Moral Injury Stems Beyond the Lack of PPE -- The Mental Health Fallout

Robert D. Glatter, MD; Christine Moutier, MD


June 26, 2020

This transcript has been edited for clarity.

Robert D. Glatter, MD: Hello. I'm Dr Robert Glatter, Medscape medical advisor and assistant professor in the Department of Emergency Medicine at Lenox Hill Hospital and Northwell Health.

The recent pandemic has been quite stressful for all healthcare workers, especially physicians, physician assistants, nurses, and EMS workers. Putting this into perspective is vital because we have to pay attention to the mental health of everyone. We have to support everyone. If we don't do that, then going forward makes the situation quite difficult.

Joining me is Dr Christine Moutier, a practicing psychiatrist, professor, and dean in the University of California San Diego School of Medicine. She is also chief medical officer for the American Foundation for Suicide Prevention. Throughout her career, Dr Moutier has focused on training healthcare leaders, physicians, and patient groups in order to change the healthcare system's approach to mental health, fighting stigma, and optimizing care for those suffering from mental health conditions.

Welcome, Dr Moutier. I am so glad you can join us to discuss this important topic.

Christine Moutier, MD: Thanks so much for having me, Dr Glatter. I'm happy to join on such an important and very serious topic.

Stressors Associated With the Pandemic

Glatter: To begin, a recent suicide rocked the soul of all healthcare providers. Lorna M. Breen, MD, was an emergency physician in New York City who was on the front lines of the pandemic. She apparently had no prior history of mental illness.

Certainly, it was an issue before the pandemic, but with added stressors that the pandemic has created, it's become much more concerning. Can you discuss these unique stressors associated with the pandemic that pertain to healthcare workers?

Moutier: When I think about our own strengths and vulnerabilities as human beings, especially those who take on the profession of medicine, I do think about our mental health, including that of not just those who have an identified mental health condition, but all of us. That's something that is so critical to how we think, feel, perceive events, and how we manage our relationships, workload, and patient care. All of that springs out of the bed of our well-being reservoir.

During a time like COVID, it depends on the role that you are in and your own internal makeup, genetic vulnerabilities, and strengths, experiences that sensitize you to past trauma, and how well-versed you've been in taking care of your mental health.

Right now, there is such an added burden of stress for many healthcare practitioners and certainly physicians who are on the front line. If we're not able to feel that the system or the setup allows us to come close to fulfilling what we want to bring to bear in our patient care (and in our other administrative roles as perhaps leaders or mentors), that can press upon our sense of well-being and how we are able to continue to draw from that reservoir to bring our best into the workplace.

This is not an easy time to do that, especially considering that the factors of shift work and sleep deprivation may have increased, and just sheer exhaustion if you are in a place where COVID cases are on the rise and your practice setting requires you to be on the front line.

Moral Injury Stems Beyond PPE

Glatter: On the front lines, I can tell you that from my standpoint, PPE was certainly an important part of feeling protected. It's our body armor; it's how we feel that we can reduce the effect of transmission. The availability of PPE to protect ourselves became an issue in the first few weeks of March and April.

Another issue is being there for our patients who might be dying, and having to choose whether to be with them or to protect ourselves. That could inflict moral injury. Can you speak to that?

Moutier: The topic of moral injury has been an important part of our dialog over these recent years. We have been struggling to understand how we can protect ourselves from burnout and take care of our mental health in the most proactive ways possible.

There's a mismatch between what you're able to bring to bear in your work and a variety of reasons that may be outside of your control (eg, the PPE shortage you mentioned), and your sense of identity of who you are at the core of what it means to fulfill your role.

When there is that mismatch and when you lack control to close that divide, a whole host of feelings and defense mechanisms come up very naturally that can cause anger, frustration, and cynicism in the system and a lack of trust.

Then, in the worst-case scenario, there is a sense of a learned helplessness, like, I'm just going to kind of hold back my usual heart and passion that I bring to my patient care. You almost go into a more emotionally numbed phase that we know can happen in the trauma model. There are a host of things happening to us as individuals ─ particularly if you are on the front line ─ that are not your fault.

They are very human responses. I will say that the more that we can be aware of them, there are things we can do as individuals to help restore our sense of selves and what we want to bring to bear in our lives and in our work. But there's also clearly a role for leadership and for institutions in protecting the mental health and the well-being of the workforce. It's a collaborative and combined effort, or at least it should be, in the ideal circumstance.

Glatter: Healthcare systems and their leadership are reaching out to recognize this important fact that you highlight. If we can't support people who make up the institution (these are the links and the lifeblood to our community), then how can we go forward?

As healthcare workers, we use defense mechanisms: We compartmentalize, deny, minimize. These are things that help us in acute situations. But going forward, it can be devastating after these mechanisms go away.

In other words, it is the emotional recovery after the acute resuscitation, for example, or after that surge in the department wherever you may work. It's dealing with the aftermath that is so key in recognizing that we do need help. We do need to support each other, and the healthcare systems owe their healthcare workers this important aspect of care afterwards.

Protecting Healthcare Workers From the Onset of Burnout

Moutier: Yes. I couldn't agree with you more. It's the most ideal crisis management plan that not only thinks about the current moment and what is needed and the various levels of that, including the human factor and protecting the well-being of the workforce. It is thinking through the timeline of the different phases that are needed during the acute phase of disaster, in the immediate aftermath, and then beyond that.


Many of us as Americans, let alone as trained physicians, have not been taught how to process conflict, trauma, and these challenging circumstances as a way to allow, like you've described so beautifully, those defense mechanisms not to evolve into something pernicious that actually harms us and our mental health, but also affects our energy and sleep, our relationships, and our work.

A study conducted at the Mayo Clinic has shown that facilitated peer groups for faculty physicians can protect against the onset or the deepening of burnout. It can be as simple as an institution putting into place various ways for that to occur, either through peer-to-peer or mentor relationships. Of course, the key thing is that they have to make it real and meet on a regular basis, and go over more than just checking in on clinical cases.

It has to occur in a more holistic way, making sure that mental health resources are highly visible and that the message is that no one will be penalized for mental health issues. In fact, it is strongly encouraged [that clinicians] reach out for mental support right now. It can be a one-time visit with a therapist or [more regular sessions] with an outside professional person whose only vested interest is to be there for support.

The Effects of Stigma

Glatter: Exactly. You allude to the fact of stigma being an aspect that prevents us from seeking help, and healthcare systems want to reduce that stigma. Having said that, I still think that is an issue in medicine and we've had minimal progress in reducing this effect of stigma.

Why do you think that is so? What is the ultimate cause of this in your mind?

Moutier: Well, it goes back to a time decades ago when we didn't have neuroscience. There's a long thread and lead-in to this stigma that surrounds the idea that if you struggle as a physician, if you have a genetic predisposition for depression or an anxiety disorder, that it somehow automatically means weakness.

If you think through that logically, that would be akin to saying, "If you're predisposed to hypertension, diabetes, or an autoimmune condition, you shouldn't be in the practice of medicine." It would be a ludicrous thing to say. And yet, there still is this misunderstanding about mental health that, in some ways, is actually making progress. This kind of change happens at the local level with leadership really starting to make it a priority as well as at the more global and national level that we have seen it take on.

Going back to what I was saying earlier, when there was no science to inform us of that, there were many assumptions made about depression, bipolar disorder, and any other mental health condition, because all you can see from the outside are the behavioral manifestations of the health condition without understanding what the person actually is experiencing and what is driving some of those behaviors.

We should jump into the modern era where we understand that the brain is a true organ in the body. Just like the neurologic conditions that can occur in the brain, so is true of mental health conditions, which simply are a different type of manifestation rather than being more purely somatic or purely cognitive.

Stigma dies slowly. You can have all the education in the world about the science, and you can still have the informal culture of the way that people speak to each other or speak about these issues that will absolutely perpetuate stigma until there's a shift that happens even in that informal layer of behavior. That's why it's so important for leadership to take it on, to message about it on a continual basis, and really allow all members of the community to have an input and dialog with it.

When I was doing medical education actively in my previous role at the University of California San Diego School of Medicine, it was so gratifying to see it expand from the dean's annual message on the importance of all physicians within the universities taking care of their mental health.

When I observed medical students and the residents taking it on and hosting panels to talk about struggles and useful resources, and starting a peer mentor program that highlighted the mental health resources, I knew that it was actually becoming a culture change that said it's safe to talk about these things and there will not be punitive consequences, especially if you seek help proactively, just like we should for our physical health.

Glatter: Yes — making that circle of practicing physicians coming out and talking about how they struggle through mental illness, and partnering with medical students and residents. Here you have a successful physician in a medical school who has dealt with mental illness, talking to medical students and residents and showing how it's treatable, and that with support and love you can get through this. That kind of partnership is integral to making some progress, in my mind.

Moutier: I agree 100% about the power of personal narrative. Not overly burdening others, but the power of self-disclosure used well can be a game changer. You do see glimmers of that happening a lot these days.

In The New England Journal of Medicine and other journals, you are likely to find a personal narrative disclosure about something related to a mental health experience — someone surviving a suicide attempt or requiring a psychiatric hospitalization — on a fairly regular basis.

I struggled early on and used my own story to help medical students understand that these are human issues that can be addressed and there will be support available. The remarkable thing is that once you go through that experience of availing yourself of support (which is very hard for us as physicians, who are accustomed to being the caregivers), and you are in a place where you're able to start talking to peers or students about it, it becomes a very freeing experience.

You become a safe person, and in hearing everybody else's stories you start realizing how these are ubiquitous human experiences. Everybody does struggle at different times with different things. For many medical people, that does include a significant mental health experience.

It becomes freeing to live more authentically where you learn to live in the utopia that we strive for, where there is no stigma because it's part of your story that's been made public and you continue to carry on and do the work. It can be a win-win if people are ready to start sharing in those ways.

Glatter: Your thoughts are quite profound. Do you have any concluding thoughts you'd like to leave with us, in light of the pandemic especially?

Moutier: Whatever your circumstances are right now and wherever you find yourself in terms of your own sense of well-being or struggle, I would just remind you of the basics: You're a human being; you deserve to have some rest on a regular basis and the opportunity to connect with the things that are rejuvenating and meaningful for you.

Don't underestimate the power that you have in your colleagues' lives to model. If [you share that] you are struggling and the ways that you are coping, that will invite their ability to think through what they are going through and stimulate their own reflection on things that they can do as well.

As human beings, we have an incredible resilience at the core that allows us to cope and get through very challenging circumstances of the past. You can tap into the same now. If you're having trouble doing that, just reach out and talk to somebody about it.

I hope and I believe that you will be met with warm support, because so many of us are in a stage of experiencing these challenges right now.

Glatter: Thank you so much for your thoughts and your expert insight. It's truly appreciated.

Moutier: Thank you for the opportunity.

Robert D. Glatter, MD, is an attending physician at Lenox Hill Hospital in New York City and assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Glatter is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Christine Moutier, MD, is a practicing psychiatrist, professor, and dean at the University of California, San Diego School of Medicine. She is also chief medical officer of the American Foundation for Suicide Prevention (AFSP). She has testified before the US Congress and spoken at the White House, and was the host of AFSP's documentary on surviving suicide loss, The Journey. Moutier has appeared as an expert in The New York Times, The Washington Post, Time magazine, The Economist, and The Atlantic, as well as for BBC, NBC, CNN, and other print and television outlets.

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