Physician burnout is all the buzz in hospitals these days. With rates of physician suicide, addiction, depression, divorce, and early death rising uncontrollably, and with physician drop out rates peaking, hospital administrations know that something has to change—or we’ll wind up with no doctors, and with no doctors, there’s no business. Sadly, that’s what it seems to take to get the attention of hospital administrators these days. The well-being of doctors doesn’t seem to matter so much. It’s dollars and cents that drive the system, and if there are no doctors, the business of health care falls apart.
But what if burnout is not the problem? What if, as this article written by two Harvard doctors suggests, physicians are not burned out; they’re suffering from “moral injury?”
We all know medicine is in crisis, and so are those of us who serve the sick and injured. Astronomical numbers of health care providers, especially physicians, suffer from abusive medical training, neglect of self care, unmet physical and emotional needs, compassion fatigue, burnout, chronic illness, addiction, depression, anxiety, broken relationships, loneliness, and PTSD from the traumas we experience and treat without proper emotional and spiritual integration. But what if the problem goes deeper than that? What if trying to practice stellar medicine inside a corrupt system fueled more by money than by patient care leads to “moral injury” in the doctors? What if this moral injury is destroying the souls of the very people we depend upon to care for us when we get sick?
What is “Moral Injury?”
First described as an injury to war veterans, “moral injury” is described by researchers as “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.” Harvard physicians Simon Talbot and Wendy Dean explain that “failing to consistently meet patients’ needs has a profound impact on physician well-being—this is the crux of consequent moral injury.”
Talbot and Dean write:
“Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.
Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay—wounded, disengaged, and increasingly hopeless.”
I can relate to this kind of agony. I am a physician who left my medical practice in 2007 because of just such moral injury. But that decision tore me in pieces. Like many others, I too had no cross-training for an alternative career, a lot of debt, a commitment to my calling, a baby on the way, and a husband who didn’t bring in an income. But I was also sick, suicidal, and suffering from a kind of soul sickness that was robbing me of my capacity to feel true joy.
I couldn’t tolerate the feeling of failing to give my patients the kind of loving, tender, comprehensive Whole Health care I knew they deserved, but I had no idea how I would pay the bills if I left, and after spending 12 years training to become a doctor- and feeling spiritually called to do so—I couldn’t imagine what else I’d do. Rock and hard place. Despair. Helplessness. Ouch.
I am not claiming any kind of moral righteousness because I left instead of staying. I don’t judge anyone who stays, because I know how desperate it feels to be caught in that space between stories—when you can’t imagine leaving medicine—and you can’t imagine staying. But I do feel like we doctors have to come together to name what is true—that practicing inside a system that makes it almost impossible to do what we feel called to do HURTS. It hurts our patients, and it hurts us too.
Because I care about alleviating the suffering of those who hurt, I feel passionate about supporting doctors and other health care providers who suffer from moral injury in the Whole Health Medicine Institute I founded five years ago. I wrote the whole story of trauma, magic, and the path to a deeper calling in my book The Anatomy of a Calling. But that’s a whole other hero’s journey . . .
Preventable Medical Error Is The #3 Cause Of Death
In 2017, I co-wrote an article Preventable Medical Error Is The #3 Cause Of Death In The U.S.. Are We OK With This? with medical school professor, Kitchen Table Wisdom author and physician Rachel Naomi Remen, MD. Shocked by the British Medical Journal article announcing that preventable medical error ranks only behind heart disease and cancer as the leading cause of death in the U.S., we touched upon this kind of moral injury in doctors, challenging the morality of a system that puts the bottom line ahead of patient safety.
Rachel and I wrote:
What goes unmentioned in most conversations about safety in medicine is that these safety protocols do not touch the root cause of this public health crisis, which lies in the priorities of the present system and the destructive effect of the economic bottom line on the health care provider-patient relationship. The problem is not a dearth of safety protocols. The problem is that the safety inherent in a genuine relationship between the patient and those who serve the patient has been sacrificed to the economic bottom line. The errors that lead to patient fatalities are rarely the result of lack of skill or training on the part of those who deliver health care. These errors are the outcome of a systemwide practice of prioritizing economic goals above safety goals.
The uncomfortable truth is that safety costs money. In the not so distant past, health care professionals knew their patients intimately. They not only knew their names, what they looked like, and the health issues that plagued them; they also knew what they did for a living, understood their family systems, were familiar with their financial challenges, and were privy to their secrets. Knowing the patient intimately helps the health professional serve the patient and protect him or her from harm. Even a decade ago, all surgeons still routinely visited patients prior to surgery to clarify what was planned, discuss the surgery, answer questions, and lay eyes and hands on the patient. They also visited their patients post-operatively to answer questions, discuss the outcome of the surgery, ensure adequate pain control, ensure that no obvious error had been made, and comfort family members. However, now it is possible for a patient to be operated on by a surgeon who only meets the patient in the operating room, often when the patient is already premedicated with sedatives or already asleep. Postoperative visits are rare and seen as unnecessary.
The problem does not just lie with surgery. Unlike doctors of the past who had genuine relationships with patients and their families, many practicing physicians now work in health care systems which require them to see 40 patients a day, many with complex problems requiring the management of multiple medications, whose side effects often interfere with each other. It is not uncommon for patients to be double booked in 15 minute slots, leaving only seven and a half minutes of time for each patient. All the fail safes in the world cannot make such a system safe. Imagine if your car mechanic had seven and a half minutes to assess and repair a significant problem with your car. Would you be surprised if your car failed on the freeway?
Learned Helplessness
Many patients are frustrated or angry at doctors, and it’s understandable why they should felt that way when they’re at their most vulnerable and not getting their core needs met. But as one of those doctors who was doing the best I could to meet the needs of my patients, usually at the exclusion of getting my own needs met, I know that it hurts to feel like patients don’t appreciate all of the sacrifices doctors make in our attempts to help our patients. To do your best to meet the needs of your patients and then to feel attacked by the very people you’re killing yourself to serve can leave you feeling desperate and in despair, resulting in what Dr. Martin Seligman calls “learned helplessness.” This learned helplessness can lead to depression, anxiety, addictions, and suicide.
What I know for sure is that doctors do not go through 12 years of grueling medical training because they are greedy, insensitive, or numb to the pain of their patients. On the contrary, most doctors care about serving the life force in others from the time they are young. In my situation, I was the “squirrel girl” of my neighborhood. From the time I was seven until I went to medical school at 22, I raised nearly 20 injured or abandoned squirrels and freed them into animal sanctuaries.
Most doctors have similar stories from early childhood days. We were born to help others heal. We were called to medicine the way priests are called to the priesthood—as a spiritual mission. We did not endure brutal medical training because we felt called to participate in a system that causes us to neglect or harm our patients. We certainly didn’t go through all that self-sacrifice because we want to prescribe expensive drugs instead of spending time getting to know our patients, holding their hands, meeting their families, listening to them tell us about what might have predisposed them to getting sick, holding space as they trust us with their stories of trauma, appreciating the intimacy of having a front row seat on their most tender moments of birth and death, and offering our generous hearts as they find their way back to their innate wholeness through the loving space we offer.
The Soul-Crushing Wound Of Practicing Inside A Corrupt System
Physicians know what we need to do in order to help others heal themselves. We are not so ignorant that we don’t realize that a patient with an autoimmune disease or chronic pain may need to muster up the courage to leave an abusive marriage or stand up for her needs to her boss more than she needs a pharmaceutical. But to open up that can of worms, to ask her about the health of her marriage or challenge her relationship to authority or ask about her childhood sexual abuse feels like an impossible task when you’re expected to see 40 patients per day. Yet to neglect such disease-inducing traumas that our patients face is malpractice, and as doctors, we know it. Thus the moral injury. Just as war veterans knew it was a moral violation to kill innocent women and children, writing them off as unavoidable enemy “casualties,” we doctors know we are selling out when we refuse to take a strong, unassailable stand for what is right for our patients.
When we are at the mercy of learned helplessness, we know something is desperately wrong, but we wind up paralyzed, feeling victimized by a system we participate with. It’s easier to feel powerless and blame “the system” than to come face to face with our own traumas, the ones that made us willing to neglect our own needs and leave us impotent when our patients need us to demand health care reform. Struck by our own stress responses, we flee or freeze—or we deny and defend—rather than own up to what’s really happening and fight for what is right for our patients and ourselves.
The Whole Health Medicine Institute: An Antidote To Moral Injury
I left my clinical practice as a doctor in 2007 because my sensitive, empath, shaman self couldn’t handle the soul-crushing blows of the way I was expected to churn patients through my practice, and I didn’t know another way to practice in alignment with my core values. So I left. And I went on a journey of exploration—first to heal myself and then to discover what really predisposes people to illness and what really makes the body ripe for miracles. (You can listen to a free teleclass summarizing what I’ve learned here.)
Five years ago, I boiled down everything I’ve learned in my quest to help doctors and other health care providers heal themselves and serve patients with soul-illuminating integrity by integrating all the tools in the medical toolbox and helping patients heal themselves. The result of what I learned became the Whole Health Medicine Institute, a certification and training program for doctors and other health care providers who are ready to move beyond the pain of moral injury and are ready to do what it takes to heal themselves, learn new healing tools, come together as allies, and reform our health care system together, taking it back from those who care more about the economic bottom line than they care about doing what’s right for the patient.
Learn about the Whole Health Medicine Institute here.
We just opened enrollment for the Whole Health Medicine Institute Class of 2018, and our first application deadline is August 17, so if you feel called to be part of this health care revolution and recover from the wounds of moral injury, enroll now.
What If We Doctors Rise Up?
How can we start to heal from moral injury and make things right? In the article Rachel and I wrote, we concluded with this:
250,000 deaths a year. It is absurd to lay the cause of such an alarming statistic at the door of the health care professional. Few health care professionals would actually choose to practice in the health care provider-patient relationship the system imposes upon them. Such relationships are inherently dangerous.
Protecting patients against danger is built into the training of all health professionals. Within moments of receiving a medical degree, every new doctor speaks aloud a vow to do no harm, often using an oath that goes back thousands of years. People enter the field of health care with the intention to serve and make a positive difference in the lives of others. “Do no harm” is the foundational goal of such people. Yet the system itself does not support or respect this intention. The system does intend to do no harm, but only if it doesn’t cost too much. But doing no harm takes time. Doing no harm costs money. By placing a greater priority on the economic bottom line than on the value of doing no harm, the intention to do no harm is violated and invalidated, often on a daily basis, by the demands of the system. Doing no harm may actually be an impossible goal within the system as it exists today.
The data presented in the British Medical Journal suggests that the present health care system has become inherently untrustworthy. This violates the intention of the dedicated people who work within the system, the ones who enter into the practice of medicine, nursing, and other health care fields in order to be someone patients can trust when they are at their most vulnerable. If you were to ask doctors, nurses, and other health care practitioners to create the health care system, we would have a very different system.
The fact that preventable medical error is the third leading cause of death in America is simply unacceptable. The system is not working, not only for patients in clinics and hospitals, but for all those who serve within these systems and experience daily the conflict between the demands of the system, the regulation of individual practice, and the wish to do no harm. The road ahead is not clear. It is tempting to wonder what would happen if doctors, nurses, and other health care professionals entrusted with the lives of Americans were to just stop. What if we were to say, “Sorry, but I am not willing to put the lives of my patients in jeopardy any longer.” What would happen if we stood up for our deep commitment to do no harm and refused to participate in a system that puts people in jeopardy on a daily basis? What might be possible then?
Are You Suffering From Moral Injury?
If you’re a doctor, therapist or other kind of health care provider, does this resonate with you? Are you experiencing the pain of moral injury? Tell us your stories in the comments below.
Holding all of us—patients and providers alike—deep in my broken open heart,
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