Moral injury and burnout in medicine

Moral injury and burnout in medicine: a year of lessons learned – STATBy WENDY DEAN and SIMON G. TALBOT – Jul 2019

When we began exploring the concept of moral injury to explain the deep distress that U.S. health care professionals feel today, it was something of a thought experiment aimed at erasing the preconceived notions of what was driving the disillusionment of so many of our colleagues in a field they had worked so hard to join.

As physicians, we suspected that the “burnout” of individual clinicians, though real and epidemic, was actually a symptom of some deeper structural dysfunction in the health care system.  

The concept of “moral injury” seemed to encapsulate the organizing principle behind myriad drivers of distress: the growing number of reasons we couldn’t keep the oath we had made to always put our patients first.

Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.

Posing a new question in the conversation around physician burnout, we published a First Opinion on moral injury on this date last year. We were stunned by the response.

That article started an international conversation among health care professionals and others about the moral foundations of medicine and has begun to change the language around clinician distress.

Why moral injury resonates

The concept of moral injury allows clinicians to express what the burnout label failed to describe:

the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice.

But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict.

Day after day, health care professionals find themselves with no viable choice but to act in ways that transgress their deeply held beliefs in the primacy of care.

Collective action for structural challenges

Clinicians get burned out because health care is rife with double binds and no-win situations for clinicians and the patients we care for.

This has become increasingly clear as we watch the so-called “opioid crisis” develop.

  • I was surprised that law enforcement was able to insert itself into the exam room with barely a peep of protest.
  • I was surprised how many doctors knew hardly anything about either chronic pain or opioids, so they relied on PROPaganda telling them that no one should every take long-term opioids.
  • I was surprised how quickly politicians jumped into the fray with complete ignorance to legislate policies that made the crisis even worse.
  • I was surprised at how many doctors force-tapered their pain patients without protest just because their bosses told them to.

Now I’m no longer surprised about any worsening of the general care provided to patients, especially where pain management is concerned.

Changing that system to make it less harmful will demand collective action from everyone called by conscience to do better.

The conversation around moral injury, then, summons clinicians to look outside their own expertise to heal the system that is harming themselves, their colleagues, and their patients.

Here are a few ways that have emerged to nudge the U.S. toward moral health care:

Value health care professionals.

When clinic or hospital policies and insurance constraints force health care professionals to deliver suboptimal care to their patients, providers feel powerless.

Administrators must recognize their clinicians’ expertise, earned by years of grueling training, and seek their input before implementing policies that could affect patient care

Privilege the patient-clinician relationship

Clinicians are stationed on the front lines of health care and are solely responsible for tailoring treatment plans to meet the needs of each patient. Insurers and health systems must allow clinicians the latitude to treat patients according to their specific needs without constraining the tests they can order, the drugs they can prescribe, or the referrals they can make without incurring undue burdens.

Reestablish a sense of community.

The hypercompetitive, perfectionistic, resource-scarce health care environment has eroded a sense of community among health care professionals

Nurses are pitted against physicians, advanced practice providers are pitted against both, and we are all pitted against patients (satisfaction surveys, anyone?). No one wins in that scenario, and patients lose the most.

all health care professionals — nurses, doctors, first responders, physical therapists, respiratory therapists, phlebotomists, technologists, and more — are in this together with a single goal: to provide the best care for patients. When we get back to this, we all win.

Author: Wendy Dean, M.D., ( is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine.
Simon G. Talbot, M.D., ( is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School.
They co-founded the nonprofit MoralInjury.Healthcare.

I was interested in this topic and took a look at their site:

MORAL INJURY – It’s NOT burnout!

Doctors have been told they need to be more resilient, that if they only were more resilient they wouldn’t be suffering.

Hmmm… isn’t this exactly what they’re telling pain patients too? was created to help all of us change the conversation about healthcare.

This is NOT about burnout.

It is about taking care of ourselves by taking care of patients.​


Awareness: To let others know the human costs of practicing in today’s health care environment.

Assembly: A place for physicians and others to come together in meaningful numbers.

Advocacy: Fostering change in how medicine is practiced.

And then one of my favorite quotes:

Act as if what you do makes a difference. It does.” –William James


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