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Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h
Correspondence: Wendy Dean (wdean@moralinjury. healthcare)
aMoral Injury of Healthcare, Carlisle, Pennsylvania
bCentre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom
cThe University of Buckingham, United Kingdom
dAlbert Einstein College of Medicine, Bronx, New York
eMontefiore Medical Center, Bronx, New York
fJacobi Medical Center, Bronx, New York
gBrigham and Women’s Hospital, Boston, Massachusetts
hHarvard Medical School, Boston, Massachusetts
Author disclosures
Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.
HARMONIZING DEFINITIONS
Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.6
The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.7 Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”8 The violator is posited to be either the self or others.
Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression). An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).9
Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.9 Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.8
Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.
MORAL INJURY AND BURNOUT
In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.
If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm.
CONCLUSIONS
Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.1 Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair.
Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades.
Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. Curr Treat Options Psych. 2023;10:199-216. doi:10.1007/s40501-023-00296-4
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. doi:10.17226/25521
3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. Daedalus. 2005;134(3):13-18. doi:10.1162/0011526054622132
5. Fuchs VR. Major trends in the U.S. health economy since 1950. N Engl J Med. 2012;366(11):973-977. doi:10.1056/NEJMp1200478
6. Molendijk T. Warnings against romanticising moral injury. Br J Psychiatry. 2022;220(1):1-3. doi:10.1192/bjp.2021.114
7. Shay J. Moral injury. Psychoanalytic Psychol. 2014;31(2):182-191. doi:10.1037/a0036090
8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
9. Brovont v KS-I Med. Servs., P.A., 622 SW3d 671 (Mo Ct App 2020).
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>0424 FED Moral Injury</fileName> <TBEID>0C02F363.SIG</TBEID> <TBUniqueIdentifier>NJ_0C02F363</TBUniqueIdentifier> <newsOrJournal>Journal</newsOrJournal> <publisherName>Frontline Medical Communications Inc.</publisherName> <storyname/> <articleType>1</articleType> <TBLocation>Copyfitting-FED</TBLocation> <QCDate/> <firstPublished>20240408T161251</firstPublished> <LastPublished>20240408T161251</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240408T161251</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline/> <bylineText>Wendy Dean, MDa; Deborah Morris, DClinPsychb,c; Mustfa K. Manzur, MD, MPH, MSd,e,f; Simon Talbot, MDg.h</bylineText> <bylineFull/> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:"> <name/> <rightsInfo> <copyrightHolder> <name/> </copyrightHolder> <copyrightNotice/> </rightsInfo> </provider> <abstract/> <metaDescription>Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the</metaDescription> <articlePDF/> <teaserImage/> <title>Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout</title> <deck/> <eyebrow>Commentary</eyebrow> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth>April</pubPubdateMonth> <pubPubdateDay/> <pubVolume>41</pubVolume> <pubNumber>4</pubNumber> <wireChannels/> <primaryCMSID/> <CMSIDs> <CMSID>2949</CMSID> <CMSID>4059</CMSID> </CMSIDs> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FED</publicationCode> <pubIssueName>April 2024</pubIssueName> <pubArticleType>Editorials | 4059</pubArticleType> <pubTopics/> <pubCategories/> <pubSections> <pubSection>Editorial | 2949<pubSubsection/></pubSection> </pubSections> <journalTitle>Fed Pract</journalTitle> <journalFullTitle>Federal Practitioner</journalFullTitle> <copyrightStatement>Copyright 2017 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">16</term> </publications> <sections> <term canonical="true">52</term> </sections> <topics> <term canonical="true">248</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout</title> <deck/> </itemMeta> <itemContent> <p class="abstract"><b>Background:</b> Moral injury had been discussed by health care professionals as a cause of occupational distress prior to COVID-19, but the pandemic expanded the appeal and investigation of the term. Moral injury incorporates more than the transdiagnostic symptoms of exhaustion and cynicism and goes beyond operational, demand-resource mismatches of corporatized systems.<br/><br/><b>Observations:</b> Moral injury describes the frustration, anger, and helplessness associated with existential threats to a clinician’s professional identity as business interests erode their ability to put patients’ needs ahead of corporate and health system obligations. We propose a framework that combines 2 moral injury definitions. An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. Moral injury arises when a superior’s actions or a system’s policies and practices undermine one’s professional obligations to prioritize the patient’s best interest. Perceived as inescapable, the resignation or helplessness of moral injury may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both moral injury and burnout can mediate and moderate the relationship between triggers for workplace distress and the resulting psychological, existential, and physical harm.<br/><br/><b>Conclusions</b>: Moral injury is increasingly recognized as a source of distress among health care professionals. It emerges from structural constraints on the ability of health care professionals to deliver optimal care and stand up for patients, their oaths, and their professions. A unified definition of moral injury must be integrated into the framing of clinician distress alongside burnout, recentering health care on ethical decision making rather than profit. </p> <p><span class="Drop">M</span>oral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.<sup>1</sup> HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.<sup>2</sup> Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.<sup>3</sup> </p> <p>Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.</p> <h2>CONTEXTUAL DISTINCTIONS</h2> <p>It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.<sup>4</sup> However, the context of each profession’s commitment to society carries different moral implications.</p> <p>The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.<br/><br/>One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.<sup>5</sup> In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.</p> <h2>HARMONIZING DEFINITIONS</h2> <p>Moral injury is inherently nuanced. The 2 dominant definitions arise from work with combat veterans and create additional and perhaps unnecessary complexity. Unifying these 2 definitions eliminates inadvertent confusion, preventing the risk of unbridled interdisciplinary investigation which leads to a lack of precision in the meaning of moral injury and other related concepts, such as burnout.<sup>6</sup></p> <p>The first definition was developed by Jonathan Shay in 1994 and outlines 3 necessarycomponents, viewing the violator as a powerholder: (1) betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation.<sup>7</sup> Litz and colleagues describe moral injury another way: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”<sup>8</sup> The violator is posited to be either the self or others.Rather than representing “self” or “other” imposed moral injury, we propose the 2 definitions are related as exposure (ie, the perceived betrayal) and response (ie, the resulting transgression)<b>.</b> An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. They may acquiesce and transgress their moral beliefs (eg, their oath to provide ethical health care), or they could refuse, by speaking out, or in some way resisting the authority’s betrayal. The case of Ray Brovont is a useful illustration of reconciling the definitions (Box).<sup>9</sup> <br/><br/>Myriad factors—known as potentially morally injurious events—drive moral injury, such as resource-constrained decision making, witnessing the behaviors of colleagues that violate deeply held moral beliefs, questionable billing practices, and more. Each begins with a betrayal. Spotlighting the betrayal, refusing to perpetuate it, or taking actions toward change, may reduce the risk of experiencing moral injury.<sup>9</sup> Conversely, acquiescing and transgressing one’s oath, the profession’s covenant with society, increases the risk of experiencing moral injury.<sup>8<br/><br/></sup>Many HCPs believe they are not always free to resist betrayal, fearing retaliation, job loss, blacklisting, or worse. They feel constrained by debt accrued while receiving their education, being their household’s primary earner, community ties, practicing a niche specialty that requires working for a tertiary referral center, or perhaps believing the situation will be the same elsewhere. To not stand up or speak out is to choose complicity with corporate greed that uses HCPs to undermine their professional duties, which significantly increases the risk of experiencing moral injury.</p> <h2>MORAL INJURY AND BURNOUT</h2> <p>In addition to reconciling the definitions of moral injury, the relationship between moral injury and burnout are still being elucidated. We suggest that moral injury and burnout represent independent and potentially interrelated pathways to distress (Figure). Exposure to chronic, inconsonant, and transactional demands, which things like shorter work hours, better self-care, or improved health system operations might mitigate, manifests as burnout. In contrast, moral injury arises when a superior’s actions or a system’s policies and practices—such as justifiable but unnecessary testing, or referral restrictions to prevent revenue leakage—undermine one’s professional obligations to prioritize the patient’s best interest.</p> <p>If concerns from HCPs about transactional demands are persistently dismissed, such inaction may be perceived as a betrayal, raising the risk of moral injury. Additionally, the resignation or helplessness of moral injury perceived as inescapable may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both conditions can mediate and moderate the relationship between triggers for workplace distress and resulting psychological, physical, and existential harm. </p> <h2>CONCLUSIONS</h2> <p>Moral injury is increasingly recognized as a source of distress among HCPs, resulting from structural constraints on their ability to deliver optimal care and their own unwillingness to stand up for their patients, their oaths, and their professions.<sup>1</sup> Unlike the military, where moral injury is inherent in the contract with society, moral injury in health care (and the relational rupture it connotes) is a signal of systemic dysfunction, fractured trust, and the need for relational repair. </p> <p>Health care is at a crossroads, experiencing a workforce retention crisis while simultaneously predicting a significant increase in care needs by Baby Boomers over the next 3 decades. <hl name="33678"/>The pandemic served as a stress test for our health care system and most institutions failed. Instead, the system was held together by staff, which is not a plan for sustained organizational resilience. <br/><br/>Health care does not have the luxury of experimenting another 30 years with interventions that have limited impact. We must design a new generation of approaches, shaped by lessons learned from the pandemic while acknowledging that prepandemic standards were already failing the workforce. A unified definition of moral injury must be integrated to frame clinician distress alongside burnout, recentering ethical decision making, rather than profit, at the heart of health care. Harmonizing the definitions of moral injury and clarifying the relationship of moral injury with burnout reduces the need for further reinterpretations, allowing for more robust, easily comparable studies focused on identifying risk factors, as well as rapidly implementing effective mitigation strategies.</p> <p class="isub">Author affiliations</p> <p> <em><sup>a</sup>Moral Injury of Healthcare, Carlisle, Pennsylvania <br/><br/><sup>b</sup>Centre for Developmental and Complex Trauma, St. Andrew’s Healthcare, Northampton, United Kingdom<br/><br/><sup>c</sup>The University of Buckingham, United Kingdom<br/><br/><sup>d</sup>Albert Einstein College of Medicine, Bronx, New York<br/><br/><sup>e</sup>Montefiore Medical Center, Bronx, New York<br/><br/><sup>f</sup>Jacobi Medical Center, Bronx, New York<br/><br/><sup>g</sup>Brigham and Women’s Hospital, Boston, Massachusetts<br/><br/><sup>h</sup>Harvard Medical School, Boston, Massachusetts</em> </p> <p class="isub">Author disclosures</p> <p> <em>Wendy Dean and Simon Talbot are cofounders of Moral Injury of Healthcare, a nonprofit organization. Dean is a speaker for LeighHealth Speakers Bureau. The University of Florida and Rothman Orthopedic Institute have made payments to Moral Injury of Healthcare.</em> </p> <p class="isub">Disclaimer</p> <p> <em>The opinions expressed herein are those of the authors and do not necessarily reflect those of <i>Federal Practitioner</i>, Frontline Medical Communications Inc., the US Government, or any of its agencies.</em> </p> <p class="isub">Ethics and consent</p> <p> <em>The Veterans Affairs Greater Los Angeles Healthcare System institutional review board determined that this study was exempt. The datasets generated and/or analyzed during the current study are not publicly available but may be available from the corresponding author on reasonable request.</em> </p> <p class="isub">References</p> <p class="reference"> 1. Griffin BJ, Weber MC, Hinkson KD, et al. Toward a dimensional contextual model of moral injury: a scoping review on healthcare workers. <i>Curr Treat Options Psych.</i> 2023;10:199-216. doi:10.1007/s40501-023-00296-4<br/><br/> 2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. <i>Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being</i>. The National Academies Press; 2019. doi:10.17226/25521<br/><br/> 3. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. <i>Fed Pract</i>. 2019;36(9):400-402.<br/><br/> 4. Gardner HE, Schulman LS. The professions in America today: crucial but fragile. <i>Daedalus</i>. 2005;134(3):13-18. doi:10.1162/0011526054622132<br/><br/> 5. Fuchs VR. Major trends in the U.S. health economy since 1950. <i>N Engl J Med</i>. 2012;366(11):973-977. doi:10.1056/NEJMp1200478<br/><br/> 6. Molendijk T. Warnings against romanticising moral injury. <i>Br J Psychiatry</i>. 2022;220(1):1-3. doi:10.1192/bjp.2021.114<br/><br/> 7. Shay J. Moral injury. <i>Psychoanalytic Psychol</i>. 2014;31(2):182-191. doi:10.1037/a0036090<br/><br/> 8. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. <i>Clin Psychol Rev</i>. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003 <br/><br/> 9.<i> Brovont v KS-I Med. </i><i>Servs., P.A.</i>, 622 SW3d 671 (Mo Ct App 2020).</p> </itemContent> </newsItem> </itemSet></root>
Reframing Clinician Distress: Moral Injury Not Burnout
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.