In a Flawed
Health Care System, Doctors Lament ‘Moral Injury’
DR. KEITH CORL was working in a Las Vegas emergency
room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests.
But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.
All those tests? They
turned out to be unnecessary and left the patient with over $1,000 in extra
charges.
The excessive testing,
Corl said, stemmed from a model of emergency care that forces doctors to
practice “fast and loose medicine.” Patients get a battery of tests before a
doctor even has time to hear their story or give them a proper exam.
“We’re just
shotgunning,” Corl said.
The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”
Corl, a 42-year-old
assistant professor of medicine at Brown University, is among a growing number
of physicians, nurses, social workers, and other clinicians who are using the
phrase “moral injury” to describe their inner struggles at work.
What’s driving the
burnout is something deeper — a sense of “moral injury.”
The term comes from
war: It was first used to explain why military veterans were not responding to
standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans
hospitals, refers to the emotional, physical, and spiritual
harm people feel after “perpetrating, failing to prevent, or bearing witness to
acts that transgress deeply held moral beliefs and expectations.”
Drs. Wendy Dean and
Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both
wrestled with symptoms of burnout themselves.
They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.
They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.
That idea resonates
with clinicians across the country: Since they penned an op-ed in Stat in 2018,
Dean and Talbot have been flooded with emails, comments,
calls, and invitations to speak on the topic.
Burnout has long been
identified as a major problem facing medicine: Four in 10 physicians report
feelings of burnout, according to a 2019 Medscape report. And the physician
suicide rate is more than double that of the general
population.
Dean said she and
Talbot have given two dozen talks on moral injury. “The response from each
place has been consistent and surprising: ‘This is the language we’ve been
looking for for the last 20 years.’”
Dean said that
response has come from clinicians across disciplines, who wrestle with what
they consider barriers to quality care: insurance preauthorization, trouble
making patient referrals, endless clicking on electronic health records.
Those barriers can be
particularly intense in emergency medicine.
Corl said he has
been especially frustrated by a model of
emergency medicine called “provider-in-triage.” It aims to improve efficiency
but, he said, prioritizes speed at the cost of quality care.
In this system, a
patient who shows up to an ER is seen by a doctor in a triage area for a rapid
exam lasting less than two minutes. In theory, a doctor in triage can more
quickly identify patients’ ailments and get a head start on solving them. The
patient is usually wearing street clothes and sitting in a chair.
These brief encounters
may be good for business: They reduce the “door to doc” time — how long it
takes to see a doctor — that hospitals sometimes boast about on billboards and
websites.
They enable hospitals
to charge a facility fee much earlier, the minute a
patient sees a doctor. And they reduce the number of people who leave the ER
without “being seen,” which is another quality measure.
But “the real priority
is speed and money and not our patients’ care,” Corl said. “That makes it tough
for doctors who know they could be doing better for their patients.”
Dean said people often
frame burnout as a personal failing. Doctors get the message: “If you did more
yoga, if you ate more salmon salad, if you went for a longer run, it would
help.” But, she argued, burnout is a symptom of deeper systemic problems beyond
clinicians’ control.
Emergency physician
Dr. Angela Jarman sees similar challenges in California, including
ER overcrowding and bureaucratic hurdles to discharging patients. As a
result, she said, she must treat patients in the hallways, with noise, bright
lights and a lack of privacy — a recipe for hospital-acquired delirium.
“Hallway medicine is
such a [big] part of emergency medicine these days,” said Jarman, 35, an
assistant professor of emergency medicine at UC Davis. Patients are “literally
stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and
dehumanizing.”
For example, when an
older patient breaks an arm and cannot be released to their own care at home,
they may stay in the ER for days as they await evaluation from a physical
therapist and approval to transfer to rehab or a nursing home, she said.
Meanwhile, the patient gets bumped into a bed in the hallway to make room for
new patients who keep streaming in the door.
Being responsible for
discharging patients who are stuck in the hallway is “so frustrating,” Jarman
said. “That’s not what I’m good at. That’s not what I’m trained to do.”
Jarman said many
emergency physicians she knows work part time to curtail burnout.
“I love emergency
medicine, but a lot of what we do these days is not emergency medicine,” she
said. “I definitely don’t think I’ll make it 30 years.”
Also at UC Davis, Dr.
Nick Sawyer, an assistant professor of emergency medicine, has been working
with medical students to analyze systemic problems. Among those they’ve
identified: patients stuck in the ER for up to 1,000 hours while awaiting
transfer to a psychiatric facility; patients who are not initially suicidal,
but become suicidal while awaiting mental health care; patients who rely on the
ER for primary care.
Sawyer, 38, said he
has suffered moral injury from treating patients like this one: A Latina had a
large kidney stone and a “huge amount of pain” but could not get surgery
because the stone was not infected and therefore her case wasn’t deemed an
“emergency” by her insurance plan.
“The health system is
not set up to help patients. It’s set up to make money,” he said.
The best way to
approach this problem, he said, is to help future generations of doctors
understand “how decisions made at the systems level impact how we care about
patients” — so they can “stand up for what’s right.”
“The health system is
not set up to help patients. It’s set up to make money.”
Whether these
experiences amount to moral injury is open for discussion.
Cynda Rushton, a nurse
and professor of clinical ethics at Johns Hopkins University, who has studied
the related notion of “moral distress” for 25 years, said there isn’t a base of
research, as there is for moral distress, to measure moral injury among clinicians.
But “what both of
these terms signify,” Rushton said, “is a sense of suffering that clinicians
are experiencing in their roles now, in ways that they haven’t in the past.”
Dean grew interested
in moral injury from personal experience: After a decade of treating patients
as a psychiatrist, she stopped because of financial pressures. She said she
wanted to treat her patients in longer visits, offering both psychotherapy and
medication management, but that became more difficult.
Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.
Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.
Dean and Talbot
created a nonprofit advocacy group called Moral Injury
of Health Care, which promotes public awareness and aims to bring
clinicians together to discuss the topic.
Their work is
attracting praise from a range of clinicians.
In Cumberland County,
Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse
practitioner after a large corporation bought out the private practice she
worked in.
She said she saw “a
dramatic shift” in the culture there, where “revenue became all-important.” The
company cut in half the time for each patient’s annual exam, she said, down to
20 minutes.
She spent much of that
time clicking through electronic health records, she said, instead of looking
the patient in the face. “I felt I short-shrifted them.”