Moral Injury in Medicine: The Leadership Perspective

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. This is the second episode of a three-part mini-series covering moral injury. In our first episode, we spoke to Dr. Wendy Dean about moral injury from a frontline clinician perspective. Dr. Dean described moral injury as a relational rupture, a betrayal by a legitimate authority in a high-stakes situation that causes clinicians to transgress their deeply held beliefs. She distinguished it from burnout, noting that while burnout stems from being asked to do too much with too few resources, moral injury is qualitatively different. It erodes a clinician sense of themselves as a good moral patient-centered person. She also reminded us that moral injury isn't limited to frontline physicians and healthcare workers. Leaders experience it too, which brings us to today's episode where we will be speaking to Dr. Jason Lassandrini about moral injury from a leadership perspective. Thank you for joining us on the podcast today, Jason. Well, thank you so much for your time. Before we get started, would you mind telling our listeners a little bit more about yourself, your background, and maybe what drew you to the intersection of ethics and leadership? Yeah, that's a great question, and I have to be honest, it's luck and chance that brought me to where I'm at today. Short story of that version is, is was walking around a used bookstore and I kicked a book called Mortal Choices by Ruth McCacklin, picked it up and it talked about modern ethical dilemmas in medicine, and I turned to my friends and said, I think I'm gonna do this. They said to me that no, that seems like the dumbest idea I could have ever thought of. I said, no, no, I think I'm gonna do this. I read a few of the first pages and it talks about being an ethicist on staff for clinicians to help them sort of resolve conflicts or uncertainties they have with patients, families in the community, went home, book was $2.36, I bought it, I read it in a week and decided that's what I was gonna do. So I doubled down and went pretty hard on, you know, studying, I ended up at Michigan State where it was a great place to do clinical ethics and bioethics, came to Georgia State, got an opportunity to work at Grady Health System while I was here, doing my masters in philosophy, and then I did some work when I was in St. Louis, and I worked for the National Center for Ethics and Healthcare for the Veterans Administration and then finished up my PhD at Duquesne and I've been working in clinical ethics ever since. I think what I saw doing bedside consultations, working with clinicians who are struggling with moral challenges or issues, you know, being with families in the crisis, you know, sitting in on those deliberations and it struck me that a lot of the problems that we see in and out aren't just individual bedside problems, their organizational problems, their problems that leaders face, and so that work led me to sort of the spot I'm in now where I get the opportunity to work with leaders on moral challenging situation, still the bedside stuff too as well, but also get to lead a team that does that work. The last three to four years have been about sort of developing ethical leaders and their responses to these challenging situations and building ethical cultures. And the rest was history, that might have been one of the most unique origin stories I've heard. I'd kicked a book. I love that. Thank you for sharing that. We're so very glad that you're joining us on the podcast today. In our last episode, Dr. Dean painted a vivid picture of how moral injuries shows up in front-line physicians and care teams. The prior authorization battles, the inability to provide patients what they need due to insufficient resources and the feeling of being unable to practice in alignment with the oath they took. So before we turn to how moral injuries shows up for leaders, I'd love to get your perspective on that front-line experience as well. How do you see moral injury manifesting among front-line physicians and care teams? Are there certain patterns that stand out to you? Yeah, I think Dr. Dean has it right. There's lots of challenges these frontline clinicians face. I think maybe the thing that I see it, I don't think it's the one-off. Dr. Farley, I think it's more an accumulated weight that sort of sits on clinicians and providers. And then you know that what starts happening after that acclamation, for me, this is how I think it shows up, is lots of detachment. Lots of disconnect become very quiet where they might have been vocal before. And I think that quietness is protective in nature. When you can't figure out why it keeps happening to me, why do they keep? Why do I keep being asked to do things in a system that seems inconsistent with what I signed up to be? And so I think that detachment and silence that comes is part of where I see it. I think the other thing I'll say is the other place I start to see moral injury really occurs after repeated instances of what I would call moral distress. So this is a phenomenon of having an ethical challenge dilemma. You can pick whatever issue, whatever it is. And then having that sort of psychological feeling of distress arise as a result and then being, you know, connected temporally. It's not the one-off again. It's not just one instance of moral distress. Most people are able to respond to that. I think when we get repetition of that of frequent ethical issues all the time, it ends up getting exactly to what Dr. Dean was talking about it, but sort of a violation of the old that they took to care for patients. It's almost, it's like it becomes a barrier. The ethical challenge has become a barrier to them providing what they were, you know, set out to do in their purpose. So what it be fair to say that that repetition of more experiencing moral distress and that cumulatory effect leads to moral injury? I think that's fair. Now it will full transparency to the audience. I don't think we have any evidence to suggest that except to anecdotal Jason here telling us what's the case. But, you know, I imagine the audience here knows that they've experienced it. They feel it. It starts off, you know, a colleague and I wrote a paper about this, but it starts off basically as moral anxiety, just feeling uncertain about the moral dimensions of things. And we see, this is from our practical experience, moral distress comes next. So if this anxiety, then you keep getting these dilemmas, challenges, whatever it may be. And then it just kind of builds up. Is it possible to jump from current state to moral injury? Yes, that's possible. Is it possible to, you know, have low levels of moral distress and jump to high? Yes, of course, the severity can be there. But again, I don't want to be this broken record. But I think I see this repetition happening time and time again. And it sort of leads to those challenges that we face. That's helpful. Thank you for fleshing that out a little bit more. And now that we have a better understanding of how moral distress and moral injuries show up in the frontline healthcare workforce, let's go ahead and turn our attention to how leaders might experience moral injury themselves. So in your estimation, how common is moral injury or even moral distress among healthcare leaders? Is this something we're just beginning to recognize? Has it always been there? Another great question. With little published evidence is what I'll say, lots of anecdote, I think if we went to a number of the professional organizations and toward the conferences, we'd hear similar themes across them that that leaders are experiencing it. I think it's always been there. I think folks like Dr. Dean and others are putting language to something that maybe we might not have been able to conceptualize before. And what's wonderful about that is that it's giving leaders a space to actually talk about it. I think there was this assumption whether you're a clinician or a non-clinician who rises up into leadership that you were supposed to be beyond this. That this isn't something that challenge you. This is, you know, you're a leader. You're supposed to have the answers, right? You're the ones who's supposed to hold everybody else together accountable, right? And so admitting that you have some challenge or struggle feels like a leadership failure and maybe seen by others who don't recognize that as a leadership failure. And so when we look at the literature and of these concepts and terms in other spaces, I think we're seeing that leaders are experiencing moral distress, moral injury, all that probably at significant rates, but it's just never really been captured sufficiently. I think the other thing that's really interesting here is it depends at the level. You might see different severity at what level of leadership you might sit in. There's quite a bit of literature on moral distress and maybe some on moral injury for the nursing profession. And there's even more evidence about nursing leaders who experience moral distress and moral injury. It's not as robust as we have it definitely in the physician space or for the nursing space for moral distress. I think we're getting to that point, but I think we're at the end of the day we're all experiencing the same phenomenon. It is the same thing. There's a there's the moral distress component, which is about experiencing ethical challenges and having distress as a result of it. And then there's this core of who you went to be a leader, the reason you went in to be a leader in health care, I think I know why I went to be a leader. I wanted to help people. That's ultimately the same thing I think that a lot of clinical providers go in. They want to help people and we're all operating in a structure that makes it even more challenging to do so. So it's interesting. I'm so very glad that you and others are beginning to shine a light on the fact that moral injury and moral distress are human experiences and not necessarily really just limited to one occupational group or profession and that our leaders can experience this as well. It sounds like there are some similar drivers of moral injury for leaders as there are for physicians and care teams. Are there unique drivers for leaders that you've seen? Yeah, I think there are a few. I'll try and highlight a couple, maybe, that sort of rise for me. So one I think is role conflict. And I do think that physicians and nurses experience this too, but I think depending on where you sit in the hierarchy of leadership, you're likely to experience it more as you're serving two ends, I guess, simultaneously. So you're supposed to be accountable to your organization, right, above you, whether that's your leader above you or if you're at the top of the leader chain to the organization at large. And so, and at the same time, you're supposed to feel accountable to the staff and the patients who might be in your direct line of responsibility. And those two interests can actually pull in opposite directions. And it puts people, leaders, I believe, in a bind that has often no clean resolution. Similarly are the ramifications or the consequences of moral injury the same for leaders as they are for physicians and care teams. And, you know, I guess I have a two-part question there. You know, what are the consequences for that individual experiencing it? And then are there unique downstream impacts on the organization because of leaders who are experiencing this and potentially not able to navigate it in a way that creates that repair? Yeah. A couple thoughts about that. I think the phenomenon that causes these things is similar in both roles, clinicians, leaders, pick any type. I don't want to say I live in a polyanna world. You know, Dr. Partley, but I'll be honest, I think most people go into health care because of the last part of that word. They go to care. That's the unifying theme amongst all of them. And we get engaged in a system. However, it gets fixed. I don't know what the answer to that is, but engaged in a system that puts pressure on that at all times. And so we see that show up in both clinicians, but I think it's the same thing for leaders. No, to the earlier question about what is it doing? I think it's doing the same thing to leaders that it's doing to clinicians. I think what we're seeing is disengagement. You're seeing cynicism. I think we're seeing physical health consequences. What I would like to call and I don't know if this is the philosophically correct term. It's morally numb that you stop being surprised by things that probably should still bother you. You'll lose those leaders who probably still have moral sensitivity because they're the ones who are likely to recognize it quickly and themselves. And then what you get left with is a leadership culture that can be skilled as it were at rationalizing whatever needs to be rationalized because they are not morally numb or they've sort of what I would call they've burned the moral awareness out of themselves. They're not aware to the moral components of a situation that they just look like just a regular decision and so they just kind of move forward. Wow, that sounds like that just sets up a vicious cycle of sorts. If you have leaders who are experiencing that level of moral distress and moral injury and have numb to themselves to that moral impact now where they will make and/or communicate decisions to the teams that they lead in a way that then induces moral injury amongst their teams. Yeah, it's a vicious cycle of it's almost like a contagion. It's a spreading of a disease that we keep spreading and it makes me think back to the earlier question about what other things might be there and you started to highlight this, Dr. Farley, I think there's this notion of complicity that comes with being a leader that you get asked to execute. That's your job is to execute, right? Even if you believe the decision is wrong, right? Something that could potentially compromise care or you think there's a policy that could be ethically problematic or a decision that will create challenge or strife for our community. And you do it anyways because it's your role. So I'd like to bring this to life a little bit. Can you share a story or an example from your own experience or maybe a leader that you've worked with? How did this show up for them and was there some sort of turning point after they've experienced this residual or compounding moral distress and moral injury? Yeah, so I'm just going to say a caveat, just like every situation in life as an asterisk next to it, of course. This is a long time ago. This story sort of sits with me, but I've changed kind of all the details because I don't want to make sure I protect that person and I'm sharing what they shared with me. So the basic idea was this that there was a leader I was working with, one of the most outstanding people I think I've ever met in my career, this is a long time ago, still stands out as an amazing leader. It's the kind of person that you would want making decisions for you when you needed it. It was the kind of leader. He wasn't an orthopedic surgeon, but I might let him operate on my knee because I trusted him enough type of thing. So he gets asked to implement a reduction. That's a staff reduction. He knew what was going on. He knew what his team, the stress his team was under, you know, the organization that he worked for was already running pretty lean. He tried to raise it up. You know, we talked about this about what he could do and he's told that the decision had to be made. That's just the reality of the world, right? That sometimes these kinds of decisions have to be made. And so he delivered the message to his team. He's super professional. I wasn't in the room, of course. This wasn't even really an organization I worked with. It was a colleague. And then I could see it in him. He spent the next six months slowly backing away from, to be honest, all of his relationships and the things that he used to care about and the people he used to care about. And the reason it stands out for me is because he backed away from me. He stopped calling. There was fewer texts. We had opportunities to be at the same conference. He would hang in his room. He would go to the required things that he knew he needed to get. And then I would ask him, hey, let's go hang out afterwards and he'd say, no, no, no. And then eventually, probably about a year afterwards, it came out. He told me exactly what he was doing and what he was sitting with. He shared that he basically became silent. He stopped advocating. I stopped raising concerns. He felt like the cost of caring about that was so high or too high for him. And we had a lot of conversation about what it meant to be in that space, what it meant to live in a space where an organization shares your values. And then when it doesn't and what that does to you, but I think what we came out on the end of it is naming it matter. We talked about what that thing was there. And so he was able to think about how he lived with his own values as a leader and thinking about how he could separate out, not just what was in his lane, but what he could influence and what he couldn't and how we reconnected with himself and what he got into the whole business of being a healthcare leader and being intentional about where he worked. And the values of the organization stood up for and how he made sure not that there was perfect alignment, but that there was congruence for the most part. That's a great example, Jason. Thank you so much for sharing that real life example. And I think it also brings to life that is a common dilemma that leaders face. They may privately disagree with an organizational decision that they are expected to carry out. How should a leader navigate that gap without betraying their own values or undermining their responsibilities and the trust of the organization? So let me say that it was there was a happy ending eventually, I think to all of that to his story and still living out his values. I'm still get texts from from him now. We actually call, you know, we share meals together. There's there's actually the relationship is back. And I'm thankful that he gets to lead a new team that gets, you know, gets to be with him and sort of make decisions jointly and really lean into their values because I think that's really important. And that's sort of what I think you're getting at right now is how do you do that? And I think that's the biggest and maybe hardest challenge in ethical leadership leadership in general. And I'm going to try and give this analogy when And you're going to battle in medieval times. would wear a suit of armor. And that suit of armor is protective for you for a while. 'Cause it can take a lot of, you know, jow sticks or things in the armor and be okay. There are things that you can be okay with. You can still defend yourself. There are things that happen. And a leader once told me, you're gonna take blows that pierce the armor. And some of those blows are gonna get you. They're gonna be deep wounds that will sit with you for a long time. And some of them are just gonna pierce the skin. And some may even just go past your armor, but not touch you. And so when I think about this question, I keep thinking about that armor analogy about, what does our armor look like? How do we navigate our values, staying whole and true to who we are? Because one day you don't wanna wake up and have taken so many hits to that armor that you're not the same night anymore. You're not the same person battling for the right answer. You know, there's a meaningful difference, I think, between things you disagree with and decisions that you think are just violations of ethics. Decisions you disagree with, listen, I get it. Different judgments, different priorities. Maybe you would have done it differently, that's fine. Your job as the leader is to raise concerns. Make sure the right people, your those concerns aren't noted, be clear about it, be specific. And then accept that what we teach our children, that you don't always get what you want, is the reality, okay? You may prefer something and we have to do that. Organizations can't function if every leader only implements those decisions they personally agree with. That's just not the way that the world works. It doesn't matter healthcare or not. But when you're being asked to do something that you believe crosses some ethical line or violates a core portion of who you identify with, is it that's different. And I think it deserves a different response. I think it deserves a harder push, being explicit. I think seeking allies, escalating, doing all of that. And what I ultimately do is counsel, sometimes leaders in this space, that at the end of the day, those two situations is to find the thing that they can honestly stand behind. Even in a decision you mostly disagree with, there's often something, could be the intention, it could be the problem, it can be something totally else that you can speak too truthfully without sort of saying I'm supportive of the whole and the whole thing that's going on. Not to spin it, not to fake it to you, make it, but to be honest with your team and lead, to find the ground that you actually can stand on and be honest about it. What an interesting analogy. So it's helpful for leaders to differentiate those decisions that they merely disagree with, but that does not deeply violate their values and pierce that armor. If you disagree with it, you can leave on your normal amount of armor and work through that. Yet when there are those decisions that violate your deeply held moral beliefs and would pierce that armor, the answer is not to just put on more armor and hunker down, but rather to, it sounds like seek away that you can find a component or potentially impact that decision in a way that you can live with. - I think the other thing I would stress is, because the last thing I would want as a leader is to wake up 20 years later and not recognize who I am. I think that's true with clinicians too. You see this, and I imagine Dr. Dean talks about this that our clinicians are taking care of patients and during this injury and 30 years down the road, they're turning around and they're saying, what happened? I'm not the same person I am anymore. I think that same phenomenon is probably happening with our leaders. I'm hearing it from my colleagues across the country. And that's the last thing I want someone to be able to do, I want you to be able to turn back and say, listen, there was a heck of a storm I weathered over the years. But overall, I still hold on to something that's core to who I am. And I didn't give up that such to that. I'm such a different person now that I can't even look back and see who that person was. We all change, of course. There's a different balancing of values in different parts of our lives. I've choked her now. So of course I have different values. When they go off to college, they'll have a different scope. But I just hope people don't look back and say, wow, I'm not that person anymore. And that's, it's a tragedy. You know, we've been shining a light on the issue of moral distress and moral injury and frontline healthcare workers. But perhaps not a similar amount of awareness has not been raised around similar experiences that are happening for our leaders. And so it sounds like there's not an opportunity or as much of an opportunity as it might be helpful for leaders to sort of share with one another what they're experiencing and to not be so isolated and to somehow normalize this experience for one another. So I'm wondering, what does that, does meaningful support look like, maybe from colleagues, maybe from other leaders, from the organization as a whole, to shift this conversation awareness and bring some of that, that normalization and support to leaders who are experiencing this? - Yeah, so, Dr. Faradah, I think it looks different at different stages. So first what I might say is in leadership training programs, we have to call it out, got to call it out and say, you're going to face this. And that needs to be in training programs. And then it behooves organizations to continue that work as their leadership development programs or whatever it may be to identify that this type of stuff is going to happen to all of us. The reason it likely will is because you actually care. So I think the first part is early recognition than to overall recognition as a leader. That when I'm in an organization it's going to actually happen to me to not recognize it. I think it's to add to that injury or distress. I will say there are things that others have talked about in this space. I'm not sure it's a resilience workshop. I'm not sure it's a 30, an EAP, 30 minute EAP session. It's actually real conversations with real people who understand the complexity of what they're doing. Here's the one thing I often put an asterisk on around this stuff. It's troubling sometimes when you get people in similar roles or professions together and you start talking about this stuff because then what happens is they start to complain to each other. They're not processing, they're complaining about it. And it feeds or it just does. It feeds each, oh, did you know this leader? I know I did that. And do you know they asked me to, oh yeah, me too. And it's just it feeds off of each other. And so I think we have to be conscious about the work and structures that we put in place. So I think pure support structures can be good. I think coaching could be good. And I will just tell you from a self-interested perspective, I think having someone with expertise and ethics to actually help you process some of that stuff is in my experience been more valuable than anything I've seen out there to work through. Why are you struggling, Dr. Farley? Let's talk about what that moral responsibility look like. Who could be better equipped to talk about moral responsibility than someone who's trained in ethics? And so my experience, as I've built up a community, I guess, of leaders across the country who connect with me over different social media venues, conferences, the telephone, email, whatever, is to be a resource to them to say when they call and I hear it and I'm like, oh, this sounds like a stressor. Oh, this sounds like injury. Oh, you're in the beginning phases of anxiety to start to name it to them and then provide that space about how do we work through this? How do I talk through what you're experiencing? Why this is a problem? Like, identify it to me. I think that's a great perspective of just raising awareness and normalizing that this is going to happen. And it's not an anomaly or a sign of personal weakness that you are experiencing this, that that in and of itself can be an effective strategy. But should be supplemented by other support structures to create that safe space for processing, whether that's ethics, consults. If you have someone accessible to you, peer support, all of that sounds like those are actionable strategies for helping create a support network for both leaders and care teams who might be experiencing moral distress and moral injury. Kind of bringing this full circle, though, those are all really helpful strategies after the fact. What can we do from a protective standpoint to help reduce the likelihood that this even occurs in the first place? Yep, I think you're exactly right. There's a reactive model and there's a proactive model and they have to work in conjunction. So we all in healthcare organizations need to be building out what I think are called ethical cultures or climates. We need to be focusing on that. We need to name it out loud and be directed and targeted about how we're building that work, right? Sounds simple. The reality is, most people don't. We have things like ethics, hotlines, reporting, systems, that's not what this is about. I'm not talking about misconduct. I'm the structures that often get built around that space or in that space. What I'm talking about is normalized ways for leaders, clinicians to raise up issues of things that don't sit right with me. Maybe not even in a formal ethics consultation, but a mechanism that enables them to be able to do that. I think the second thing is we got to build this stuff into the structures of the work that we're already doing. For example, if I'm on my team and we're going to lead a new program, I'll say something like this. Do you think this is inconsistent with what we're trying to put forward in this department or consistent with our organizational values? That level of moral awareness is the shiny coat on that armor. It's like wax that helps those scrapes not happen. You're basically avoiding the scratches from coming on that armor. By saying, I'm going to do everything I can to build that culture. I'm going to work as hard as I can, but sometimes I'm not going to be able to see it. I got to ask others around me, "Are we living up to it?" It worked with a leader in an organization. They're talking about all these things that get approved and all these programs. No one thinks about the downstream moral injury or moral distress impact. I said, "How about you just ask them? Like, could we put in the process?" Has someone thought about whether this is going to have any impact on moral injury for leaders, clinicians, or moral distress? Just ask and come to find out. Their organization was open to it. That's what you got to try to do. Now, that in of itself can cause more moral injury, more moral distress. If you say you're going to do something, and then you don't end up doing the right thing that could facilitate that, but I think those are the kinds of things we need to start thinking about in organizations about how do we put in structures that are proactive, that help us identify these components before they come to the end. I do some presentations on this stuff and talk about in proposals. That's what you should include. You should write a sentence in there. Here's a risk or concern that we need to be afraid of. It's going to do X, Y, and Z, and I think that could lead to moral distress or moral burnout or moral injury, and let your leaders see that and let all the leaders see that so that it becomes not like, "Why is Jason writing this and his proposals?" But maybe we need to be writing this and our proposals. I like that. I'm a huge proponent for hardwiring some of these processes into our organizational behaviors and more operations so that it again is woven into the fabric of just how we do things here, versus an afterthought. Coming to the end of our time here, but I'd love to leave leaders with a concrete call to action. If more moral injury is a symptom of an organization's ethical climate, what is one concrete thing that a healthcare leader could do to start shifting that climate and protecting the people that they work with and themselves? That's a great question and tough. I think this is going to sound repetitive, but I think it's honest. I think the first place we have to start is naming it. So when you see it, name it. Even Dr. Farley, if it's for yourself, if we're in a, we come out of a meeting and we look, "Wow, that just didn't sit right with me," and sitting with yourself, even for just a second to say, "Let's do this moral injury test. Why is this? Is this getting at who I am as a core? Is it just something I disagree with? Is it an ethical, just a general, you know, an ethical issue that I'm feeling some distress about? Start to name it and process it ourselves. I think all leaders can do that, right? And I think it can start with all of us, all of the leaders on this call about self-reflection. And am I being honest about the challenges that I'm faced? And then what do you do to address it? And you can name it for yourself and also name it for your team and that shifts culture. Yeah, yeah. Well, that sounds like a perfect place for us to land. I do want to ask you, as we close out, Dr. LaSundry, do you have any other pearls of wisdom from your experience that you'd like to share with our audience? I think these phenomenon, moral injury, moral distress, and I mean, pick any of them are there because we care. And the last thing I want to see happen is reduction in care. We need it for ourselves, but the beautiful thing about healthcare is that we are taking care of someone else. That's what this is about. And there are more and more people need help from healthcare organizations, clinicians, everything. And I'd hate to see this be the cause of people leaving. You know, as Dr. Dean says, clinicians leaving, but I think even leaders leaving. There are so many of me. I've just had the opportunity to interact with so many amazing leaders in this country and actually and beyond. And I hate that they all experience this stuff, but don't have either the name for it or resources or ways to start to begin to think about it. And I want to just thank you for the time today to be able to say that we named it hopefully for folks and know that there are things that they can do even in their small spheres of control and influence that can make it better. Dr. LaSundry, thank you so much for joining us today and sharing your experience and wisdom. Thank you. Thank you guys. Thank you all very much. Our guest today has been Dr. Jason LaSundryney. In our next and final episode in this three-part mini series on moral injury, we will be joined by Dr. Catherine Mies, who will help us bring these first two conversations together, bridging the frontline experience we explored with Dr. Dean and the leadership perspective we covered today with Dr. LaSundryney. And looking at what it takes to close the trust gap between them. For our listeners, 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.