A Wound in the Soul of the Caring Profession
The Unspoken Moral Cost of Care.
This blog is inspired by topics covered in Episode 12: Moral Injury & the Musical Chairs of Housing with Dr Margot Kushel.
If you haven’t listened to it yet, check it out on Apple, Spotify or wherever you get your podcasts.
The Mental Health Cost of a Medical Career.
When considering a medical career, it’s easy to imagine a fulfilling job dedicated to helping others.
However, few realise the true cost of such a role, where statistics paint a grim picture with greater risks of burnout, depression, drug addiction, and suicide compared to the general population123.
Nearly two decades ago, during one of my first lectures in medical school, the topic of our atrocious mental health was briefly raised, before we swiftly moved on to caring for others. It wasn’t until the COVID-19 pandemic when the public eye was focused on healthcare, that we were reminded of clinicians’ well-being.
While not new, burnout became the catch-all term to describe the feeling of an overworked and undervalued workforce. This went beyond mere stress at work; but a deeper, pernicious, feeling of overwhelm, cynicism, emotional exhaustion and depersonalization. Despite not being a clinical diagnosis, its interconnectedness with depression and anxiety highlights the significance of the experience.4
Some contributing factors to burnout are readily apparent, including burgeoning administrative tasks, chronic understaffing and constant time pressure. However, there is one often overlooked driver that threatens the very soul of the caring profession.
The Disconnection Between Values and Reality.
The story goes that people choose to pursue medicine because people wish to care for others. While this common trope is admirable - and no doubt true for many, it unintentionally implies that those who choose different paths lack the same compassion. Caring for others is a fundamental human trait, but not everyone has the opportunity (or luck) to express it through a healthcare career.
Most medical students enter their study, with limited firsthand experience of what it truly means to care for a sick person as a clinician. This means they are ready to be primed with the idealism of developing powerful clinical skills to make a meaningful difference in people's lives consistently.
Unfortunately, this is often unchallenged until the stark realities of work life expose a disconnect to be uncovered later.
As clinicians go through their careers, they start to collect experiences that force them to compromise their values and work. From discharging patients who have nowhere to go, to prescribing medications that a patient can’t afford, to keeping a patient in hospital because their home is unsafe, to patching up a wound that will get the proper follow-up care and so on. Each story chips away at that original idealism that once drew them into the field.
“We would be the ones that would have to tell patients that they had to leave and I would have all these patients begging me to not kick them out of the hospital and we would have to.” — Dr Margot Kushel
Moral injury arises from such painful stories. Ones where clinicians are continuously forced to operate within a system that prevents them from providing what patients truly need.
Over time, they internalise this unique form of psychological harm.
How Clinicians Respond to Overwhelming Odds.
Left unaddressed, moral injury often manifests as defensive medical practices, emotional detachment, and maladaptive coping mechanisms like substance abuse. Clinicians may restrict their sense of contribution, subtly avoiding particular environments, or patient cases as a form of self-protection. This can be illustrated by clinicians refusing to ‘take’ (medical speak for ownership) a patient who may be on the borderline of their area of care.
By controlling your contribution and care you minimise the risk of further moral wounds.
This professional cynicism can be a norm in some hospitals and medical cultures, turning altruistic intentions on their head. Behaviours that are antithetical to the mission of healing but are rational in the face of overwhelming odds.
Three Places to Address Burnout.
Addressing moral injury as a driver of burnout requires a multi-faceted approach that extends beyond individual mental health support resilience.
It necessitates a shift in the burden from front-line clinical workers to the decision-makers who can advocate for and implement systemic changes at the organisational and societal levels.
At the organisational level, healthcare systems must commit to creating and utilizing evidence-based strategies to reduce burnout. The National Institute for Occupational Safety and Health in the US offers a framework to help organisations address burnout, which includes six steps;5
Complete a Hospital Wellbeing Review.
Build a Professional Wellbeing Team.
Break down Barriers to Seeking Support.
Prioritize Two-way Communication.
Integrate Professional Well-being measures into ongoing Quality Improvement measures.
Developing a Long-term Professional Well-being Plan.
It is crucial to recognise that the healthcare sector alone cannot solve all of the moral injuries it faces.
And while a well-funded healthcare system is necessary, it is not sufficient due to the significant impact of the social determinants of health, which are the seeds of moral injury.
This requires healthcare leadership that is in relationship with other sectors to solve our common concerns - such as in housing and welfare.
Despite the aversion of many clinicians, political engagement and mobilisation offer a key opportunity to address the drivers of moral injury. While clinicians could be a powerful force, they are typically less likely than non-clinicians to participate in the public debate on how to fix these issues6. This creates a paradox, where if we truly dedicate our lives to improving the lives of others, then there is an obligation to contribute in some way to the public policy changes needed to better their lives.
In Eric Topol’s article ‘Why Doctors Should Organise’, he outlines a rallying cry around the common cause of patients and organisations who’ve taken the lead - while shaking off some historically self-interested activities.7 Action may start in the form of gradations of participation - such as simply joining advocacy groups or turning up to listen at a local community meeting.
“There are these advocacy organizations for this issue or any other issue that you care about. Trust me, those organizations would love nothing more than getting a phone call or an email from someone saying, my name is so-and-so, I am a nurse practitioner, I'm a physician, I'm whatever. This issue really outrages me, how can I help?”
— Dr Margot Kushel
The Key Takeaway.
Moral injury is a pervasive, yet often overlooked driver of burnout in medicine. It acts as a wedge between the idealistic values we should strive for in healthcare and the harsh realities of clinical practice.
When left unaddressed, moral injury inflicts profound harm on healthcare workers with devastating consequences for the caring professions.
To effectively tackle this crisis, systemic changes at the organizational and societal levels are needed. This requires courageous and compassionate leadership that spans outside the clinic. It is willing to be humble and embrace meaningful relationships with other contributing sectors. This also includes clinicians actively engaging in political advocacy, to share their unique personal insights and begin to address the root causes of moral injury.
Emer Ryan et al. The relationship between physician burnout and depression, anxiety, suicidality and substance abuse: A mixed methods systematic review. Front. Public Health, 30 March 2023 Sec. Occupational Health and Safety Volume 11 - 2023 | https://doi.org/10.3389/fpubh.2023.1133484
Douglas A. Mata et al. Prevalence of Depression and Depressive Symptoms Among Resident PhysiciansA Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845. https://jamanetwork.com/journals/jama/fullarticle/2474424
Ann I McCormack. A perfect storm: towards reducing the risk of suicide in the medical profession. Medical Journal of Australia. Volume 209, Issue 9p. 378-379 https://www.mja.com.au/journal/2018/reducing-risk-suicide-medical-profession
Panagiota Koutsimani et al. The Relationship Between Burnout, Depression, and Anxiety: A Systematic Review and Meta-analysis. Front. Psychol., 13 March 2019. Sec. Organizational Psychology. Volume 10 - 2019 https://doi.org/10.3389/fpsyg.2019.00284
Impact Wellbeing Guide. CDC. https://www.cdc.gov/niosh/impactwellbeing/guide/
A Zhong et al. Reported Political Participation by Physicians vs Nonphysicians. JAMA. 2024;331(16):1413-1415. doi:10.1001/jama.2024.1996 https://jamanetwork.com/journals/jama/article-abstract/2816775
Eric Topol. Why Doctors Should Organise. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize