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February 3, 2020

'The real epidemic in medicine today': Why this MD believes 'moral injury' is hurting doctors—and patients

Daily Briefing

    When Wendy Dean's husband's health rapidly deteriorated, his physicians were bound by such tight scheduling and non-clinical roadblocks that they struggled to provide him with thorough care, Dean, a psychiatrist, writes for WBUR. Dean says the scenario highlights health care's "moral injury" problem—a phenomenon she believes is often conflated with burnout.  

    Infographic: The 4 ways you can fight physician burnout

    A terrifying experience

    Three years ago, Dean "watched, horror-stricken and helpless, as [her] husband tried very hard to die," she writes.


    Dean's husband, who is also a physician, was born with a heart condition that had been well-managed for most of his life. But in the summer, his health began to deteriorate, he was tired and walked more slowly. Then in the fall, a cardiologist sent him to the ED where he had two procedures, both of which went unfinished because of concerns about a blood clot. But eventually, his condition deteriorated to the point that he "could no longer catch his breath lying flat in bed," Dean writes.

    When this started happening, Dean's husband tried to contact his doctors. "[H]e asked to speak with the doctors taking care of him. Instead, receptionists and nurses returned his calls," Dean writes. "He could not get answers. He could not get their attention. … He could not get one of the specialists to listen, and we could not sort out which one of the group was responsible for his care."

    Eventually, when he struggled to walk 100 yards, Dean's husband was hospitalized.

    "Finally," Dean writes. "[W]e would get answers and get this under control!"

    Over the weekend, five different physicians treated her husband. "Each one just tried to keep the situation from deteriorating too far during his or her shift, then handed him off to the next in line," Dean writes. When she asked the doctors about next steps in her husband's treatment, she writes that she "was met with defensiveness" from each clinician, but no one was able to give a clear treatment plan.

    Eventually, Dean texted a colleague at another hospital to get her husband a bed in their ICU. "I was worried he would not survive another night at the local hospital," she writes.

    At the second hospital, "the experience was dramatically different," she writes. He was cared for by "a nurse who almost never left his bedside; a care team that showed up, in person, with a sense of urgency about his condition and new ideas about medications to try; and clinicians who were hungry to know not only who he was in the moment, but who he had been before he got sick," Dean writes.

    According to Dean, her husband's condition improved "dramatically" within eight hours. Ten days later, he was released. 

    The consequences of physician 'moral injury'

    Dean's husband spent two months in outpatient care and four days in the ICU, and during that time "the physicians were shockingly absent," she writes. However, blaming the clinicians for what happened would be "misplaced," she adds. "It is the system, designed and overseen largely by non-clinicians, that is to blame."

    The physicians were completely "bound" by the system with "scheduling control, data and metrics, policies and punishments that they, too, could barely breathe," Dean writes. "They had almost no control over their patient interactions or their referral options."

    "They knew what patients needed, but did not have the latitude or the autonomy to get it." Dean writes, "They looked beaten, distant, as if they had given up, disengaged, stopped empathizing, depersonalized, as if they felt that they couldn't accomplish much, so why even bother to try?"

    It was the first time Dean so clearly witnessed the potential patient harms of "moral injury," or damage to one's conscience.

    It became clear to Dean that "the autonomy and latitude of practice that protect against moral injury …   has a profound impact on everyone around them." In turn, Dean states that "changes are essential to improving health care for all of us."

    But the first step is to acknowledge that moral injury is the "real epidemic in medicine today," she writes. "We need to start with honesty, and with clarity that what many are now calling 'burnout' is actually moral injury" (Dean, WBUR, 1/24).

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