March 8, 2024

Dear Interested Readers,

 

A Better Understanding of Moral Injury

 

My long journey this year exploring the origins of my medical-moral sensibilities was inspired by an article that first appeared in the Sunday New York Times Magazine last June entitled “The Moral Crisis of America’s Doctors: The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.” The article was written by Eyal Press a journalist and sociologist. It was an article that spoke to me and returned me to the subject of moral injury which I had first referenced in a 2015 article. I wrote that post after discovering that a dear friend and former colleague had left our practice and relocated to the West Coast as the outcome of a troubling episode of moral injury, and not as I had always imagined an expression of trouble in his marriage. If you want to read that story, just click on the link. It is not my usual long story. 

 

In my first article on moral injury, I referenced the work of a military physician, Dr. Jonathan Shay. A frequently quoted reference is a 2018 article in Stat by Simon Talbot and Wendy Dean entitled “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.” It seems that with time we are discovering that it is not just the volume and intensity of work that diminishes the joy of practice. Who would not feel distressed and perhaps feel morally compromised if they continued to work in a way that made them feel that they were short-changing patients?

 

The subject has been appealing to me, and I have given it a deep dive because although I accept the concept of “burnout,” I am not convinced that the proposed fixes will work or even address all of the concerns that damage professionals. I do believe that the sense of desperation and widespread professional dissatisfaction that we see today is a consequence of multiple factors including poor planning decades ago for workforce development, systems driven by the need to turn a profit in a fee-for-service environment, and a failure to improve the social determinants of health. I don’t think that the best repair of this problem and the best effort to help medical professionals survive within the dysfunctions of their environment is to teach them how to pay more attention to their own mental and physical health while exposed to the continuing organizational, structural, societal, and financial problems that face American healthcare.

 

When you are retired and live in a small town/rural environment the daily trip to the post office is one of life’s pleasures. There is nothing that gives me a “dopamine” hit like getting something nice, especially if unexpected, in the mail. There is also a predictable routine. My copy of The New England Journal of Medicine usually arrives on Tuesday. The New Yorker is more random, but it usually comes no later than Thursday. I often start reading the cover of the NEJM while standing in front of my mailbox. 

 

When I read the cover I often discover that all the articles are about new cancer drugs with names I can’t pronounce. On a good week, I am rewarded with a thought-provoking article about the profession, the social determinants of health, healthcare delivery, public health, or medical training. I guess that when you can’t keep up with the science it is best to direct your attention to the slower-moving issues of professional values, healthcare policy, and public health. 

 

This week’s Journal gave me a lift before I left the Post Office because I have always enjoyed the thoughtful writing of Dr. Lisa Rosenbaum. Her article this week, Beyond Moral Injury — Can We Reclaim Agency, Belief, and Joy in Medicine?, appears under “Medicine and Society.”

 

Dr. Rosenbaum begins her essay with a story from Dr. Kathleen McFadden, then a chief resident at Massachusetts General Hospital. Dr. McFadden’s experience with a difficult patient left her with the idea that she wasn’t spending enough time with patients. She realized that even though to meet her patient’s needs she had to stay late, helping her patient was a gratifying experience. As Dr. McFadden pondered her experience she had a radical thought, “What if improving our own well-being sometimes means spending more time at work rather than less?” She put her question to those who followed her on Twitter which is how Dr. Rosenbaum learned of the story.

 

That hook was an invitation for me to take a deeper dive into our medical moral sensibilities and the current challenges to the experience of care for both patients and “providers.” I was reminded of an odd reality in my own practice experience, I enjoyed weekend “call.” It was even better if it was on call for a three-day weekend. 

 

At the beginning of my career, I hated being on call. I wanted to be at home with my wife and children and free to enjoy my time off. When on call on a weekend, I would rush to the hospital and make “blitz” rounds. I did what was necessary as quickly and efficiently as possible. I would have been offended if someone implied that I was compromising care. I don’t think my idea of “weekend call” was much different than the opinion of most of my colleagues. After “blitz rounds” I would head home and pray that if my beeper went off it would be to announce a problem that I could manage on the phone. Sometimes, I was lucky, and all was “quiet” giving me a “perfect” weekend. 

 

Much more frequent than perfect weekends were busy weekends. It was common for me to need to wrestle with the moral dilemma of whether or not to go back to the hospital. I don’t know how it happened, but I eventually realized that my rushing out of the hospital after rapid rounds was neither good for me nor my patients. I reversed my process. I slept in a little longer and took a longer time getting to the hospital where I would begin my work with a “sticky” cinnamon bun and a large cup of strong black coffee. I took my time. I had time to sit at the bedside of each patient and try to have a meaningful conversation that would help me understand them better and provide insight that might lead to better care. I spent a little more time reading notes in the medical record. I talked to the nurses. I had family conferences. I had good conversations with the house staff.

 

All of this was possible because no patients were waiting back in the office. I was not bombarded with emails and telephone calls. If I did get a call, it was often likely to come in while I was still at the hospital and there would be no moral dilemma about what I should do. I am sure that I am embellishing my weekend experiences. But, I share Dr. Rosenbaum’s belief that there is merit in Dr. McFadden’s paradoxical concept that more time with patients might be a beneficial consideration for those suffering from burnout and moral injury. 

 

Dr. Rosenbaum is sensitive to the disdain that many physicians have to the current “therapies” that are being offered to help them with their “burnout.” She writes:

 

…many argue that individual clinicians shouldn’t have to constantly work harder to overcome the system’s shortcomings. That’s why being told to be “resilient” is infuriating: it implies that individuals are responsible for solving systemic problems. It’s also why well-being interventions often feel farcical. Rather than making doctors do modules on sleep hygiene, why not create work environments that don’t force us to spend our nights managing exploding inboxes?

 

I am sure that if those words were part of a presentation to current house officers and many physicians in practice there would be a standing ovation. Dr. Rosenbaum suggests that there is reason to give more consideration to “moral” injury. She continues:

 

Such frustrations have contributed to a shift in the framing of widespread physician distress, from “burnout” to “moral injury.” If “burnout” places the onus on individuals to do yoga, for instance, “moral injury” recognizes such solutions’ inadequacy by focusing on systemic problems that fundamentally compromise well-being. The term “moral injury” initially described the emotional wounds of soldiers whose duties forced them to relinquish their values; its application to physicians’ distress highlights the sense of moral transgression clinicians may experience when the system prevents them from meeting patients’ needs.

 

She then brings up the moral injury article by Eyal Press followed by an interesting observation: 

 

If Press emphasizes how the system quashes well-being, McFadden highlights the individual’s role in reclaiming it. 

 

What follows is an interesting discussion of “well-being” and “meaning.” Eventually, she concludes that with both subjects there is no one-size-fits-all for both items, but for her:

 

Medicine has always offered me an inherent belief system; no matter how often I fail, I still believe there’s something sacred in the possibility of making other people’s lives a little better.

To people becoming doctors in systems where that mission has been corrupted by corporate ones, however, medicine may feel less worthy of faith. And when attempts to improve well-being manifest as further work-hour reductions, it seems natural to concentrate on the clerical work for which we’re held accountable rather than on direct patient care. Work thus becomes more transactional, increasing ennui, and many clinicians want to do even less of it.

 

Her next point references Joseph Heller’s “Catch 22.” She points out that the term stuck in our language because it describes a situation that previously did not have a name. It occurs to her that “moral injury” is naming something a reality that had not been named before. Now with a name we may be able to discuss it more effectively. She writes:

 

“Moral injury” seems to fulfill such a need in medicine. By encapsulating the distress physicians feel when they can’t give patients needed care, it names our pain. By acknowledging how the profit motive compromises care and exploits clinicians’ goodwill, it identifies a cause. And by implicitly saying, “It’s not your fault,” it soothes our wounds. But if the resonance of “moral injury” lies in its recognition of the systemic factors destroying individuals, it can’t tell us how individuals can help improve the system…When do the system’s failures become our own?

 

Dr. Rosenbeum is a good storyteller and uses her stories to underline her points, and then she makes a remarkable statement:

 

…Many generations have similarly perceived the world as falling apart. What seems specific to this moment is an erosion of the belief that physicians can make the world better simply by caring for the person in front of us.

If training requires accepting that agency, the moral injury narrative risks creating its own version of a Catch-22. We must acknowledge the structural forces constraining clinicians if we’re to inspire systemic change, but fully embracing medicine’s “capitalist hellscape” narrative may obscure our own agency, convincing us that we’re hapless victims of a corrupt system. That sense of disempowerment can harm both well-being and patient care, even though the anguish associated with not meeting patients’ needs gave rise to moral injury’s application to health care workers in the first place. How, then, can we recognize the system’s failures without becoming its victims?

 

I guess that is one of the questions that has plagued me. I know that the sort of changes that are needed for us to reach the Triple Aim are not going to come quickly, if ever. How do we avoid being victims until improvements finally evolve?

 

Too many minds are not open to the radical idea of being paid anyway other than fee-for-service. The status quo is well defended, if not by hospitals and healthcare professionals, but also by politicians and the industries that benefit from the waste and overuse in practice. As I accept the idea that change will come slowly, I remind myself of the idea that even if a work can’t be completed in a lifetime, it’s no excuse for not beginning the work. 

 

Dr. Rosenbaum wants us to focus on the training of the next generation of providers as a path for improvement. She writes:

 

All trainees deserve to be guided by physicians who see in them the possibility of making medicine better. That sense of possibility is critical not just to well-being, but to recognizing — and preserving — the joys that remain.

 

I think that if you have been following my story since I began to explore where my sense of morality in medicine began you would realize that I am the product of being trained by a host of professionals who relished the joys of practice and were always looking for ways to improve the experience, the quality, and the stewardship of care. For that I am thankful.

 

As she finishes her essay, she brings up a point that I haven’t seen in other discussions of moral injury. She writes:

 

…any suggestion that the problem is our attitudes rather than the pressures we face is enraging. But I think the fear of eliciting this rage — the sense that describing the joys of physicianhood could be misconstrued as dismissing systemic problems — creates a social pressure to embrace the angst. 

 

It’s complicated. I love the practice of medicine. I detest many aspects of its current operating and finance systems. I can hold both of those thoughts because what I love about practice is the source of much of my motivation to support its continuing struggles to be better as it strives to treat both patients and caregivers more justly and humanely. I am impatient for change but realistic enough to know that I will have to settle for a dream rather than a current reality. 

 

My practice life and life as a healthcare leader are over. I have now moved on to being mostly a patient which has further enlightened me to the great need to preserve and make central the quality of the experience between the patient and the care provider. Just as I expect that the work will not be completed in my lifetime, I do believe the day will come. I salute Dr. Rosenbaum for her contributions to the hastening of that day. 

 

Turning Quality Into Income

 

Next week, I will get back to delivering the final chapters of my saga with my memories of our involvement with the very remarkable offering created by Blue Cross of Massachusetts, the Alternative Quality Contract, or AQC, as it was known. 

 

Goodbye to Winter?

 

On February 2nd, Punxsutawney Phil predicted an early end to our winter. Such predictions are always dangerous for New England where I have seen blizzards in May after there are leaves on the trees and flowers in the garden. It’s been a while, but the “Blizzard of May 1977” will not be forgotten by those who experienced it. I bring up how fickle our weather can be to underline the point that an early end to winter doesn’t necessarily mean an early end to bouts of winter weather. It is quite possible to have a snowstorm wedged between two days with sunshine and temps in the mid-fifties.  

 

I think that “ice-out” is a better indicator of our weather than our snowfall. It took a long time for our lakes to freeze solid this year. My lake froze and then thawed two or three times before we finally had a lasting freeze. It may snow in May but for me, winter is over when the ice is out. If you read the link at “ice-out,” you know there is debate about its exact definition. Having an accepted definition is important since bets are placed on when it will occur. It seems to me that on “big” lakes, ice-out usually means that you can navigate a boat from one end of the lake to another. I prefer ice-out to mean that there is no ice to be seen. Ever since Punxsky made his prediction, I have been expecting the earliest ice-out in my experience. The earliest that I can remember within the past ten years was in mid-March. We may beat that this year.

 

I have mixed feelings. Who would not want spring to come? The problem here isn’t winter going away early or spring coming late, it is the back and forth of the dance between winter and spring that will occur over the next 2-3 months. What I fear is that we are trading in beautiful winter days in March for more mud season days that are characterized by squishy footing, impassable roads, and damp chilly days with low-hanging clouds. During mud season the temps are often in the low forties but there is a dampness in the air that chills you to the bone. It can feel like the temp is in the teens when the thermometer reads 45.  Mud-season days are the most miserable days of the year for me, and I fear that this year global warming will give us the gift of an extra month of mud season. 

 

I am staying pretty close to home while waiting for my surgery so my world has suddenly become quite small. We live in a home that emphasizes an open concept. The space we use is less than 1000 square feet in the center of a much larger home that is constantly looking for visitors. It occurs to me that my world for most hours of the day these days lies between the door to my deck which is next to the fireplace and the kitchen which is not far away.  

 

The only exercise I have been getting as I tick off the days to my surgery is pulling my daily cart full of firewood from the woodpile to the deck. For reasons I don’t understand that activity does not increase my discomfort. The picture in today’s header is the scene I saw last Sunday afternoon as I pulled a load of wood up to the deck. It’s easy to see that the ice is looking thin.

 

One of the big positives of the current experience for me has been the discovery of how effectively both Dartmouth and Atrius use the “My Chart” modality to communicate with patients. Having it available has been a great source of connection with my providers. To see how it has been incorporated into practice gives me hope that we are making progress toward that “better day” of the Triple Aim.

 

I hope that you enjoy the weekend whether you are at home with family and friends or “on call” for someone who will be delighted to receive any care you may be able to provide.

Be well,

Gene