​ Behavioral Health

Physician Moral Distress

A reckoning with unmet needs

By Timothy J. Usset, MDiv, MPH,  Mike Koopmeiners, MD and Joshua T. Morris, PhD, BCC

ystemic change in health care delivery to improve clinician well being, and thereby patient outcomes, has long been overdue. The need for it now has become even more acute. Physicians were experiencing well-documented rates of burnout, as high as 60%, before the pandemic began. New workplace realities have multiplied the complexities of this problem. These factors include caring for individuals who knowingly or unknowingly have COVID-19, concerns they will contract the virus and infect loved ones, wondering whether their institution will provide the necessary PPE, juggling child care, elder care, personal paid time away from work if they get sick, wrestling with furloughs and a struggling economy, and the numerous issues around the COVID-19 vaccination.  Add to this the pressures that arise leaving work to have conversations in the community with people about the efficacy of masks and shelter-in-place protocols.  Physicians and other healthcare professionals, often lauded as “heroes” continue to experience the above stressors in ways that are further complicated by inconsistent political responses and lack of appropriate response from society at large. Day to day decisions people make about mask wearing and social precautions are the front line of the pandemic.

Multivalent Factors

At minimum, the reality of the pandemic moves beyond burnout to include the paradigms of moral distress and moral injury, considerations that are being amplified for physicians during the pandemic. Moral distress takes place at the intersection of recognizing the appropriate clinical course of action, but due to internal or external constraints, being unable to take that action. The literature on a complementary term to moral distress; moral injury, defines that in high stakes situations, and from key leadership personnel, there is a betrayal of what’s right or the experience of acting in ways contrary to individual moral value. It is precisely through naming the betrayal of what is right and in acknowledging the moral stress of working in the pandemic that we can affirm what physicians are experiencing.

​The reality of the pandemic moves beyond burnout.

Further, the totality of the stressors physicians and other healthcare professionals are carrying needs a reckoning.  This stress leads directly to emotional and physical harm. Many studies aptly identify elements of how our health cares delivery system works that contribute to burnout. Well-meaning healthcare advocates and administrators encourage workers to practice self-care, take respite, and focus on one’s self in preparation for taking on this virus. Individual practices of centering oneself and self-care are, of course, vital for caregivers however treating a robust systemic failure with individual manners of reliance does not adequately address the issues.

Moving Forward

What is needed, or at least has the potential to move the industry in the right direction, is for the community of physicians to remain tethered in solidarity. There are exceptions, but our health systems will not be making drastic changes overnight to bring about healthier work environments for physicians. The dark irony of how slowly vital issues in our healthcare and political systems are addressed is found in the need for individual and collective practices among physicians to support and sustain one another.  Physicians can not fix the problems of burnout, moral distress, or moral injury through just self-care, but can take steps toward maintaining meaning and purpose amid the increased challenges of their work to weather this storm.

Making meaning and valuable practices

Resilience may be a protective factor against things such as burnout or moral distress, but it is a not vaccine.  High levels of burnout have been found even among “resilient” physicians.  In concert with building one’s capacity to thrive, holding and fostering one’s capacity to resist despair and bitterness during incredible adversity is a necessary and possibly more appropriate way of framing resilience during the pandemic.  There are practices and interventions that have been found to be effective in addressing the impact of morally challenging events.

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Service members and veterans frequently experience guilt and/or shame following morally challenging or ambiguous circumstances. Similar to those in the military, physicians may also experience guilt and/or shame following the stress of practicing medicine during the pandemic. Not to conflate or equate military experience with practicing medicine but there is a similarity in guilt/shame responses that has been studied extensively and has yielded coping techniques that present options for physicians. Specifically, there are practices that have been integrated into new wave interventions to facilitate those who have experienced moral injury.

 Moral injury can arise from the challenges of treating patients in the resource-constrained environment of the pandemic. The way in which physicians are taught to and value practicing medicine has been challenged by the utilitarian processes that were implemented to manage scarce resources. For some physicians, these dilemmas create a sense of guilt over “not having done enough” for their patients. This is a prime example of moral injury and there are several effective techniques to process this experience.  One method is the practice of writing brief letters to a present or deceased compassionate person. This should be a person you trust to act with compassion toward you. The purpose of the letter is to briefly share what you are finding distressing in your practice and what you would like to do differently about it. If the letter is written to someone that is deceased (i.e. a trusted grandparent, sibling, parent or friend), the next part of the process is imagining how that individual might respond to you in a compassionate way. If the letter is written to someone still living, you can setup a time to share it with them to receive their feedback. If you would prefer not to share it, you can imagine that person’s compassionate response to you.

​It is important for physicians to remember and maintain their agency.

 Another method is to gather a small group (3-4) of peers that you trust and schedule a time-share about what is most stressful in your practice right now. This should be in a semi-structured environment that allows everyone to speak briefly, then receive and offer feedback to others in the group. A recommended outline could include:

Step 1:  30 seconds to share something distressing in your practice

Step 2:  15 seconds of silence

Step 3:  3 minutes for feedback from other members of the group

Step 4:  1 minute to respond to the feedback from the person that originally share

Repeat steps 1-4 for each person present.

The purpose of this group isn’t to solve all of the problems in medicine or our healthcare system, but to connect with and receive feedback from other professionals. The outline above could be completed in as little as 15-20 minutes for meetings of three to four people. Hearing from others can help identify other perspectives and moral contexts that can foster your “capacity to resist” the pull of shame, despair, or bitterness. In addition to providing insight on guilt or shame, the above practices work to address loneliness and isolation. By connecting with trusted individuals in or outside of the profession you can tend to your ability to practice compassion toward yourself and others.

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When/Where to seek more formal support?

When it comes to seeking support from peers or professionals, what we call the various stresses and challenges of medical practice is less important than noticing their impact. Physicians need to have an active sense of what their equilibrium looks like in their practice. This includes everything related to professional practice and also time spent with family and other life-giving activities. What changes have been especially noticeable during the pandemic? Less time with family? Drinking more? Spending more time in the EHR? Changes in equilibrium are not in and of themselves problematic, but unrecognized changes can lead to new work/life equilibriums that are at odds with one’s values. On the more serious side they could result in medical errors, adverse patient outcomes, and negatively impact relationships with family and friends.

Though stigma around seeking help for behavioral concerns is still alive and well,  even among clinical disciplines, this should never discourage any physician to take those steps, or to recommend them to a colleague who they may know is suffering.  Many systems have internal behavioral health staff or chaplains that are available to support clinicians. In the event internal staff are not available, EAP programs are another option for seeking short-term support. Physicians Serving Physicians has been providing support to physicians experiencing substance use concerns since 1981. The Physicians Wellness Collaborative (PWC) was created in 2020 as a program of PSP to reflect the expansion of PSP’s services to include physician mental health and wellness. The PWC offers peer support and mental health services to physicians (at no cost to them) that prefer to work with resources outside of their employer.   In these unique times it is important for physicians to remember and maintain their agency, ability to make meaning, and practice whole-heartedly in the midst of incredibly challenging circumstances.

Timothy J. Usset, MDiv, MPH, is the Executive Director of Physicians Wellness Collaborative www.psp-mn.com

Mike Koopmeiners, MD, is the Medical Director of  Physicians Wellness Collaborative.

Joshua T. Morris, PhD, BCC, is the Chaplain at Children’s Mercy Hospital, Kansas City.