Beyond Burnout: Doctors Decry ‘Moral Injury’ From Financial Pressures Of Health Care

Yves here. Emergency room doctors already have difficult jobs….the thought of having them made draining by too often poorly-fitting routines.

By Melissa Bailey, a Boston-based correspondent on the KHN enterprise team, whose stories have appeared in The Washington Post, TIME, USA Today, PBS, the Chicago Tribune and other publications. She was a Nieman Journalism Fellow and previously reported for Stat. Originally published at Kaiser Health News

Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

“We’re just shotgunning,” Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”SIGN UP

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.’”

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for hospital-acquired delirium.

“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.

Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”

Jarman said many emergency physicians she knows work part time to curtail burnout.

“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they’ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.

“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

Their work is attracting praise from a range of clinicians:

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw “a dramatic shift” in the culture there, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them.”

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.”

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.

“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”

Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.

“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”

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26 comments

  1. Carla

    All these good docs better join Physicians for a National Healthcare Program post haste. And you don’t have to be a doc to belong to PNHP. I have supported them for years at the “Health reform advocate” level of membership ($50 annually). For medical and nursing students, membership is free. http://www.pnhp.org

    Reply
  2. Amfortas the hippie

    learn something new every day: “Hospital Acquired Delirium”
    https://khn.org/news/for-many-patients-delirium-is-a-surprising-side-effect-of-being-in-the-hospital/

    and i suppose it’s nice to have a word for what i’ve heard expressed all too often by doctors, nurses and nurse’s aides for a good long while:”moral injury”.

    I’m reminded of a cooking job i landed after i had to close my cafe, post-9-11.
    during the interview, bossman asked if i was a republican. I lied and said “libertarian”. this was acceptable.
    that night, first shift, i was expected to cook and serve rotten chicken…maggots and everything.
    i refused, and quit on the spot…bossman(a real bit of work) chewed me out out the door, in front of customers about my bleeding heart P&ssy-ness.
    but i was friends with the health inspector for our area…who rarely made it this far east…and called him at home.
    place got shut down the next day, and bossman was fined.

    the system selects for psychopathy…and if you ain’t a psychopath, you must pretend to be one in order to get along.
    i never even tried to get paid for that 4 hours work…and i really needed a job at the time. having standards(refusing to sicken or kill my customers) was seen as a shocking and insane position to take.
    but i did take the effort to call that bossman a week later and tell him that it was me that got him shut down(using evil big gubmint, no less), and over his spluttering, i ripped him a new one. very satisfying.

    i’m pleased that people are talking about this, finally…especially healthcare people, who have a pretty big moral standing still.
    for all the 40 years of repubs yelling about “morality”, the dog eat dog they’ve helped to erect into the highest calling has sure ruined that.

    Reply
    1. notabanktoadie

      for all the 40 years of repubs yelling about “morality”, the dog eat dog they’ve helped to erect into the highest calling has sure ruined that.

      “Helped to erect” is correct because Progressives have done their part too; e.g. FDR’s administration gave us government guarantees for private, including privately created, bank deposits instead of taking the great opportunity of the Great Depression to finally euthanize all privileges, explicit and implicit for private depository institutions.

      Reply
        1. notabanktoadie

          To be fair to FDR:

          President Franklin D. Roosevelt himself was dubious about insuring bank deposits, saying, “We do not wish to make the United States Government liable for the mistakes and errors of individual banks, and put a premium on unsound banking in the future.” from Establishment of the FDIC

          Nonetheless, FDR signed the authorizing bill.

          Well, live and learn EXCEPT:

          The big names in MMT either ignore (e.g. Bill Mitchell) or would INCREASE (e.g. Warren Mosler) privileges for private depository institutions including UNLIMITED deposit guarantees FOR FREE.

          Fool me once … ?

          Reply
          1. Paul Jurczak

            The same Wikipedia article reads: “The FDIC and its reserves are not funded by public funds; member banks’ insurance dues are the FDIC’s primary source of funding”. That seems like a fair deal.

            Reply
    2. Susan the other

      If social biology/evolution has been the key to survival (EOWilson) how did we get this “system that selects for psychopathy”? I agree that’s what we’ve got. And the system permeates everything. Not just medical care. It’s like social biology for the sociopaths at this point. And there stands the Donald, who doesn’t know anything whatsoever about “socialism” saying “this country will never be socialist” referring to the Left’s momentum for M4A. If that isn’t the very definition of Moral Injury, what is? Our system is a network of “Nodes of Dishonesty.” The reform needed to cure medical care is single payer; sufficient nurses and doctors; state of the art labs and technology; quality and price controlled pharma, and the end of private health insurance. We know all the ingredients we need to make freedom and justice for all.

      Reply
      1. Amfortas the hippie

        the lippman colloquy and robert bork and that managerial revolution guy—starts with a B.(James Burnham)…and the whole tellerite american legion anticommie hysteria…
        then add paul weyrich and his napkin plan in the lobby of the hojo in st louis,wherein they weaponised roe v wade to obtain footsoldiers, and here we are.
        the wholesale purchase of the democratic party helped a lot, too.
        an hundred year plan…with many setbacks and rejiggering…but that’s how we got a system that selects for psychopathy.
        all because a few very wealthy men didn’t want to share, and made a sort of religion out of not sharing.
        1100 ad, with cell phones.

        Reply
        1. notabanktoadie

          all because a few very wealthy men didn’t want to share, and made a sort of religion out of not sharing. Amfortas

          Government privileges for private credit creation ENABLE equity owners (companies, the rich) to BYPASS the need to share their equity but instead to use it to obtain what is then, in essence, the public’s credit but for private gain.

          Again, Progressives then and now (including the MMT cohort), to the extent that they support such privileges, share the blame.

          “Ya can’t cheat an honest man?”

          Also, I reminded of the Monkey Trap

          Reply
          1. Amfortas the hippie

            yeah. there’s a lot of tidbits in the rootcode of civilisation that enable all this mess…a jigger here, a jigger there, esoteric manipulation that no one notices or understands, but that have large effects.
            to have an actual….and actionable…political-economic discussion with your average american means first teaching a class about deep history…which is so often nothing like what they teach in school.
            (i’ve reviewed every history/social studies book my kids have been given, and it’s crazy what they leave out…and no wonder all the flag waving and paradigm defense continues apace)

            Reply
  3. Dugless

    I worked as an emergency physician for 10 years (3 years residency and 7 years full time practice). At that point I almost left medicine completely but had the opportunity to join an anesthesiology residency and have now practiced anesthesia for 15 years. I can attest to the reality described in this essay.

    I went into EM because I liked taking care of sick patients but the true reality of emergency medicine practice outside of an academic center is to see as many patients as you possibly can during your shift.
    I worked in a high acuity community hospital for 5 years. After a while, I no longer cared what the patient actually had but I simply wanted some type of disposition. I would try to figure out in 1-2 minutes one of three things: if the patient needed hospital admission, if they could be safely discharged or if I did not know. If they needed admission or could be discharged, I would get the ball rolling on their disposition. If I didn’t know then I quickly needed to figure out what tests, consults, etc I needed to put them in one of the other 2 categories. There was a continual rack of charts for patients waiting to be seen that never seemed empty. I rarely used the restroom or ate during a shift. By the end of the shift I frequently had 1-2 hours of charting that I didn’t have time to do during the shift. Coming to work felt like Sisyphus pushing the boulder up the hill for eternity.

    I now work in an academic practice in anesthesiology and am responsible for quality improvement for my department. The job is far more satisfying. I frequently work with medical students. I do not try to talk them out of emergency medicine but I try to make them understand what the reality of day to day EM practice is like. When you are in medical school, you get to see a lot of interesting medical and trauma cases that are admitted through the ED (for many hospitals, half of their admissions come through the ED which is why they advertise heavily, especially in competitive urban settings). However, when you are actually working daily in the ED, you are just trying to move people as quickly as possible through the process without missing anything serious.

    Reply
    1. Carla

      Dugless, I do hope you see that the problem is much bigger than Emergency Medicine and has contaminated the entire U.S. medical field. And I hope you will join the millions of Americans working on systemic change, if you’re not with us already.

      Reply
      1. Dugless

        I have been advocating for a single payer system since medical school. My wife is a gastroenterologist (who also wants single payer). Her paperwork requirements are ridiculous and while her work hours have increased, actual patient contact is continually cut back. Neoliberalism is destroying healthcare.

        Reply
        1. Carla

          Thank you, thank you, thank you, to both you and your wife. I had a wonderful friend, an internist, who was an activist for single-payer for decades. Unfortunately, he died of cancer before his time. I miss him so much, as does everyone in the Single Payer Action Network of Ohio.

          Reply
  4. rd

    My daughter broke her forearm in the fall. She went to an urgent care center to have x-rays and initial diagnosis, then to ER to get it set and put in cast, and then some repeat doctor visits to x-ray and make sure it would not need surgery/pin etc. She is on a high deductible plan, so she pays for everything as it is inside the deductible.

    So the natural question to ask at each step of the way is “What does this cost?” Invariably nobody could give you an answer or whatever they told you turned out to be wrong by a factor of three (not in your favor, do not pass “Go”). I think all of the bills have come in now and can be totaled, but she might still be waiting for a bill or two from December doctor visits.

    The cost totals up to a year’s worth of car payments, but nobody can give you an accurate estimate until 2-3 months AFTER the last visit. This was banned in industries like car sales, home sales etc. years ago but is the system that Trump claims everybody wants to keep.

    Reply
  5. hemeantwell

    A little OT, but Quinn Slobodian has written about Hayek’s worry that the anti-corporate culture of the late 60s was an attempt to regress to a communal organization of society in which concern about our fellows is prioritized over market calculations. Hayek feared that we might become so concerned with the millions who toiled in the fields and factories to make our commodities that we would see them as products of wrong and harm, leading to market paralysis. For him market society had to mean a society of indifference to the producers. What the article describes seems in some ways worse: all that matters is a kind of facsimile of a person constituted by metrics overdetermined by profits.

    Reply
  6. RubyDog

    I want to comment as a recently retired Family doc. I experienced the above and witnessed the evolution (devolution?) of American medicine into the current thoroughly dysfunctional and corrupt and yes, immoral system. The insidious change in language, when we went from “Doctors and Patients” to “Providers and Consumers”, shows who is really in control and what the actual priorities are. I support PNHP and the goal of Medicare for all and a single payer system.

    However, we should not be naive and assume that a single payer system alone will in and of itself fix the problem of burnout in Medicine. Vox is doing a good series on universal health care systems around the world. The closest approximation to the single payer system that seems to be most advocated around here may be Taiwan.

    https://www.vox.com/health-care/2020/1/13/21028702/medicare-for-all-taiwan-health-insurance

    Patients are for the most part pretty happy with their system. It seems they get good care, access is truly universal and very cheap at the front end. Guess who is not all that happy. The doctors and other practitioners! Why? Because they are overstressed, overworked, and burned out. The reasons may be different (the system is underfunded and demand exceeds supply), but the outcome is the same. So if (and it’s a big IF) we somehow arrive at the holy grail of a single payer system, it will be a huge challenge to organize and fund it in a way that meets all the needs and expectations. And no, it’s not just as simple as saying “MMT” is going to pay for it.

    Reply
    1. rd

      There is a good link to a Reinhard paper in the vox reference. It shows that Taiwan is at 6.1% of GDP spending on total healthcare (public and private). From everything I have seen, including experience in Canada, 10% is pretty much minimum to get an acceptable system that everybody is reasonably comfortable with. 11% or 12% is probably better.

      The zone from 12% (Switzerland, next highest compared to US 17% of GDP) to US 17% is where the waste is. That is how much the US is spending to be noncompetitive with the rest of the world. The US spends 3.2% of GDP on military spending, so the waste in the US healthcare system above the next highest country would pay for 150% of the entire US military budget.

      Businesses should be lining up at the door to support single-payer (or some other similar system) in the US, especially small businesses. Healthcare insurance costs would largely vanish as both a financial and time cost so they could focus on their core business.

      Reply
      1. Ping

        The cost of education for medical professionals needs drastic reduction if powering up to single payer or medicare for all.

        Reply
        1. rd

          Its an issue, but it doesn’t explain why the US is 50% more expensive than the 2nd most expensive country. However, many of those countries do have reasonably subsidized universities so student debt isn’t a big issue there. Canada’s universities are effectively US state university costs across the board.

          Reply
  7. Eclair

    Moral injury: the emotional and spiritual harm one experiences when bearing witness to acts that transgress deeply held moral beliefs and expectations.

    That explains my state of mind after venturing out, by bus, into Seattle’s various urban neighborhoods. And, my angst is only a tiny fraction of what health care providers experience on a daily basis.

    As in, Sunday afternoon, a rare sunny space in Seattle’s rainy winter grayness. On Capitol Hill’s main shopping and dining avenue, a distraught young man, grubby and disheveled, his pants down around his ankles (he did have on long johns), held by two burly policemen, who talked to him for almost 15 minutes, until the ambulance arrived. A few people were capturing the scene on their cell phones. I chose to stand and bear witness. It was painful.

    On the bus ride home. A small, dark woman, Somali maybe? Swathed in gorgeous red fabrics from her head veil down to her black boots, pulling an enormous red rollie almost as tall as she was. The courteous bus driver pleaded with her to take a seat; she did not want to leave her suitcase. Finally, he chanting softly, “Please, please,” she allowed herself and her baggage to be safely installed. For the next 20 minutes she kept up a unceasing, low-voiced monologue: I could make out the repeated words, “white woman,” “I paid the rent,” “She said I didn’t pay the rent.”

    I stopped counting the number of bodies, cocooned in sleeping bags and huddled in shop doorways.

    Arriving home … imagining how I would feel if I did not have that home …. a raw sense of futility engulfing me … I wanted strong drink to blot out my emotions. It is morally wrong to have this may people in need in society that is as wealthy as ours.

    Reply
  8. Tim

    I’m for single payer, but to be honest some of these specific issues being brought up about process and procedure are a result of continued tinkering by bureaucratic overlords to have everything be process driven for maximum efficiency with minimal error.

    Single payer won’t fix that. Rewiring the MBA’s to understand it all starts with bringing out the best in people, not procedures and processes, is the only way to fix it.

    Reply
  9. Neighborhood Pharmacist

    Moral Injury describes exactly how I as a pharmacist practicing in an independent pharmacy feel about how the pharmacy industry is set up.

    Essentially as the system works today I have two choices if I continue to run a regular retail pharmacy: 1) fill every prescription that comes my way passively and be constantly insulted by the incredibly low reimbursements (a pharmacy benefit manager recently had the gall to tell me the negotiated price for a prescription was $0.47) and celebrate the one or two prescriptions that randomly has a very high reimbursement. This path leads to slowly going out of business.
    2) play a very sketchy game of deliberately seeking out new prescriptions for those couple of high reimbursement items, and try to convince patients that yes, Fenoprofen is a much better drug than Ibuprofen and yes, you definitely need cyclobenzaprine 7.5 mg not 10 mg or 5 mg, because I make money on 7.5 mg, where I get paid about $2 for the 10 mg.

    It costs about $10-15 per prescription on average to cover the overhead.

    That’s just the beginning of the moral injury imposed by the massive PBM/insurance carrier conglomerates.

    Reply
  10. This Family We Love

    Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medicati c ons and let a lower-paid therapist handle the therapy.

    Reply

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