3 August 2018
Dear Interested Readers,
Looking At “Burnout” From a Different Perspective
Last week I received a brief note from an Interested Reader who lives in Miami, Florida, and who is admirably active as a Quaker in activities that he hopes will increase the peace and understanding in our world. He writes:
Given what I’ve been reading (and being moved by) in your writings, I saw that this might contribute to your thinking, too. I’ve heard of and read some about moral injury through contacts with counselors and staff at Quaker House in Fayetteville, NC. –Warren
Attached to the email was a link to a July 26, 2018 article entitled “Physicians are not ‘burning out.’ They’re suffering from moral injury” that appeared in the online journal Stat. I was surprised that I had not seen the article because I am a regular Stat reader. Stat is an online medical news and opinion publication with high quality writing, that was created a few years ago by the Boston Globe after it was purchased by John Henry, the same investor who is the principle owner of the Red Sox. I visited their office at the Globe a few years ago when they were just getting started and had a conversation with one of the editors, but I have never written for them.
I like the fact that most of Stat’s content is free. They publish daily in several forms and have weekend editions. Their talented staff journalists cover a broad range of subjects in health care including political issues, personalities, new directions in practice, and basic science. They also have a focus on the business of medicine including software innovations, pharma, biotech, and bioengineering. The “premium edition,” Stat Plus, “includes exclusive reporting about the pharmaceutical and biotech industries as well as other benefits.”
The article that Warren brought to my attention was written by two physicians: Simon G. Talbot, M.D., who is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School and Wendy Dean, M.D who practices psychiatry, and is vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.
I hope that you will take the time to read the article yourself, but I want to give you my comments and the ideas that come to mind as I have reflected on the concepts they put forward for our consideration.
The authors begin by pointing to the fact that there is a lot of military language in the way we think about practice and healthcare these days. I will expand on their example of “doing battle” on the “frontlines.” We talk about the insurance companies, the government, healthcare administrators, and even other hospitals, clinical services, and other clinicians as if they were military enemies. I have heard stressed clinicians use dehumanizing terms to describe difficult patients with labels like “crock,” “gomer,” and “gork” which are not unlike the way North Vietnamese insurgents were called “gooks” by American soldiers.
Beyond the embarrassing reality that there are times when under stress we use derogatory and dehumanizing terms to describe our patients in the ways that seem similar to the way stressed soldiers dehumanize their enemies, we use terms from combat to describe our activities. We “fight” disease. We “blast” tumors. We “bomb” bacteria. When we face a real challenge we bring out the “big guns.” The authors suggest that we should realize that perhaps we should think about the emotional state of clinicians in the way with think about the distress of our military personnel.
There is evidence for “moral injury” in military service going back at least as far as Homer‘s Iliad and Odyssey. Jonathan Shay and others have tried to describe the differences between “moral injury” and PTSD. As described by the VA psychologists Shira Maguen, PhD and Brett Litz, PhD, moral injury shares some characteristics with PTSD but is probably different.
Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations”. Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.
They describe the outcomes of moral injury:
In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:
- Shame, which stems from global self-attributions (for example “I am an evil terrible person; I am unforgivable”)
- Guilt
- Anxiety about possible consequences
- Anger about betrayal-based moral injuries
Behavioral manifestations of moral injury may include:
- Anomie (for example alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
- Withdrawal and self-condemnation
- Self-harming (for example suicidal ideation or attempts)
- Self-handicapping behaviors (for example alcohol or drug use, self-sabotaging relationships, etc.)
Indeed, there are clinicians who suffer from symptoms that seem to be very much like the ones that are described above. Sadly, there are increasing numbers of suicides in both military veterans and clinicians.
PTSD does not arise from being part of a morally reprehensible activity, but rather as the result of being subjected to physical and emotional trauma. Maguen and Litz answer the question of whether or not PTSD or moral injury are the same or similar:
At present, although the constructs of PTSD and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts.
- PTSD is a mental disorder that requires a diagnosis. Moral injury is a dimensional problem – there is no threshold for the presence of moral injury, rather, at a given point in time, a Veteran may have none, or mild to extreme manifestations.
- Transgression is not necessary for PTSD to develop nor does the PTSD diagnosis sufficiently capture moral injury (shame, self-handicapping, guilt, etc.).
Consequently, it is important to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment.
Perhaps that is more background about “moral injury” than you need to fully consider the points that the Stat article raises about burnout. They continue by presenting their core argument:
Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.
They go on to point out that burnout is a “constellation of symptoms.” Many of those symptoms are experienced by professionals which include a sense of physical exhaustion, cynicism, and failure to adequately perform which the individual may or may not connect to their work. Those symptoms are not much more helpful diagnostically than vague physical symptoms that often bring patients to the doctor and can be theoretically attributed to many different primary diagnostic possibilities: fever, sweats, weakness, weight loss, unexplained fatigue, or abdominal cramps. They imply that since the symptoms that get recognized as burnout are vague and could have a variety of origins like financial difficulties, domestic discord, or anxiety about job insecurity, more than fifty percent of physicians can be labeled as burned out when most physicians, and presumably nurses, and other clinicians will deny that they are burned out.
I have been maintaining contact with the Interested Reader that I have mentioned before who is currently doing interviews with a variety of healthcare professionals as research for a book that she is writing. This week she wrote to say:
In talking to doctors, nurses, residents, and CEOs I’ve yet to find any who say they are burned out. While some acknowledge that burnout exists, those I’ve interviewed so far say they haven’t experienced it themselves–with the exception of one nurse who has since left her job to work in home health care and one social worker who is leaving his job with a city government to work in a high school with a large immigrant population this fall.
Frankly, I don’t understand it. Has burnout gone underground? Is it something healthcare professionals don’t want to admit to experiencing?
In my interviews I’ve heard multiple reasons for the lack of joy in work–many of which are beyond the control of individual providers, such as legislative requirements and bureaucracy–but not one person has addressed what I’ve been told (and have read) are the realities of physician abuse, pulling rank in a hierarchical culture, “pajama time” with EMRs, etc.
Where are the people suffering from these things? The OR nurses, the hospitalists, and physicians caught in these situations? I want to talk to them and I’m asking for your help.
I was surprised by her letter, but then I realized that we are essentially addressing a problem in epidemiology. Lack of clarity about definitions, mislabeling, lack of accurate methodologies for quantification, issues of bias, and problems with self reporting are always sources of confusion when examining a problem with social origins. When I read her letter it occurred to me that in the article the authors had something to say that might help with her research. Their comment that underlines what she has discovered is:
…the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work….We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience… The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.
I am drawn to any discussion that considers the “internal” motivating issues for caregivers. Perhaps the saddest part of the whole debate about burnout for me is the same issue that I have mentioned many times before, and what Robert Coles discussed in his 1994 book THE CALL OF SERVICE: A Witness to Idealism, that people who are driven by their own internal motivation to serve very often suffer disappointment and despair when their ideals run up against the realities of the unbending world, or their physical resources are depleted by the demands of the work. The authors seem to be saying some of the things that I have tried to say recently when they reflect:
Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.
I would recommend that you click on the link in the quote above. It will take you to a recent analysis from the Rand Corporation. At the end of the conclusions section, the paper makes a very logical observation that aligns with the idea that almost everyone has good reasons to be dissatisfied or manifest some symptom of burnout. My take is that they are suggesting that finding solutions will be facilitated by recognizing that there are a wide range of issues that vary from organization to organization. Nevertheless, there are some common realities to be identified. Making progress will require industry wide participation.
Put another way, producing a greater number of “satisfied” physicians is not the only goal. Even physicians who report high overall professional satisfaction will have sources of stress, frustration, and burnout in their clinical practices. Some of these stressors interfere with patient care. Solving them should be a high priority for multiple stakeholders.
The authors’ of the Stat article push us to widen our considerations. They may be speaking from personal experience as well as from their observations of colleagues.
In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.
Every caregiver who has managed patients and dealt with the tension between what the patient wants and what the “system” wants them to do from a point of optimal financial performance can easily understand where Talbot and Dean are going. They paint a picture where caring people are forced to be part a dilemma that seems beyond their control and frequently requires that they compromise their fundamental principles or violate their sense of professionalism. It is a recipe for moral injury and despair with emotions directed inwardly on one’s self as depression, or externally toward the “system” as hostility. The issues that define healthcare today create such conflict that they created widespread moral injury that is being called burnout.
Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care…
The authors do not see “burnout” as the problem that causes despair for physicians, and we can assume by extension, other healthcare professionals. They postulate that what might “fix” burnout–better work flows, better EMRs, team based care, help with documentation, or group efforts to improve work life balance– are not solutions to the issues created by “moral injury.” The solution will require recognizing the intolerable situation of caregivers being caught in the middle between what they think the patient needs, and what the practice, the hospital, the government, or the insurer deems is best and most financially efficient. In short they say:
What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.
They think that leadership should respect “senior physicians” and listen to their concerns. They also think that patients should be better advocates for themselves and “demand that their insurer or hospital or health system provide it.” They also advocate for a “free market or insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care.”
They envision an outcome of this change in point of view and reality that is a “win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of health care.”
My answer to their request and the outcome they envision is not so crass as to say “When pigs fly!” But I have “been to the theater” and although their admonition that we alter our diagnostic considerations from just “burnout” to include the complexities of “moral injury” is a very positive contribution. The idea that we can address the problem of moral injury by ignoring the complex tensions in healthcare finance is as unlikely to be successful as the suggestion that we will have no more soldiers with moral injury if we have no more war. Both are aspirational and worthy of our efforts and perhaps our prayers for guidance, but unlikely to provide meaningful relief in the moment.
They are not all wrong. Unfortunately until we change our politics and change the operating system of healthcare there will always be issues of finance in conflict with optimal patient care. I know that it is possible to do better than we are doing now in most places. I have seen “what good looks like” at ThedaCare, Kaiser, and Virginia Mason. At the old Harvard Community Health Plan and in its legacy organizations we experienced some success in cost containment and I never felt a sense of moral injury even when we were working hard to improve our finances through more efficient and appropriate practice. I look back and realize that it was truly remarkable that Harvard Community Health Plan agreed to send a patient of mine, a young woman with congenital heart defects and pulmonary hypertension, to Norman Shumway at Stanford for a heart lung transplant before either heart or lung transplantation was available in Boston.
The point of Lean transformation for the elimination of waste and increased clinical efficiency, team based care, better management of the systems of care, and in fact all of the theory and practice of Population Health are designed to eliminate or mitigate the pressures from finance and, by extension these efforts should result in a decrease in “moral injury.” Perhaps I am overreading or misunderstanding the authors’ advice about finance. When they advise a world of practice “without financial obligations being pushed to providers” I may have overreacted or misunderstood their intent, but I can never imagine improvement in healthcare finance without clinicians leading the way in the reduction of “overuse, misuse, and underuse of medical resources.”
Medical systems can not achieve the lofty goals of the Triple Aim without physician engagement and leadership. Judicious management of scarce resources is a professional responsibility. The Triple Aim is a proposed exercise in stewardship and professional and institutional responsibility that should decrease the possibility of any clinician being in a situation that results in moral injury. Don Berwick’s concept of the Third Era in Medicine: The Moral Era is a direct response to the issues that the authors identified as the circumstances that generate moral injury.
I appreciate the authors’ help with the formulation of a more accurate diagnostic concept than just “burnout” for the pain that so many clinicians feel. I hope that the insight they have offered will lead to more enlightened discussions of the extent of the problem, and eventually to solutions that are grounded in possibilities of success. For positive change to occur some number of providers in every organization will need to see that realizing their initial objective of “doing good” that brought them into healthcare will ultimately require that they gain some of their professional satisfaction from finding workable solutions that diminish the likelihood of moral injury.
The Lake Is The Place To Be At Sunset
The scene in this week’s header is one that I have enjoyed hundreds of times but could never have captured quite as well as my neighbor has with his drone. This screenshot from his video shows a sunset view through the passage at the end of the peninsula that divides our lake. If you look very closely, you will see a kayaker just beyond the trees on the tail end of the peninsula.
The peninsula is a glacial esker several hundred yards long. It’s like a nose between two eyes. Because the peninsula almost completely divides the lake, the lake has been called Twin Lakes and although most locals call it Little Lake Sunapee its official name is Little Sunapee Lake.
Overlooking the eastern end of lake is an old nineteenth century resort that is still in operation and was aptly named “Twin Lake Villa.” Now it is officially called Twin Lake Village. If you look at the photos that you can find by clicking on the link, you will understand why for more than a century families have been returning to Twin Lake Villa summer after summer. I have met several people who have retired to New London after first coming to Twin Lake Villa in the summer with their parents and grandparents, and then returned for decades with their own children. I walk down to Twin Lake Village and back on the majority of my daily walks. Down and back is a rolling five miles from my house, and I have a view of the lake most of the way.
On many summer evenings I go into the “eastern basin” to fish for rainbow trout because the water there is deeper and colder. The trout go down to the deeper, colder water when the surface temperature is in the seventies. The big bass, both largemouth and smallmouth, like my side of the lake, the western basin, though I do catch trout on my fly on my side too, especially in the spring when the water is colder. Against all expectations, I was recently surprised by a nice 18 inch rainbow in an area of shallow water on my side in water that was in the seventies. It’s the surprises, the unexpected gifts, that I find on the lake that explains why I love being on the water.
Seeing a summer sunset over water, with the purple, blue, red, and orange light reflected both in the clouds and by the water is such an awe inspiring event that we should really seek them out and set ourselves up to catch as many as possible. I hope that this weekend you will position yourself to catch the sun setting in the west over some body of water, or perhaps see it reflected off the Hancock and Prudential Towers as you settle into a seat at Fenway Park to see the battle continue between the Red Sox and the Yankees.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
