Editorial: It's More Than Burnout—The Moral Injury Crisis in Orthopaedic Surgeons

Abstract

We physicians entered our profession as dedicated, educated, and talented individuals ready to devote our lives to what we believed to be a noble profession. But over the past several years, there has been a noticeable change in physicians’ satisfaction levels: some are leaving practice early, others are depressed, and an alarming number are suicidal. Estimates suggest more than 50% of us suffer from burnout and moral injury [4, 11], the latter being a term I’ll define, because not everyone is familiar with it. But it’s well studied, and suffice it to say, I think we are missing the boat (and are probably on the wrong pier) about these critical issues. I believe that to reverse these insidious, silent blights, we need to focus more on what’s causing our moral injury instead of channeling all our efforts into repairing the physician. Let’s start by defining the terms. Burnout and moral injury are not the same. Burnout is a stress reaction from work-related conditions that is associated with emotional exhaustion, malaise, frustration, cynicism, depersonalization, and a lack of sense of personal accomplishment [4, 11]. By focusing on individual-level characteristics, burnout implies that physicians are the problem and are weak, not resilient, and therefore need to “suck it up.” The onus of solving burnout is on the physician: The doctor is broken, not the system [5]. Recently, burnout has been distinguished from moral injury, a military term from the Vietnam War era. Returning soldiers displayed emotional, PTSD-like symptoms from participating in or observing atrocities at war, and these symptoms did not respond to PTSD treatments. The difference between moral injury and burnout is perhaps ill-defined, but moral injury in medicine, as described by Dean et al. in 2019 [4], is a serious problem in our physician and nursing workforce today. Moral injury pertains to a perceived disconnect between what a person feels or knows is the correct (or moral) way to do something and the imposition of external forces that lead or compel a person to do something they perceive as incorrect or immoral. In the Vietnam War, moral injury was the difference between soldiers fighting the enemy and the reality of external pressures resulting in those same soldiers murdering innocent noncombatants in the prosecution of that same war. For medicine, moral injury arises when physicians spend years getting educated, learning what good care is, and developing the skills needed to deliver it, only to run against system constraints that impede or prevent our ability to provide that good care. Moral injury is worse than burnout because it is irreversible if the system doesn’t change. I believe that moral injury is at the root of today’s physician crisis. We dedicate our lives to helping patients but are thwarted by the dominant forces in real-world practice that require us to focus more on the needs of the electronic medical record and billing priorities than on our patients. “Production pressures” edge out human interactions and distract from high-skill interventions. Shorter, more impersonal visits, billing and documentation priorities that bleed into family time, and cost containment efforts eclipse things that should matter more. We have become overpaid data-entry personnel when what we signed up for was improving the health of people who need us. The result is a stressed healthcare system, poorer quality care, and more-frequent errors committed by stressed, distracted physicians [8]. The system has failed us. In exchange, it has given us wellness classes and yoga. Those are fine, but they won’t solve the problem. A better approach would be to modify the corporatized environment that is today’s medicine. I first learned of moral injury from Jennifer Weiss MD when she delivered an informative orthopaedic grand rounds presentation at Harvard about this issue. Moral injury, as I learned from Dr. Weiss, is amplified by the language now being applied to our profession. We are no longer “physicians” (who used to be held in high esteem), but instead are “providers,” who provide for (instead of treat) clients (instead of patients). These terms erode our self-esteem and devalue what we do. We all know that language matters—these terms demean our profession, and we should stop using them [7], as some national physician associations have suggested [1-3]. When we lump everyone on the healthcare team together without titles, we devalue the professionalism of those who have earned their designations and confuse our patients [9]. And when we stop acknowledging the physician-patient relationship, we lose trust, purpose, altruism, and compassion. Dr. Weiss, in personal communications, reasoned that the surgeon is a canary in a coal mine of a toxic, broken healthcare system. This concept of the canary was also raised by Michael J. Goldberg MD in a CORR® column [12], and it is an apt analogy. It is time to stop blaming the canary and focus on the environment that is sapping the energy of both patients and surgeons. It turns out that physicians, if anything, are more resilient than workers in other fields, but despite that, have a high rate of burnout—even among those physicians with the highest resiliency scores [10]. This is why we in orthopaedics and other specialties need to convince our system leaders to focus on the root causes of moral injury and burnout instead of focusing all our efforts on repairing the physician through yoga, wellness programs, and mindfulness workshops. We need to fix the system [5] rather than trying to create better-adapted canaries to send back into the coal mine [12]. I believe that a way to start doing this is to treat moral injury the same way we treat wrong-site surgery: as though it’s a “never-event.” Early on in my career, as a chair of an orthopaedic department, I got a call that one of my surgeons had performed wrong-site surgery. It turned our world upside down for weeks. We had high-level meetings including and led by the CEO as we looked at root-cause analyses, drilling down what aspects of our system led to this “never-event,” and what we could do to make sure it never happened again. We did not blame the surgeon or his team. You know the results of that process: sign your site, time outs in the operating room, and more. It was all good, and it improved patient safety. We provided a lot of support to the patient who had the incorrect site operated on and she let the surgeon do the correct site in large part because of this supportive care. Why aren’t we performing an analogous root-cause analysis of physician health and safety in our individual institutions? So far, this doesn’t seem to be a high priority for hospital system leadership even though it is essential if we are to have any hope of maintaining productive physician and nursing staffs that deliver high-quality care. As some have said, “we are not suffering from a yoga deficiency” [6]. Until we divert resources to help physicians care for patients—get their heads out of the computer and facing their patients so that they can do what they are educated to do—this problem will continue, patients will suffer, and the quality of healthcare will decline. I still believe that there is no truer calling nor better profession, at least for me, than that of orthopaedic surgeon. I would do it all again. But we must insist that hospital leaders work with us to find ways to treat our moral injury. It won’t be easy or cheap, but the costs of not doing it are so much greater. To get this started, I think surgeons need to work with our institutions to: Do a root-cause analysis of moral injury in the workplace. Remind administrators what a patient chart is meant to be: a record of pertinent history and medical findings for each patient to reach a diagnosis and treatment plan clearly and efficiently. We likely won’t get rid of the electronic record, nor do we want to. But we need to make it more about patient care, not reimbursement. Find better solutions for entering data into the electronic medical record. Strike the word “provider” from our vocabulary when referring to medical doctors—use words like “doctor,” “physician,” “surgeon,” or “professional” instead. At CORR®, we encourage authors to do this when we find the word “provider” in manuscripts. Consider ways to increase the time surgeons have for genuine face-to-face, eye-to-eye time with their patients.

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