I think it's so powerful when we have a personal reason for why we're doing the work that we're doing, and I know that you are incredibly passionate about the concept of moral injury. So let's dive in. And for those who might not be familiar, what is moral injury and why is the language surrounding it so important? I'm a big believer that until we have the accurate language, we can't really talk about how to get to better solutions. So that's the first place that I started. And it also came from a place of talking to a lot of clinicians who are friends of mine, who would say, burnout doesn't really land for me. And so when I, that was the place where I started thinking we need to search for better terminology so that people can accurately describe their experience. So moral injury is betrayal by a legitimate authority in a high stake situation that leads you to transgress your deeply held moral beliefs. And those deeply held moral beliefs from a professional standpoint in medicine are the oaths that we take to put our patients first. And so do you think that we, you know, you mentioned that the terminology of burnout doesn't necessarily land or hasn't resonated quite as clearly or deeply with many practicing physicians. And so do you think that we should throw out the term burnout and go with moral injury or how do these fit together? I love that you asked this question because this is something we have been fighting since our very first paper came out in 2018. And we, we did not get to title that paper. And it said physicians aren't suffering burnout. They're suffering from moral injury. And we were like, wait a minute, that's not what we said. And I think sadly, there's no need for anybody to have a corner on the market of clinician distress. There's plenty of room for burnout and moral injury. They, they, to me, represent two different things. Burn out is sort of the transactional operational challenge of workforce distress. I'm being asked to do too much with too few resources. Moral injury is a qualitatively different thing, which is the relational rupture rooted in that betrayal, which by the way is not always intentional. And what it, what it leads to is I am no longer able to practice as I believed I could. And the way that I'm being asked to practice is interrupting my sense of myself as a good person, a moral person, a patient focused person. I'm so glad to hear you say that. And I think there are many who see as you do space for both the concepts of moral injury and burnout and the unique experiences that they describe. So, you know, you describe moral injury as stemming from the frustration and helplessness that clinicians feel when business interests compromise patient care. How does that manifest and what does that look like in the real world? Oh, boy, there are so many, so, so many examples. One that we talk about a lot is prior authorization. One of my favorites. Gosh, right. So this is a particular struggle of my patient and I have had a very clear conversation. We have done some shared decision making around the challenge that they're facing and made a treatment plan, but their insurance doesn't cover that or their insurance requires prior authorization and perhaps the physician who's on the other end of a peer review doesn't have my certification, my board certification and my specialty. How do we get to a place where we arrive at a good decision for my patient when we're coming with different knowledge bases, right. Another one that came up when I was writing if I betray these words was a physician who quit two jobs in as many years because she was not allowed to refer outside of her healthcare system. She knew that the person who was best suited to care for her patients was an hour away, but outside of her healthcare system. And if she were to do that, her job was on the line. Those are just two of many, many different examples that I've come across in the last decade. And I think those two examples capture how there are business interests coming from outside of the individual health system that are impacting the experience of our physicians and leading to moral injury and moral distress. And then there are forces coming from within one's own health system that are the source of this distress as well. And it often can be just for lack of a better word, infuriating and incredibly frustrating and demoralizing to have these forces acting against your ability to just take care of your patient, which is why you went into medicine in the first place. So many of us went into medicine because we didn't want to we didn't want to go into business and yet here we are having to understand the business of healthcare in order to navigate the care decisions for our patients. I think that physicians aren't necessarily saying we should never talk about business interests or worry about the bottom line. I think that simplifying things too much. And I think physicians in general understand that we've got to keep the lights on. But perhaps it's it's how we're doing that and how intrusive those forces have become versus the primary need to put the interests of your patients first. I want to talk about a recent paper that you wrote and you described an updated approach to the foundational definitions of moral injury. How does this integrated framework clarify the experience of clinicians and help enhance our understanding of moral injury. The initial definition was by Jonathan Shay and he talked about the trail by a legitimate authority in a high stake situation. A couple of decades later, Brett Litz updated the definition and said that moral injury came from perpetrating failing to prevent or bearing witness to acts that transgress our deeply held moral beliefs. When we started looking at those they they had typically been viewed as either an external source of moral injury or an internal source of moral injury. And we said actually we think they're connected because when you experience that betrayal, there is a moment when you decide whether to stand up and speak out and push back which reduces your risk of moral injury or whether you acquiesce. And transgress your deeply held moral beliefs. And so when you when you start to think about those two in that way, their Victor Francois stimulus and response. And in that moment is the time when you decide what will you do will you put yourself at risk. Well, maybe I should say at what way in what way will you put yourself at risk because we all know that speaking up can also feel risky. It feels all of this sounds risky. It's risky to make the decision to not stand up and you know try to change the system in some way in which we. we're practicing because you're risking the quality and safety of the care that you provide to your patients and you're risking, again, transgressing those deeply held moral beliefs internally. But then on the other hand, you're risking potentially your career and your ability to continue to practice in your health system. Should you stand up in perhaps what's viewed as the wrong way? Right, which is also why I think the addressing this challenge really means creating community. You know, as we have talked at moral injury of health care, the very conceptualization of moral injury means that the fabric of your culture, of your social connections has started to fray because someone feels that a betrayal, even if it is unintentional, does not require an attempt at repair. And that is a very challenging place to be. That's so interesting. I really never had thought about it that way of the social, the fabric of social connection, the impact it has on that and that piece around, you know, the implication that you don't need to repair that rupture. Correct. And I think this is a lot of what physicians talk about is I am not expecting perfection, but I am expecting you to listen to me. I am expecting you to hear my side of this story and to acknowledge that it has value. And I think that that goes back to why we have such a trust gap right now between frontline healthcare workers and our healthcare leadership because, you know, when those ruptures occur, you know, having trust requires acknowledging those ruptures and attempting to heal them. Correct. Exactly. You know, this is something that has been on my mind for a very long time. When the pandemic first started, maybe we were only a few weeks, a few months in, I wrote an article and I remember thinking, as I wrote the article, I'm really worried that in five or 10 years, I'm going to be rereading this article and thinking, yeah, here we are. Because what I said was, if we don't invest in repair on the end of this pandemic, we are going to be in a world of hurt because there will be a trust gap between our leadership and our workforce. And we have not, you know, understandably, there were financial constraints that we had to address coming out of the pandemic. We had to get back to business as usual as quickly as possible. However, completely ignoring the trust gap has left us with a workforce that is very feeling devalued, destabilized and tenuous. Yeah. Yeah. And those insults to the trust gap or those ruptures continue to happen without the necessary repair. And I think that's maybe the lever that we as a healthcare ecosystem need to focus on more because we're not perfect. Our clinicians aren't perfect. Our healthcare leaders aren't perfect. And trust isn't perfect, but how do we, when that trust is ruptured, we know that it's going to happen, but how do we, how do we preempt that with ensuring that people feel like they have a voice and input into how healthcare is designed and executed? And when it doesn't go down as planned, do we have enough of a relationship amongst our teams and with our leaders that we can have real discussions about that and address any ruptures and trust? And I'd love to see us get there. Right. Well, and the other thing that we have to realize is that when our workforce does not trust leadership, that bleeds over into the patient relationships. And so if we have a workforce that is untrusting or distrusting, mistrusting, we have patients who also pick up on that. And in our current environment, we can't afford that. Yeah. So well said. Wendy, when we talked earlier, you alluded to three levels at which one can experience moral harm. Could you tell our listeners a little bit more about those levels? Sure. This is this is also something we think about a lot. And again, to break things down into their components so that we create solutions that are accurate and effective. The first level that we think about is the personal level. So these are my personal moral beliefs. It may be the family that I grew up in, the family values that I hold from growing up. It may be my religious views, all those sorts of things. That's one level of potential moral injury. The second is my professional obligations. I chose to be part of this profession of medicine, which has certain ethical and moral obligations. Those may be different from my personal beliefs. And when there's a delta between those two, that's between me and my family, my own sort of supervision to figure out how to bridge the gap between that. And then there's the societal level of moral injury, which I always used to struggle to come up with examples of it. And currently I have examples every day when I open the newspaper. So I think it's important to think about those different levels because they require different interventions. So as I mentioned, the personal moral values might need a priest. You might need to talk to a priest. You might need to talk to one of your trusted elders. How do I, how do I square my personal values with what's happening elsewhere? On the professional level, that's really what we talk about at moral injury of health care more most often. How are the decisions or the pressures that I face in medicine impacting my professional obligations? And the commitment that I made to my patients, the covenant that I made with society to obtain this level of training and expertise in exchange for certain other privileges. I think that framing is very helpful as we think about the necessary approaches to prevent or ameliorate any moral injuries. So thank you for sharing that framework. And I'm going to move us on to talk about what are the structural constraints or policy-related factors that most commonly drive moral injury within health care institutions if we're talking about that level? Oh gosh. I mean, I think when we look at it broadly, those sort of policy constraints are all the regulations and legislation and layers upon layers of administrative constraints. That leadership has no control over. We have little control over. They are things like all of the requirements for CMS has hundreds of regulations that pertain to any given health care encounter. Until we start looking through those and stripping away the ones that don't matter anymore. And I think about Jen Polka's work in other areas of the government where she's talking about, you know, let's streamline government a little bit more. I wish we could do that in health care. And there are some organizations that have done that, the gross initiatives of getting rid of stupid stuff, brilliant idea. It's a great start, but we also need to be looking at sort of what are the other regulations that we might need to talk to Congress people about changing. Things like, can we put constraints on certain types of health care investment? Can we put constraints around how giant health care entities can become? Can we maybe level the playing field in terms of payment structures to different entities? No easy questions or solutions there. But I think those structural constraints and policy-related factors that you just described at both, you know, that speaks to, again, those changes that would be helpful at the health system level as well as at the broader health care ecosystem and governmental level. And so there's definitely opportunities here for redesigned within health systems. you mentioned the getting rid of stupid staff initiatives, which is a personal favorite of mine and the de-implementation work. And then there's opportunities, you know, at this state and federal level from an advocacy standpoint of what we need to do collectively. So I really like the way that you've sort of sewn all of that together. Thank you. I have a better understanding now of where those opportunities exist. And so let me shift gears a little bit and ask you some more specifics around, let's say I'm a health care leader, how do I know if my team is experiencing moral injury? Are there signs that I should be looking out for? I think that depends on the culture of your organization. So in an organization that really values feedback, your workforce will tell you they will tell you as long as you then take their feedback seriously and act on it. When you stop acting on it, people will stop telling you what's happening. Instead, they start leaving. So most of the work in what the manifestations are was done in the military. In health care, the manifestations of moral injury look a little bit different. They look like they look more like anger, frustration, a little less shame-based because people could still sort of say this is not about me, this is about the system I'm being asked to work in. But that frustration and that anger and that demoralization all sort of come together as the result of these challenges. When you're being asked again, you know, it comes down to you're being asked to work in a way that you don't think accords with your professional obligations. That is a very difficult place to be in a high stakes entity like health care. So you're being asked to work in ways that you know might lead to outcomes that aren't as good. Patient satisfaction that isn't as good. A relationship with your patient, which, oh, by the way, we know is a healing part of that encounter that is lower quality than it could be if you could align with your professional obligations and values. So I'm now as a health care leader realizing that members of my team may indeed be exposed to drivers of moral injury and are experiencing moral injury themselves. And now I've woken up to this and I recognize that this is a problem. What practical steps can health care institutions or leaders implement immediately to mitigate moral injury among their physicians and care teams? I think that so so first of all, we did a study from the pandemic that showed that 40% of executives and managers experienced some level of moral injury during the pandemic. So this is definitely not related just to clinicians. When you start questioning whether or not this is happening, the best thing to do is to ask people to get curious, to get vulnerable, to be humble and say, what don't I know about the struggles that you're facing? And do you have ideas about what we could do? When you start realizing that your workforce isn't your problem, but your solution, everything gets clearer and I would argue easier. Your workforce is not your problem, it's your solution. Put an exclamation point behind that. Now, we keep coming back to the fact that having trust and open conversations with your workforce, really getting curious and trying to understand what their experience is like and asking them, what do they need to take good care of their patients? Ultimately, we all want the same thing. Patients want great care. Our physicians and care teams want to provide it and our healthcare leaders and administrators want that too. We've got to figure out what are the things that get in the way and that requires people to ask and to really care about those answers and to do their best to attend to them together and to have that feedback loop of, we heard you, I heard these concerns, here's what we're doing about it. And even when the answer is no, I can't fix this, here's why. So that again, we understand. And to your point, I think you said so clearly that moral injury is not limited to the physicians and care teams, it's also experienced by leaders too. And that requires a lot of vulnerability on the part of the leaders to acknowledge that, I think, with their teams too, that they're struggling. The leaders are struggling to create those conditions for care teams to provide excellent care. And that's hard for them too. We're going to dive into that more in our next podcast episode, but the little bit of a teaser, I think. Yeah. I mean, I think, I think when you think about it in an organizational context, you know, we did a study where we asked moral injury scholars around the world in very different sectors. If you could imagine a non-moral injurious organization, what would that look like? And we had 113 different recommendations that met consensus. That was a tough one to write up. But it broke down into three different buckets. And basically what it said was, in the first instance, you need to identify as morally centered. That has to be your guiding light, your guiding purpose. Next, you need to align your behaviors and practices with that identity so that your behaviors and practices, like non-retaliatory feedback mechanisms, are integrated into how you function as an entity. And then finally, the last part of that is to make sure that you are continuing to monitor whether or not you are stepping off that path. So you need to do continuous surveillance, asking people, are we staying true to that identity that we defined? Are our behaviors and practices creating the outcomes that we want to see? So important for us to talk about and think about solutions here. You know, I think we, now we all are sort of having a better awareness and understanding of some of the drivers of moral injury and burnout. And everyone's like, great, yeah, great. Now we get it. Now we know that we're in a not great place. What do we do about it? So it's wonderful to hear that there are some consensus developing around what we need to do to get to a better place. With that in mind, do you have examples of health systems that are getting this right? Give us some hope. Well, I think there are places that are trying to do it right. On our podcast, we just had a conversation with a CEO from a small system in Missouri who described sort of this model of leadership. Steve Edwards at Cox Health. He was very work force centric. His culture was the most important thing about his leadership because if he took care of his people, they would take care of his patients. And taking care of the community was the most important thing for that organization to do. So I think they're out there. I think we look to a lot of times, we look to very large systems, but it's hard to get it right at that scale. It's just, it is hard. And I think sometimes we overlook the smaller systems, but there's a lot we can learn from that. So true. As we think about solutions, where does wellness-centered leadership fit in? Do you think that sort of that wellness-centered leadership principles and trainings that exist? Does that help health systems and health system leaders? I hope so. To get it closer to right. I think I think an awareness of wellness is important. But I actually think what's what's equally important or maybe more important is a simple understanding of who you work for. Meaning I'm not working for myself. I'm not working for my boss. I am working for the people who are working for me. I'm a servant leader. So when I was, when I was an executive for a half billion dollar nonprofit, I had 2,000 people working for me around the world. My boss was a former two-star general, and he would say to me, "You're not, you're not answerable to me. You're answerable to those 2,000 people who are walking point for this organization. Thousands of miles away." So, I want you to make sure that you are clearly aware of what they need and that you are turning this organization to be responsive to them. And I think that is the primary challenge that we have in healthcare right now. We're focused on, you know, what risk management needs, what the CFO needs, what the real estate folks need and so all of our frontline clinicians are answerable to headquarters for lack of a better word. We need headquarters to be responsive to the people who are providing the care that is the mission of that organization. Wellness fits in there. You have to be aware of some of the wellness pieces, but I also think understanding what your leadership role is, meaning who you are as a leader, being reflective, introspective, having integrity, honesty, humility, vulnerability are all essential components of really good leadership. And I think this all ties in together because when leaders do get that and create that environment, it ultimately creates that environment where their workforce can thrive. And that is well-being. And I think it all ties in there and ultimately helping everyone to understand that these are not mutually exclusive investments, where you are investing in the experience and well-being of your workforce at the expense of operational efficiency, revenue. Those are not mutually exclusive, that's understanding that investing in your workforce actually is a strategic imperative in order for a health system to deliver on their mission, etc. Correct. If you don't have a health care workforce, you don't have a health care organization. So let me ask you, when you have conversations with health systems, with leaders, with people in general, about the concepts that we just talked about, about moral injury, do most people get it or do you get a lot of pushback? And if you get pushback, where is that coming from? Let's get it immediately, immediately, that I can't tell you how many people have reached out to me and said, "This is the language I've been looking for for the last 10, 15, 20, 30 years." So it lands immediately. Where we tend to get more pushback are with folks who are non-clinicians who are like, "Well, isn't moral injury turning the burnout happy to glad?" Aren't we just changing terminology? And I understand that. It's very hard. As clinicians, we sort of take it for granted what this mindset is. And as a non-clinician, my parents never quite understood the commitment of being a physician. They tried, they tried very hard, but they hadn't been through the training that it takes to sort of integrate that mindset into your identity. And so it's sometimes as hard for non-clinicians to understand why this is so very important and why this part of professional identity is important for well-being. If you have this sort of moral disorientation, you can never get to well-being. You can never get to thriving. And so this is sort of the foundational piece. And we can put all of the other pieces of wellness around it. But if we don't have this one thing, if we don't have this one thing, we will always struggle. I am hopeful that the conversation that we're having today helps our listeners understand better some of these concepts and help to give them the language they need to have conversations amongst themselves and within their organizations because this is such an essential and foundational issue for the thriving and well-being of our healthcare workforce. Wendy, any other pearls of wisdom from your experience that you'd like to share with our audience before we wrap up? I just want to make a plea that this is an experience we probably all have had. And it's one that we can come together around to understand each other better and to make healthcare better for our patients and more sustainable for clinicians and administrators. It is not a one-sided challenge. It is such a great place for us to land. Thank you, Dr. Dean, for sharing your insights and expertise with us today around such a compelling topic. To our listeners, thank you for joining us. Our guest on today's podcast has been Dr. Wendy Dean. Please join us for part two where we will dive deeper into how moral injury impacts administrators and health system leaders as well. Please check out the episode description to explore the resources associated with this episode. And until next time, stay well. Thanks for listening to the AMA Steps Forward podcast. For more episodes, resources, and CME opportunities, visit StepsForward.org.