Moral distress, moral injury, and burnout: Clinicians’ resilience and adaptability are not the solution

Moral distress, moral injury, and burnout are terms used to encapsulate the difficulties that arise when the relationship that individuals have with their work goes awry.^{1, 2} Burnout, in particular, exquisitely captures the feeling of having had fizzled out. What started as a purposeful and fulfilling profession ends in a disappointing way. Among clinicians, the incidence of moral distress, moral injury, and burnout exceeds 50%.^{3, 4} Moral distress, moral injury, and burnout—collectively termed moral suffering^{5, 6}—stem from a self-evident reality: grief. Clinicians suffer, and as a consequence, so do patients. Among clinicians, the angst is moral—it is the distress that arises in response to an adversity that challenges our integrity.⁶

Moral distress is the emotion experienced by an individual when the appropriate course of action is evident, but a series of obstacles such as scarcity of time, limited resources, lack of seniority, an organization's power structure, institutional policies, red tape, or legal considerations make it difficult to pursue the right course of action.^7-9 Moral distress tends to be situational, and as such it can be a collective emotion. In healthcare, moral distress arises from having to remain silent in the face of rude behavior, from witnessing wasteful use of medical resources, when doing things to the patient and not for the patient, and from lack of autonomy.⁴

Moral injury goes a critical step further. It is the enduring psychological, spiritual, behavioral, social, and emotional harm inflicted on an individual's conscience when that person perpetrates, fails to prevent, or witnesses acts that conflict with their values or beliefs.^{4, 10} Because moral injury stems from an affront to an individual's integrity, it can leave those who endure it feeling victimized, betrayed, wounded, guilty, and ashamed.^{6, 11} If moral distress is situational and possibly collective, moral injury is individual and transcendent.⁴

While we might speak of them in the same breath, moral distress, moral injury, and burnout are not the same. The latter can be a consequence of either one of the former two. Burnout is a syndrome caused by intellectual, physical, and emotional exhaustion in the face of unrelenting stressors in the workplace.⁴ The burnout syndrome's signs and symptoms include malaise, frustration, cynicism, low self-esteem, hopelessness, isolation, sleeplessness, emotional exhaustion, despondency, broken relationships, alcohol and substance abuse disorder, suicidal ideation, and completed suicide.^{12, 13} Burnout thwarts our ability to adapt to the present, and it gives us the impression that our future is chaotic, fractious, and perilous. Wrongly so, some assume that in burnout the problem is with the clinician who lacks the resilience necessary to adapt and withstand the work environment.¹⁴ The concepts of moral stress and moral injury make evident that the clinician is not broken; it's the system that is broken.^{14, 15} As clearly stated by Dr. Christine Sinsky, the American Medical Association's Vice President of Professional Satisfaction, “While burnout manifests in individuals, it originates in systems.”¹⁶

Moral suffering has long been recognized in clinicians.^{1, 2} The COVID-19 pandemic, however, ushered in an unprecedented increase in moral suffering.^{11, 13, 17-20} Not only did we have to take care of extremely sick patients while navigating uncharted straits with limited resources, we also had to fend off politician- and media-fanned flames of misinformation, charlatanerie, and science denial.¹⁸ Shanafelt and colleagues reported that in 2020, 38.2% of US physicians had at least one manifestation of burnout. That number jumped to 62.8% in 2021.¹⁸ While recognizing that the effects of the pandemic might not have been the only reason, the fact is that by the end of 2022, 117,000 physicians had left the profession—the largest number among healthcare professionals.²¹ These are facts, and they have real-life consequences not just for clinicians but also for patients and healthcare organizations. Burnout is associated with a decline in quality of care, an increase in medical errors, an increase in healthcare costs, a reduction in work effort, and an increase in workforce turnover, to name a few.^{3, 21-23}

In the clinical setting, moral suffering arises when practitioners recognize wasteful utilization of medical resources; when there is inadequate or adversarial communication among colleagues; when clinicians are not able to meet the expectations—founded or unfounded—of patients; when medical decisions have to be justified against the backdrop of an internet search engine's results; when clinicians experience the erosion of civility; when through the actions of others, clinicians are reminded that years ago we stopped treating patients like patients and started treating them like clients—and the client is always right!

What about us pediatric neurologists? After all, this journal is Annals of the Child Neurology Society. Sadly, we don't fare well either. If you consider yourself more of a neurologist, over 60% of us show at least one symptom of burnout.²⁴ Depending on whom you ask, this number is either the highest or the second highest among medical subspecialists.^24-26 If you consider yourself more of a pediatrician, our burnout rate is 41%.^{25, 27} Which industry's leadership would be reassured knowing that almost half of its personnel has signs and symptoms of burnout?²⁸

Is there a solution to the problem of moral suffering? Many have tried to find it. Alas, the problem has not abated.^{4, 29-32} We have programs for boosting our resilience, harnessing our strengths, connecting with others, acknowledging our feelings, enhancing our emotional intelligence, finding work-life balance, building stronger teams, practicing mindfulness, practicing meditation, practicing relaxation, learning time management, learning interpersonal skills, learning assertiveness, and learning how to improve our eating habits. Yet, the problem has grown worse.¹⁸ Why? Because believing that moral distress, moral injury, and burnout will be forestalled by yoga is foolish.¹⁴ And suggesting that things would improve if only we ate a well-balanced diet is offensive!

At least in the United States, management of the healthcare system is on its head—we have mostly charged the healthcare administrator, not the admiral, with the responsibility of piloting the aircraft carrier. How else can we explain the meteoric rise in healthcare administrators?^{9, 33} Few data on the topic are more striking, and few graphs are more in-your-face than those presented by Cantlupe.³³ Between 1975 and 2010, the population of the United States grew by about 150%, and the number of physicians paralleled that growth. In that same period, the number of healthcare administrators soared by 3200%.³³ Defenders of this growth claim that such disproportionate expansion is justified by the need to adapt to an ever-changing healthcare environment—increased scrutiny, increased regulation, and financial pressures.^{9, 33} Those who know the healthcare system from within—clinicians—assert that administrators impose top-down rules devoid of medical context, expect clinical encounters to be focused on efficiency and profitability, limit clinicians' flexibility and control over work, ignore the exponential increase in clerical work that clinicians have to complete, assume that clinicians' practices can be modified through financial incentives, and launch into expansion projects with no regard for staffing.^{9, 33}

The problem of moral suffering is the makings of the healthcare system and the organizations that oversee its practice—we clinicians bear the brunt of it, but we are not the problem.¹⁶ In a 2001 review on job burnout, Maslach et al. asked the question, “Assuming that it is indeed possible for people to apply new coping skills at work, does this lead to reductions in burnout?”^{2 (p. 419)} Sadly, the answer was no: “In some cases, a reduction in exhaustion has been reported, but in other cases it has not. Rarely do any programs report a change in cynicism or inefficacy.”^{2 (p. 419)} Eighteen years passed, and little changed. In the 2019 report on clinician burnout, the US National Academies of Sciences, Engineering, and Medicine acknowledged that there is limited evidence that stress management interventions ameliorate healthcare professionals' burnout: “The evidence suggests that organization-focused interventions are more effective at reducing overall burnout than individual-focused interventions.”^{34 (p. 129)} Placing on us the burden of finding a hobby instead of ameliorating the causes of moral suffering at the organizational level will not fix the problem—because we clinicians are not the problem. At the end of their systematic review and meta-analysis on interventions to reduce burnout in physicians, Panagioti et al. concluded that “physician-directed interventions led to very small significant reductions in burnout. We found no evidence that the content (e.g., mindfulness, communicational, educational components) or intensity of these interventions might increase the derived benefits based on our critical review. This finding, in combination with the larger effects of organization-directed interventions, supports the argument that burnout is rooted in the organizational coherence of the health care system.”^{29 (p. 203)} Yes, clinicians are part of the system, but making meaningful changes to the system is, for most of us, beyond reach.

In his commentary, Dr. Roach questions what makes some clinicians more apt to manifest burnout than others.³⁵ The reality is that his question has no simple answer other than pointing out the obvious—physicians are but a slice of society. As such, the most common mental health diagnoses of physicians—anxiety, depression, and substance abuse disorder—mirror those of the general population.¹³ And like the general population, some of us are better equipped to handle stress than others. The inherent stresses of a medical career, however, likely provide fertile ground for the risk factors of mental health disorders: personal history of mental illness, family history of mental illness, and lack of social support.¹³ Given the nature of the profession, the emotional burden builds on the foundation of risk factors and takes a toll on clinicians' mental health.^{13, 19} To complicate matters, the stigma around mental health within the medical community can make it even more challenging for those of us who struggle to find the support so desperately need.^{13, 19}

Clinicians’ moral suffering is a worldwide clear and present danger that is here to stay. Legislators, professional associations, insurance company executives, and healthcare organization executives must make legitimate changes to the way medicine is practiced instead of suggesting that the problem would go away if only clinicians were more resilient and adaptable.

Additional resources:

- British Medical Association. Moral Distress and Moral Injury: Recognising and Tackling It for UK Doctors. Accessed May 6, 2023. https://www.bma.org.uk/media/4209/bma-moral-distress-injury-survey-report-june-2021.pdf

- American Medical Association. AMA Recovery Plan for America's Physicians. Reducing Physician Burnout. Accessed May 7, 2023. https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-physicians-reducing-physician-burnout?utm_effort=DAPSRH&gad=1&gclid=EAIaIQobChMI0ZCEgqvj_gIVkhutBh2a3ggyEAAYASAAEgLnPfD_BwE

- Fix Moral Injury. Accessed May 12, 2023. https://www.fixmoralinjury.org

- American Medical Association. Saving the Time Playbook. Accessed August 25, 2023. https://www.ama-assn.org/practice-management/sustainability/saving-time-playbook

- American Medical Association. Taming the EHR Playbook. Accessed August 25, 2023. https://www.ama-assn.org/practice-management/ama-steps-forward/taming-ehr-playbook

Pedro Weisleder: Conceptualization; writing—original draft; writing—review and editing.

The author is Editor-in-Chief of Seminars in Pediatric Neurology. The opinions expressed in this essay are solely those of the author.