Are Your Physicians Suffering from Burnout—or Moral Injury?

The concept of moral injury expresses the systemic nature of the strain on physicians and the need for a comprehensive approach to address the problem.

A pair of doctors believe they have pinpointed the cause of physician burnout symptoms.

Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.

The root of the problem is "moral injury" resulting from the multiple roles physicians are playing in contradiction to their moral imperative to take care of patients, Simon Talbot, MD, and Wendy Dean, MD, wrote this month in a blog post published by Medical Economics.

"The underlying problem is, we are being pulled in too many directions. We took oaths to put the needs of our patients above all else, but over time that priority has eroded in the face of economic drivers in healthcare and competitive realities. Too often now, physicians must choose between the needs of their patients and the demands imposed by their employers, productivity metrics, insurance companies, mandates to reduce 'leakage,' and satisfaction surveys," they say in the post.

Measures vs. mainspring
 

The commonly cited Maslach measures of physician burnout do not illuminate the causes of the condition, Talbot and Dean told HealthLeaders recently via email.

"As healthcare has become increasingly driven by business requirements, physicians are facing a situation where they are unable to provide the best care possible because of the double and triple binds that get in the way. The crux of these binds is competing allegiances to the patient, the insurer, the hospital, and to themselves," they said.

In their email, Talbot and Dean gave several examples of competing priorities that are resulting in moral injury for physicians.

"Physicians may feel that their ability to provide the highest quality of care is limited by an expectation of seeing too many patients each day, generating an RVU target, completing insurance prior authorizations, and using a cumbersome electronic health record, just to name a few. This has been exacerbated with the corporatization of healthcare, increased profit-drivers, and a move away from the traditional doctor-patient relationship," they said.

Healing moral injury
 

Fundamental changes are required to limit physician moral injury, Talbot and Dean told HealthLeaders.

"Breaking down the competing allegiances that face physicians requires refocusing the goal of healthcare to ensure the needs of the patient are central to all parties involved. It requires that health system leadership have deep roots in patient encounters, and a vast reservoir of empathy for how systems' decisions impact patients' experience of care, as well as the impact on physician distress."

In the current state of medical practice, business model imperatives are at odds with physician training and tendencies, they said. "When physicians cannot keep their Hippocratic Oath to put patient needs above all else, that is deeply troubling to them; they are forsaking deeply ingrained, over-trained patterns of selfless thoughts and behaviors in service of business motives."

Talbot and Dean gave five prescriptions to treat physician moral injury.

• Replace the term burnout, which implies a locus of control within the individual, with the term moral injury, which expresses the systemic nature of the problem and the need for a comprehensive approach.
   
• Develop physician leaders with first-hand experience of the problems and the solutions who have been chosen for their investment in improving clinical care and their abilities to lead.
   
• Focus on physician agency and autonomy as well as maintaining relationships—rather than transactions—that empower physicians to do what is right.
   
• Minimize administrative burdens to allow physicians to focus on patient care.
   
• Deploy information technology that adds value to the patient-physician encounter, does not distract from the human connection, does not slow down physicians, and does not shift tasks such as billing to clinicians.

Talbot is a reconstructive plastic surgeon at Brigham and Women's Hospital in Boston and an associate professor of surgery at nearby Harvard Medical School. Dean is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine in Bethesda, Maryland.