COMMENTARY

MD Says: How Doctors Can Stop Burnout and Moral Injury

; Wendy K. Dean, MD

Disclosures

October 07, 2019

This transcript has been edited for clarity.

Leslie Kane, MA: Hi. I'm Leslie Kane. I'm director of Medscape's Business of Medicine site. I'm here today with Dr Wendy Dean, a psychiatrist from Washington, DC.

Wendy and her coauthors have recently written articles describing the difficulties, frustrations, and some of the burnout that physicians have been experiencing lately. According to Wendy, this is not burnout. It's much, much worse. This is moral injury that's being inflicted upon physicians.

As a matter of fact, Wendy feels that calling out burnout is a false attempt to try to blame physicians for their inability or their lack of resilience in dealing with burnout, when actually the true problem is our healthcare system.

Wendy and her coauthors recently wrote a Medscape article about moral injury.It gained attention across the entire healthcare community and received hundreds of comments.

We are very fortunate to have Wendy here today to speak with us about moral injury, and more importantly, to talk about what physicians can do about it. Wendy, thanks so much for being with us today. I'm happy you could take the time.

Wendy K. Dean, MD: Thank you. It's such a pleasure to be here.

Kane: You recently had an article on Medscape about moral injury, and it received so much commentary. How did you come up with this idea? Why is it not burnout?

Dean: First, I think it's important to define what moral injury is. Moral injury is perpetrating or bearing witness to acts that transgress deeply held moral beliefs.

What that means is that clinicians who take an oath to give the best care to their patients, who are taught throughout their training to put their patients first as the top priority, then are faced with the business framework of healthcare, which oftentimes requires that that provider will take into account not only what's best for the patient, but also maybe what's best for the economics of the healthcare system, what the insurer will allow, or even what's best for the hospital system.

Kane: Do you feel that this is different from things that many people face in their careers or jobs?

Dean: I think the difference is when it's somebody's life or health that's at stake and you're being asked to choose an economic imperative over what might keep that person well or alive. That's where the real challenge comes in, which is different from other industries.

Kane: Another thing you talked about was gaslighting. You said that physicians are being gaslighted. Can you tell me a little bit about that?

Dean: "Gaslighting" is a great term, and it comes from a [1940s] film in which a husband was constantly making small changes in the apartment that he lived in with his wife. His wife would notice these changes and would say, "Oh, gosh, that candlestick wasn't there. How did that move?" And he would say, "Oh, no, it's always been there." He was constantly manipulating her perception of reality and telling her that it was wrong.

When we apply this to healthcare, physicians are being told that they're burned out and that the cause of their burnout is that they're not resilient enough or that they're not well enough. They're being told that they are not attending to their wellness, so they should eat more healthy meals, get more sleep, and exercise more. Every physician knows that those things are all good for them.

No amount of yoga, running, or salmon salad is going to make doctors feel better when their patient who needs chemotherapy was denied by their insurance company.

They also know that no amount of yoga, running, or salmon salad is going to make them feel better when their patient who needs chemotherapy was denied by their insurance company, when a patient needs a certain medication that's not on their insurance formulary, or when a patient needs a referral to a tertiary care center that isn't allowed because that causes leakage outside of the healthcare system and hurts the economics of that system. There's no amount of wellness that will allow us to be resilient to those kinds of insults.

Kane: I thought it was interesting that there was so much controversy that arose about the terminology. Some people said, " Moral injury? Forget it; that's way too extreme." Some people said, "Well, burnout is burnout," and then others called it physician abuse. Is the terminology important?

Dean: I have a couple of feelings about that. There's always arguing about taxonomy. People are always going to slice things pretty finely and want to use very specifically accurate terms. I agree with that to an extent. The reality is that this concept and this language have resonated so profoundly, not only with physicians, but also with nurses, first responders, physical therapists—everyone across the healthcare community has written to us to let us know, "This is us, too."

When language resonates that profoundly, I feel like there's something really important about it.

Kane: Right. You're touching a nerve.

Dean: Exactly. Whether we call it moral injury, moral trauma, or moral distress, they identify with "moral." I think it's important to keep that language while acknowledging that there are some nuances in it.

Kane: What can physicians do about [the situation]? There were many suggestions, including learning more about the electronic health record and simplifying documentation. Can these suggestions work? Will these help in any significant way?

Dean: I think all of those are necessary but insufficient. We need to make all of the changes that we can, one by one. If we can make life easier for physicians or allow them to focus more on what their patients need and that relationship, the moral injury will get better. Until we can allow physicians and other clinicians to think primarily about what is in the best interest of their patient, we aren't going to solve the problem. We'll make it better, but we won't fix it entirely.

Kane: Some people suggested more extreme actions, like to stop taking insurance and move to direct pay so that you don't have to worry about claims, documentation, etc. What do you think of that? Is that realistic? It has been proposed a number of times, but it doesn't seem to happen.

Dean: I think that direct patient care is possible in certain markets for certain physicians, but it's not for everyone. It may trade the challenges of regulation and worrying about insurance hassles for the challenges of marketing, accounting, regulations, and all of those other things that come with direct patient care.

Kane: So, ultimately, it would be different but potentially not better. Is that what you're saying?

Dean: And that's why for some people, that is a better option, because they're more comfortable with the entrepreneurial aspects, right? They're comfortable doing the marketing, going out and making sure they're getting a referral basis, and not getting paid if they don't work or if they go on vacation.

For others, those complications of running a direct patient care practice can be really challenging and stressful. I speak from experience. I ran my practice that way for 10 years and it was not easy.

Kane: When you say "not easy," which do you think is preferable? Which do you think is more difficult?

Dean: I made the decision to go that route because I couldn't take care of patients the way I wanted to if I were to take insurance. This, for me, was more challenging in some ways for my own peace of mind, but it was better for my relationships with my patients. That's why I chose it and stayed in it for so long.

Kane: Let's talk about another suggestion that came up, which was that doctors are just too hard on themselves. Basically, if they can't do everything perfectly, they feel terrible. If they're not getting all of their paperwork done, they'll stay up until midnight to get it done. What's your take on that?

Dean: I understand that perspective. I think that is moving in the direction of a physician's work being a job rather than a career or calling. There may be a place for that sometimes, but I also worry about that approach. I'm not sure I want it for myself or for my family.

Kane: In terms of trying to make things easier, what about the medical organizations? Are the medical organizations doing enough? Is there anything they can do differently?

Dean: I honestly think that they are very well intentioned. They really want to do the best for physicians, but I worry that they're not listening to their constituents. Their constituents are saying to us, "Moral injury is the language that we think is the right language; we're not burned out."

If our professional organizations are working on the theory that we're all burned out and are coming up with solutions to burnout, but we're not thinking that we're burned out, then those solutions aren't going to work. Maybe we need to start having more listening campaigns to understand exactly what clinicians are experiencing, so that we can develop the proper approaches to what we're struggling with.

Kane: So the $64,000 question is, what can doctors do? People are upset, people are unhappy, people are committing suicide; it is a terrible situation. But there's a lot of talk about what they can do. What can doctors do?

Dean: I think there are three things that we can do and that administrators can do with us. We can value the physicians who are on the front lines taking care of patients every day. We need to value those relationships that they have with their patients because that relationship is the cornerstone of care. If that isn't working well and if the team isn't focused on supporting that relationship, then we've lost a lot.

Third, we should reestablish our tight community of physicians working together to a better end. Beyond that, we should expand that tight community, not only to physicians from all different specialties, but also to other clinicians: physician assistants, nurses, and first responders, because they're all saying, "This is our language too. We're all suffering the same thing."

If we can all work together in the service of our patients, I think we can get healthcare to a better place.

Kane: It certainly sounds optimistic in the sense that something needs to be done, and you have some good suggestions. Is there any message you'd like to leave? Is there anything we haven't covered or that you'd like to say to the audience?

Dean: I think physicians are in a tough place right now, as are other clinicians. I also think that if we work together, if we can break down the barriers between us and with our patients, and if we start recognizing, noticing, and pushing back in strategic places, healthcare can change. We need to be in collaboration with our fellow clinicians and with our patients to help that change.

Kane: We've had some terrific insight and a great message today from Dr Wendy Dean. I'm Leslie Kane from Medscape. Thank you for joining us.

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