The idea for Healthassist came to me following numerous conversations with individuals who, once they learned I had practiced as a nurse, proceeded to share their “tales of woe” about the healthcare system and the healthcare professionals with whom they interacted.
I always felt sad about their experiences, because I knew in my heart that most people who choose a career in healthcare do so out of a desire to help others. Unfortunately, the stress, complexity, and competing forces within the healthcare system can lead to discouragement, frustration, and the decision to leave the field entirely.
And so in 2009, when surgeon and New Yorker staff writer Atul Gawande wrote The Cost Conundrum, I shared the article widely, to help those who complain about the high cost and perceived lack of quality better understand some of the underlying causes.
Now, after attending this year’s Massachusetts Healthcare Advocate (MAHCA) Symposium and listening to Simon Talbot MD (who wrote the seminal article on Moral Injury in 2018) describe the difference between moral injury and burnout in healthcare, I feel the same way about sharing his insights with you.
An Important Distinction
A shortage of primary care providers and specialists; months-long waits for appointments; rushed and sometimes inattentive healthcare providers… these are just a few examples of things we as healthcare consumers may experience. Often, the reason given is that healthcare professionals are “experiencing burnout” and leaving the profession in droves.
Burnout manifests as emotional exhaustion, leading to emotional detachment and, over time, a feeling that you cannot make a difference. Most interventions to combat burnout are focused on the individual experiencing it, rather than systems that may have contributed to its development.
Yes, burnout certainly plays a role. But Dr. Talbot argues that much of what gets labeled in this way is actually “moral injury,” and is better understood through a different frame — one in which healthcare professionals repeatedly impacted by systemic constraints (insurance denials, productivity quotas, short visit slots, billing pressures, staffing cuts, etc.) are faced with situations in which they can’t act on what they know to be right for the patient.
Moral Injury Has Many Possible Causes
The term “moral injury” began in the military, a profession that likewise requires a specialized knowledge base, strict standards of behavior and practice, and judgments (often life and death) made with uncertain information and based on one’s own ethical principles.
In healthcare, moral injury may occur when there are potentially helpful interventions available, but that are denied by health insurance companies and other entities. Or think about the early days of COVID-19, when healthcare professionals were forced to choose which patients to place on the few available ventilators.
Other examples include witnessing the behavior of colleagues that violates one’s deeply held beliefs. It may begin with a betrayal by someone who holds authority in a situation where stakes are high, but where speaking out can come with serious consequences.
An experience that haunts me to this day occurred in 1985, when I was a nurse caring for a 27-year-old woman with end-stage cancer. Her surgeon visited often and repeatedly told her everything was “going to be fine.”
But those of us caring for her 24/7 knew she was dying — and she knew it too. And yet, despite repeated attempts by our manager to encourage the physician to interact with the patient and her family differently, we were instructed to follow his lead and not openly discuss what was about to happen.
Whatever the circumstances, moral injury is not burnout, nor is it simply a reflection of a given individual’s strength; it is a function of the system in place. As such, interventions to combat it must take a structural approach — one that changes the conditions that force compromise, rather than simply asking individuals to “cope better.”
Handling Moral Injury as a Healthcare Consumer
Few of us have the power to change the healthcare system… but we can choose how we operate within it. Understanding moral injury’s potential impact on the professionals with whom you work can improve your own interactions and those of your loved ones.
As always, my best advice is to be kind, appreciative, and curious, rather than judgmental. When you align your goals with the healthcare provider’s fundamental desire to help you, you can create a satisfying experience.
Three suggestions for initiating interactions:
#1. Express your desire for shared goals. “My goal is to be as healthy as possible, and I assume you want the same for me. I value the expertise you are about to share with me.”
#2. Encourage collaboration. “I would like decisions about my care to be shared with you. I’d like to understand all my options, describe my preferences, and decide on a plan together.”
#3. Share your values. “I’ve lived a long and wonderful life and I value quality over quantity. I am sharing this with you so you know my perspective as we begin this discussion about further treatment options.”
Finding Common Ground
When we recognize that many healthcare professionals are struggling not from a lack of resilience, but from the pain of being unable to provide the care they know their patients need, it becomes easier to approach each encounter with empathy.
By working as partners rather than adversaries, patients and providers can help restore the trust, connection, and shared purpose that lie at the heart of beneficial healthcare.
P.S. The HBO Max series The Pitt offers a realistic view of both burnout and moral injury, seen through the experiences of the fictional staff at Pittsburgh Trauma Medical Center. Recommended!