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Neurasthenia was once a diagnosis ubiquitous enough to be household vernacular, but by the 1930s, as physicians became interested in more precise, narrower diagnoses, fewer patients were diagnosed as having this condition.1 The widespread use of the diagnosis had diluted its utility. In 2019, member states of the World Health Organization accepted the International Classification of Diseases and Related Health Problems, Eleventh Revision, which retired neurasthenia, and replaced this term with bodily distress disorder.2 Today, it is possible that the term burnout may be approaching, and perhaps should have, the same fate. The use of burnout to describe current occupationally related issues (such as stress, frustration, dissatisfaction, and depression) affecting physicians and other health practitioners has become widespread. Challenges with accurately identifying and measuring a subjectively assessed constellation of symptoms are interfering with efforts to quantify and address widespread clinician distress.3,4 Shifting the language of distress to incorporate etiology could potentially allow better assessment and more targeted solutions to the crisis.
A National Academy of Medicine report, released in October 2019, acknowledged, “The evidence for system interventions that significantly address clinician burnout is limited,” noting that “the study committee was not able to provide specific recommendations for system interventions.”5 In the wake of more than a decade of assessments and interventions focused on burnout, none of which has proven to systematically improve conditions, it is time to consider reframing the concept of clinician distress.
Conversations, whether written or spoken, need to discriminate between moral dilemmas, moral distress, and moral injury, rather than simply discussing burnout. It is essential to use the correct language to address the current challenges that clinicians encounter. If aligning the language of distress with clinician experience leads to a reconsideration of the condition along a continuum of severity, or a change in how distress is categorized, that does not equate with abandoning a body of knowledge but rather evolving as a result of it.
There are 3 important reasons to use precise terms: (1) to ensure that those who are experiencing this challenge have language that accurately reflects their experience and they feel understood; (2) to promote consistent terminology that refers to the same condition or symptoms; and (3) to establish an accurate diagnosis, which is the requisite first step in developing an effective treatment plan.
All clinicians know they will encounter moral dilemmas in medicine. Such situations are inescapable, for example, deciding whether to salvage a severely injured extremity in a patient, which might make recovery much longer and more precarious but might avoid a long-term disability or deciding when to stop life-sustaining treatment for a child who is no longer a candidate for an organ transplant. These are difficult and, at times, deeply challenging decisions because more than 1 answer is morally defensible, but none leads to an ideal outcome.6 Resolving dilemmas is an expected part of medical practice. Clinicians must be educated about when and how to initiate team discussions and ethics consults because, although expected, these situations are nonetheless extraordinarily difficult.
Moral distress occurs when an individual believes he or she knows the right thing to do, but institutional or other constraints make it difficult to do what is right. For example, increasing clinical volume may reduce the amount of high-quality time with patients. Moral distress happens at the intersection between the clinician’s own moral framework, which remains intact, and the values of the health care system.
As each episode of moral distress passes, either it is resolved with sufficient processing or leaves moral residue. Moral residue, the unresolved emotional and psychological conflicts attendant to episodes of distress, makes subsequent incidents of moral dilemma or moral distress less tolerable.7 As moral residue accumulates, moral injury becomes more likely with subsequent dilemma or distress.
Moral injury implies an erosion of a person’s moral framework as the result of a single egregious violation or persistent, repeated moral distresses. The accumulation of these incidents could drive clinicians to question their perceptions of medicine as a safe, benevolent profession and the belief that those working in it are trustworthy.
Litz et al8 defined moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” In health care, the deeply held moral belief or expectation is the oath individual physicians took to provide the best care possible for patients and to make a patient’s needs the first priority. Moral injury occurs when a clinician’s ability to provide optimal patient care routinely conflicts with or is repeatedly frustrated by other factors (frequently today by the financial framework of medicine).9 This occurs to the extent that clinicians begin to question the moral framework of the system and their own moral framework for continuing to work within that system.
When clinicians are physically and emotionally exhausted with navigating and perhaps struggling in a challenging system in their efforts to provide good care, many of them reach a state of learned helplessness and some give up. They feel less effective and as though they cannot accomplish what they perceive should be possible with the diagnostic tools and treatment modalities at their disposal. When a clinician feels the challenges are futile, that individual must emotionally distance himself or herself, or depersonalize, to tolerate inescapable exposure to his or her patients’ suffering. Depersonalization, then, is a coping strategy to withstand an intolerable, inescapable situation. At this point, moral injury has reached an end stage of distress, and meets criteria for the constellation of nonspecific symptoms that describe burnout. But while “end stage” may imply an irreversible state, this condition is reparable with appropriately targeted interventions to address the structural and process-driven challenges clinicians encounter, which will allow them to be more effective.
Because burnout is nonspecific, the symptoms can derive from any number of situations, not just moral injury. However, conversations with clinicians suggest that moral injury contributes to a large proportion of what has been termed burnout.
Clinicians have navigated challenging educational paths, intense training, and demanding positions. They already have well-developed coping strategies such as mindfulness, resilience, and emotional freedom techniques. If the coping strategies of those highly adapted clinicians are overwhelmed, then the magnitude and intensity of the stressors they encounter require careful scrutiny.10 Constructing the framework of clinician distress as a continuum that begins with moral dilemma and progresses through moral distress, moral injury, and only rarely to burnout could offer an opportunity to develop more effective prevention strategies. The focus must shift to what will make a difference: eliminating unnecessary barriers that interfere with delivering good health care and recognizing the value of human experience and relationships—among clinicians, with patients, and with leadership.
The terms used to discuss clinician distress and to frame its progression are central to understanding the problem in its entirety. Limiting conversations and investigation only to the end stage of burnout precludes exploration of earlier stages of distress—moral dilemmas, moral distress, and moral injury—when mitigation strategies could be more effective. Only with language that is specific and clearly defined can the underlying drivers of distress and appropriate solutions be accurately identified. And only by understanding the progression of experience will it be possible to intervene early enough to make a meaningful difference.
Corresponding Author: Wendy Dean, MD, Moral Injury of Healthcare LLC, 1130 Creek Rd, Carlisle, PA 17015 (firstname.lastname@example.org).
Published Online: January 31, 2020. doi:10.1001/jama.2019.21576
Conflict of Interest Disclosure: Drs Dean and Talbot are cofounders of the nonprofit (501c3) Moral Injury of Healthcare Inc. The foundation receives fees and travel support for speaking engagements. No other disclosures were reported.
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Dean W, Talbot SG, Caplan A. Clarifying the Language of Clinician Distress. JAMA. Published online January 31, 2020. doi:10.1001/jama.2019.21576
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