Sawyer, 38, said he has suffered moral injury from treating patients like this one: A woman had a large kidney stone and a “huge amount of pain” but could not get approval for surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.
The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”
Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research for moral injury among clinicians as there is for moral distress, which happens when someone feels responsible for addressing a moral problem but is not able to follow through as they feel they should.
But “what both of these terms signify is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past,” Rushton said.
Dean grew interested in moral injury from personal experience. After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.
Dean and Talbot created in 2018 a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.
Their work is attracting praise from a range of clinicians.
In Cumberland County, Pa., Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the small private practice she worked in. She said she saw “a dramatic shift” in the culture there after the change, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them,” she said.
In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.”
In Chambersburg, Pa., physician Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.
“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”
Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.
He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.
“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
