Moral Injury: The Pandemic for Physicians
By Eldo Frezza, MD Texas Medicine March 2019

March_19_TM_Commentary_Frezza

Moral distress in health care, as defined in 1984 by Andrew Jameton1, is “knowing what to do in an ethical situation, but not being allowed to do it.” 

While moral distress in everyday clinical practice has been identified in the nurse’s arena for more than 30 years, only recently has the same concept been applied to physicians. This is secondary to the fact that most physicians now are hired through corporations and hospitals, where they have lost their freedom by joining a structured practice. For physicians, this has made a big difference in practice. Corporate rules now apply, and there is no difference between physicians, nurses, and administrative assistants — all must obey rules. It makes no sense to ask a physician to sit in the office even if there are no patients to see, just because the physician has a contract to do so, and despite the hours the physician might put in at night or during the weekend. Yet this happens.

In my book, The Healthcare Collapse, I explore the problem of corporate influence on doctors’ ability to practice medicine and the physical reaction to these new situations, including the depression and the distress secondary to these situations.2

Moral distress not only has implications for satisfaction, recruitment, and retention of physicians, but also has consequences regarding the delivery of safe and competent quality patient care.3 A key component of moral distress is a sense of powerlessness. As explained by R. H. Savel and C. L. Munro4, this constraint can be internal, such as anxiety or self-doubt about creating conflict, or external, related to power imbalances in the workplace. One can distinguish between a moral dilemma — in which there are multiple choices to make and the correct path may not be clear — and moral distress, in which the way is clear, but the ability to implement a solution is somehow blocked.5 In 2004, the American Association of Critical-Care Nurses published The 4A’s to Rising Above Moral Distress to help nurses recognize and address moral distress.6 This document recommends the four A’s — ask, affirm, assess, and act — to help combat the frustrations in complex, morally distressing situations. Failure to handle the stress can result in post-traumatic stress disorder (PTSD), even suicide.

Physician suicide 

Physicians, in general, have a higher rate of suicide than other professional groups and the public. Female physicians’ suicide rates are reported to be up to 400 percent higher than those of women in other professions. Male physicians’ rates are 50 percent to 70 percent higher.7

Physicians have a lower mortality risk from cancer and heart disease relative to the general population (presumably related to knowledge of self-care and early diagnosis), but they have a significantly higher risk of dying from suicide. Suicide is the most common cause of death among medical students as well.8

Physicians’ “increased propensity” to die by suicide has been acknowledged for more than a decade. Reseachers in 1977 estimated that on average the United States loses 300-400 physicians a year — a doctor a day.8 The medical profession consistently ranks near the top of occupations with the highest risk of death by suicide. 

Litigation stress syndrome, burnout

The symptoms of depression and PTSD are similar to the signs that define litigation stress syndrome, which many physicians undergo during a malpractice lawsuit experience9:

  • Physical: Headache, fatigue, insomnia, muscle ache and stiffness, heart palpitation, gastrointestinal syndrome;
  • Mental: Inability to concentrate, memory loss, confusion, indecisiveness;
  • Emotional: Shock, anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, guilt, shame, insecurity; and
  • Behavioral: Hyperactivity, changes in eating habits, defensive approach with patients, smoking, drinking, yelling, abusive disorders.

 

Guilty until proven innocent! That’s what it feels like when you’ve been sued. “Innocent until proven guilty” is profoundly flawed — everybody looks at the physician like he or she is a criminal. It doesn’t even matter if the charge isn’t all that damning.10

Adverse effects of stress may affect not only the individual doctor but also his or her family, marriage, and social life. And since the pressure of being a physician nowadays is already high, a malpractice lawsuit can bring the physician over the edge. Such lawsuits increase the risk of suicide by more than 50 percent.11

Stress is associated with burnout12, and burnout is associated with suicides. They are all connected. These are the same symptoms some soldiers experience after being deployed. PTSD among soldiers is now being discussed in terms of moral injury because of the ongoing inner turmoil and conflict that may develop and then persist over time.13

Moral injury

Simon Talbot and Wendy Dean wrote that physicians don’t just burn out; they are suffering from a moral injury.14 They reported that physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans, it is diagnosed as post-traumatic stress; among physicians, it’s portrayed as burnout. But without understanding the critical difference between exhaustion and moral injury, the wounds will never heal, and physicians and patients alike will continue to suffer the consequences. …

The term ‘moral injury’ was first used to describe soldiers’ responses to their actions in war. It represents ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.’ Journalist Diane Silver describes it as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.’ 14

To battle moral distress, one must understand that it exists, understand what it is, and realize there are structured approaches to help recognize and manage the problem.4 The same can be said about moral injury.

Talbot and Dean concluded that: 

[T]o ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members), signaling something is desperately wrong with the system.14

Difficult battle

A person who can effectively achieve emotional detachment can set clear boundaries. Be it in social situations, during family strife, or in their professional judgment, these people earn respect for their ability to remain calm and make firm decisions, all the while respecting the emotions of others. For most people, emotional detachment is a far cry from reality. Choosing not to engage when emotions run high seems impossible to most. Unfortunately, the news media, entertainment sources, politics, and even religious leaders can feed this disempowering mind-set. Done right, emotional detachment includes empathy. Without empathy, emotional detachment would be cruel. There is a common myth that compassion requires vulnerability. It is only through honest emotional detachment that one can realize compassion.

This is the balance a doctor strives for every day. Whether we must give a patient bad news, or we are helping a patient come to an informed decision from an emotionally charged place, we must first empathize, and then we must detach. Doctors can find themselves in the face of shocking trauma at most any time; it’s one of the characteristics of the profession. A doctor must learn emotional detachment and must own it completely. This is a large part of why doctors often have an air of authority and often are seen as wise.2, 11

Emotional detachment in empathy allows one space to choose responses rationally without becoming overwhelmed or being manipulated. Emotional boundary management is a useful tool. Whether responding to an overwrought patient or an overwhelmed peer, control over emotional boundaries is crucial to maintaining one’s integrity, dignity, and choice capacity.

There is almost a mystique around a self-possessed, emotionally detached person. The simple act (once learned) of deciding to step aside from current drama is compelling. Anyone can learn it, but few realize this. 15

Fear of losing their license

The problem is that physicians cannot easily get help. If they look for guidance, they are required to report their status, and automatically they can lose their privileges and their board license. There is no safety net, and there is no protection for the physician who is left to get by on faith, like sending the soldier back into battle and closing the door.

Louise Andrew writes that because of the stigma associated with depression, self-reporting likely underestimates the prevalence of the disease among physicians and other medical professionals. In addition: 

Depression is also a leading risk factor for myocardial infarction in male physicians, and it may play a role in immune suppression thus increasing the risk of many infectious diseases and cancer. … Physicians feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. … The concerned colleague or partner may say nothing while wondering privately if the colleague has become impaired.8

Medical licensure and renewal applications often require answers to “broad-based, time-unlimited questions regarding the physician’s mental health history without regard to current impairment” — despite courts having determined they are impermissible because “the resultant examinations and restrictions constitute discrimination under Title II of the Americans with Disabilities Act based on stereotypes.”8

Physicians also fear losing hospital privileges if treatment for depression is disclosed. Hospital administrators increasingly use mandated psychiatric treatment as a bullying tactic to remove independent-thinking, patient-focused physicians from hospital staff.7

As a result of all this, many physicians suffering from depression resort to self-treatment. 

Because many states require reporting by other licensed physicians of a physician who may be suffering from a potentially impairing condition, physicians can be reluctant to seek treatment from colleagues, or from using their insurance coverage, or even from using their names when seeking treatment. A physician whose thought processes are clouded by depression and the anticipated consequences of seeking treatment for it may honestly believe that self-treatment is the only safe option.8

Alone in the battle

Unlike a soldier who can rely on the Department of Veterans Affairs system for treatment, disability income, and other benefits, the physician is alone in this battle, left to deal with hospitals, organizations, and medical boards.

It is enough of this. We need a safety net for physicians, private psychological support reportable to no one. Otherwise we will continue to see physician burnout and suicide increase. 


REFERENCES

A. Jameton.  Nursing Practice: The Ethical Issues. Engelwood Cliffs, N.J.: Prentice-Hall; 1984. 

E.E. Frezza. The Healthcare Collapse. New York, N.Y.: Routledge; 2019.

C. Varcoe, J. Storch and B.M. Pauly. Framing The Issues: Moral Distress In Health Care. Journal of Health and Human Services Administration; 2012 Mar;24(1):1-11. doi: 10.1007/s10730-012-9176-y. 

R. H. Savel, C.L. Munro. Moral distress, Moral Courage. Am J Crit Care July 2015 vol. 24 no. 4 276-278.

A Gallagher.  Moral distress and moral courage in everyday nursing practice.  OJIN: The Online Journal of Issues in Nursing. 2010;16(2). 

Available at: www.emergingrnleader.com/wp-content/uploads/2012/06/4As_to_Rise_Above_Moral_Distress.pdf. Accessed Jan. 4, 2019.

E.L. Vliet. Physician Suicide Rates Have Climbed Since Obamacare Passed. Physicians News Digest. https://physiciansnews.com/2015/05/19/ physician-suicide-rates-have-climbed-since-obamacare-passed/. Accessed Jan. 2, 2019.

L.B. Andrew. Physician Suicide. Medscape. Updated Aug. 1, 2018. http://emedicine.medscape.com/article/806779-overview. Accessed Jan. 2, 2019.

E.E. Frezza. Tangled Sutures. Austin, Texas. Texas Medical Association: 2018.

E.E. Frezza. The Miserable Doctor. Sonora, Calif. Sonora: Press Inc.; at press.

E.E. Frezza. Medical Ethics. New York, N.Y.: Routledge, 2018.

J. GSW Wong. Doctors and Stress. The Hong Kong Medical Diary, Vol. 13, No. 6, June 2008. The Federation of Medical Societies of Hong Kong. www.fmshk.org/database/articles/03mb1_3.pdf. Accessed Jan. 2, 2019.

S. Maguen, B. Litz. Moral Injury in the Context of War. PTSD: National Center 

for PTSD. U.S. Department of Veterans Affairs. www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp. Accessed Jan. 2, 2019.

S. Talbot and W. Dean. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed Jan. 2, 2019.

E.E. Frezza. The Moral Distress in Nowadays Physicians. New York, N.Y.: Routledge; at press.


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Last Updated On

March 01, 2019

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