Burnout vs. Moral Injury - And the Winner Is ...

Note: This is part one of an ongoing blog series on burnout vs. moral injury. This first installment dives into moral injury as a concept and how it differs from burnout. In part two, we will discuss managing improvement through the Quadruple Aim rather than focusing solely on patients and “the bottom line.”

A popular article published in STAT argued that physicians today are not suffering from burnout, but rather “moral injury.” From the article:

“Physicians on the front lines of healthcare today are sometimes described as going to battle. It’s an apt metaphor. 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 burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.”

 
FIGHT night! (2) (2).jpg
 

The authors’ perspective on "moral injury" is valid. My added perspective is that physicians are very well trained in NEGATIVE resilience and poorly trained in POSITIVE resilience. There are so many viewpoints on this topic, and I believe the vast majority are truthful. Certainly, the article’s popularity confirms that the concept of burnout may not resonate with many physicians. There are so many health conditions that have been described with different names or terminology. As physicians, discussing mental and emotional issues with patients comes naturally to us. Turning the lens on ourselves and our colleagues is more difficult. Our lack of self-awareness, our competitive nature, and our negative perception of the word burnout could all explain the lack of resonance of “burnout” with physicians.

The Weigh-In - What the Literature Says

We certainly do not need to be stuck in the old literature, in which Maslach defined burnout as a series of symptoms including emotional exhaustion, depersonalization (or cynicism), and a decreased sense of personal accomplishment. Much has been learned about burnout over the last few decades. If you are interested in a deeper dive, feel free to check out the article Understanding the burnout experience: recent research and its implications for psychiatry by Christina Maslach and Michael Leiter. Burnout is not a failure of resourcefulness or resilience.

Moral injury in medicine is described as the failure to consistently meet patient’s needs or to provide high-quality care. It results from highly conflicted allegiances to patients, organizations, and self.

While I personally believe that you don’t have to measure everything in medicine in order to manage change, many of those involved in healthcare, including a lot of physicians, want to follow the science. For those, we need to be measuring something and tracking the effectiveness of our interventions. One can attempt to measure resilience, attitude, productivity, and much more. There are many available assessments that can help - such as the Maslach burnout inventory and the Physician Well-Being Index.

Moral injury in medicine is described as the failure to consistently meet patient’s needs or to provide high-quality care, and one that results from highly conflicted allegiances to patients, organizations, and self. In part two, we will discuss managing improvement through the Quadruple Aim rather than focusing solely on patients and “the bottom line.”

Scoring the Fight - Who Wins

All of these descriptions of “the problem” are valid. Currently, I am not aware of an assessment tool to measure moral injury, or the number of repetitive cuts that one can endure before healing begins or recovery is no longer possible. If we want to find solutions, what if we moved past which words are better? Resilience? Burnout? Well-being? Moral injury? I am passionate about working on them all, for “I do what I do to make a major positive impact on other people’s lives.” I am willing to measure subjectively, rather than just objectively. Many in our healthcare system want or demand an objective measure. Without an objective measure of moral injury, we may need to continue to measure burnout or well-being.

I commend the authors for a very well-written article. When the system is burning out or morally injuring surgeons, physicians, and many others in healthcare, who is the winner?

No one wins.

Let’s change the system in many ways and keep supporting each other as we do it together.

SurgeonMasters is building a community of surgeons and physicians focused on changing the practice of medicine. Email Team@surgeonmasters.com to contribute your voice to the conversation.


Source - Physicians aren’t ‘burning out.’ They’re suffering from moral injury, By SIMON G. TALBOT and WENDY DEAN, JULY 26, 2018.

The Straw that Broke the Camel's Back

A series of irritating occurrences that eventually lead to one final thing that causes a person to lose their patience or react in a strong way.” 

Sounds a lot like post-traumatic stress or burnout to me!

Everyone’s life experience is different, but you might be able to relate to mine.

In my first full-time job as a surgeon, the irritating occurrences were many. In one very difficult operation, a surgical device attached to the patient’s femur trapped my hand with an excessive amount of force. A scrub nurse trying to assist me inadvertently increased the force on my fingers. Over the next minute, which felt like ten, I finally released my hand just before I would have passed out. With the assistance of the residents, we proceeded to complete the surgery, and the patient’s outcome was good. In our system of training and practice, I never would have considered taking time off for an injury such as that.

Camel.jpg

How about the time I sustained a needlestick injury during suturing a wound on a patient that was Hepatitis C positive? The future wonderful news that both my positive and the patient’s positive screening tests were false positives did not seem to allow a full recovery from the stressful decisions that I had to make regarding very high-risk anti-viral drugs for myself, as well as the risks to my wife and our sex life.

My job also had lots of unreachable dangled carrots. In addition, the inefficiencies in providing quality patient care and associated emotional challenges were numerous. One time, I was accused of Medicare fraud by the mother of a high-level physician administrator for whom I bent over backward taking over the care of her wrist fracture treated four weeks earlier in another state. I converted a plaster splint to a removable wrist brace, which had the same CPT code and led her to believe Medicare was being billed twice. The brace company and I both had to eat the cost of care on that one, but the harder pill to swallow was that the patient and her son never appreciated the lack of fraud. In another instance, we were accused of malpractice by a patient who had tremendous muscle disruption of the gastric muscle from the 2000 or more pound object that fell on his leg. At the time of fasciotomies, he had no muscle ischemia for an early compartment syndrome. He felt he could not work more than 8 hour days or run on the treadmill the same after a year. He sued and the university settled because the nurse had not adequately documented the notes while in pre-op.

Despite these events that could easily lead to paranoia, I have remained completely dedicated to the welfare of my patients. What is best for my patient? How can I see that my patient receives the care that they need? What can I do to provide my patient with the most straightforward path to recovery? Unfortunately, one day, when I saw my patient being blocked from surgery, it was the straw that broke the camel’s back. My sudden reaction brought out a lot of negative energy. This uncharacteristic, as well as unacceptable, behavior, resulted in some anger management counseling as prescribed by the hospital administration. As this was the first event in my file, I was able to recover my job and my career. Interestingly, the comments provided to me and my superiors after this event included signs that I was burning out. While I accepted responsibility for my actions, the overall system did not change. No one offered assistance for burnout. No one actually seemed to care. And I kept performing at the high-stress level expected of someone in my profession because the system doesn’t offer reciprocity in its relationship with physicians. The system gives very little, and it takes a tremendous amount from us.

Camels are amazing animals capable of surviving the very harsh conditions of the desert. In particular, they are able to go for a long period of time without water.  When they do drink, they can drink up to 20 gallons or more.  Like the camel, the surgeon appears to be sustainable with very little self-care. The surgeon trains to handle limited energy, some amount of sleep deprivation, high adrenaline situations, several thousand pieces of straw, and other adverse conditions like the barren desert with very little water. Surgeons are capable of going a very long time without normal wellness efforts and activities. Or so we think. We adopt the old adage of “don’t fix something if it ain’t broke.” But why don’t we try to fix something before it breaks? Before it burns out. How do we know what will be the final straw? How can we prevent the break before it occurs?

Through the evolution of the surgeon and adaptive training, the surgeon and physician learns to carry every increasing burden. The system continues to put more and more straw on our backs. We are expected to carry the straw longer distances.

Now I have choices. I choose how much straw I am willing to carry. I also choose to drink lots of water. We also have a choice to change the system, so that we do not overload our physicians and we provide wellness to both patients and our colleagues.

If not, eventually not enough wellness and just one more burden will be the straw that breaks the camel’s back.

At SurgeonMasters, we are committed to helping physicians struggling with burnout. We offer coaching services, wellness programs, podcasts, webinars, and much more aimed at arming physicians with the tools they need to thrive in their careers.

Contact us today to learn more about our programs and join our mailing list to get regular updates.

Seeking Help for Something Rotten

A recent article - “There is Something Rotten Inside the Medical Profession” - written by an anonymous physician and published on kevinmd.com, discussed the issues in the medical profession that can lead physicians to burnout and suicide. During my first 5 years in practice alone, I knew three physicians who committed suicide at my institution. One was a renowned burn surgeon who seemed, from a distance, superhuman - respected by patients, peers and trainees alike.

These experiences impact me deeply in many ways. I imagine their lives and experiences as surgeons were much like mine. Early in my career, I did not know what to make of it. At the time, I knew I was pretty unhappy, and I started getting a sense that I would rather get out than feel stuck in a job that could lead to me taking my own life. Now that I have been studying the issue for several years, I am much more knowledgeable on the causative factors.

Seeking Help

Many doctors of all generations and at all points of their career feel they do not have many options. Often the feeling is if we admit to suffering or struggling, WE are the outlier. Simply wanting to talk to someone or seeking help suggests weakness or failure.

According to the article:

“Medical training has long had its culture rooted in ideals of suffering. Not so much for the patients — which is often sadly a given, but for the doctors training inside it. Every generation always looks down on the generation training after it — no one ever had it as hard as them, and thus deserve to suffer just as much, if not more. This dubious school of thought has long been acknowledged as standard practice. To be a good doctor, you must work harder, stay later, know more, and never falter. Weakness in medicine is a failing, and if you admit to struggling, the unspoken opinion (or often spoken) is that you simply couldn’t hack it.”

Surgeons, physicians and trainees voluntarily seeking help is very rare. There is a sense that if we do, there are potentially career-threatening consequences that await us. How does one go on when your lifelong dream is over? Mandatory reporting programs further discourage physicians from seeking help. If you don’t seek help, there is nothing to report.

How can we expect physicians to seek help if the system is set up to fail them? More importantly, how can we help each other?

30253713_l.jpg

What are Potential Positive Steps? 

Let’s look at four potential positive steps we can take to improve the practice environment for physicians.

  1. Stop the shame and stigma. We are all human. Burnout is not a weakness, but rather a symptom of chronic and/or acute injury or abuse. Show compassion to your peers.

  2. Remove mandatory state reporting requirements. A mental health history should not disqualify anyone. Treated mental health issues are much much better than untreated and unrecognized. Current impairment may be an issue, but past impairment is not.

  3. Offer mental health services to ALL health professionals and trainees.

  4. WHAT IF all physicians were able to reach for support from psychiatrists, psychologists, coaches and others outside their institution or local environment to receive confidential assistance?

At SurgeonMasters, we are committed to helping physicians struggling with burnout. We offer coaching services, wellness programs, podcasts, webinars, and much more aimed at arming physicians with the tools they need to thrive in their careers.

Contact us today to learn more about our programs and join our mailing list to get regular updates.

Source: https://www.kevinmd.com/blog/2017/01/something-rotten-inside-medical-profession.html