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Viewpoint
January 31, 2020

Clarifying the Language of Clinician Distress

Author Affiliations
  • 1Moral Injury of Healthcare LLC, Carlisle, Pennsylvania
  • 2Brigham and Women’s Hospital, Boston, Massachusetts
  • 3NYU Grossman School of Medicine, New York, New York
JAMA. Published online January 31, 2020. doi:10.1001/jama.2019.21576

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.

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Article Information

Corresponding Author: Wendy Dean, MD, Moral Injury of Healthcare LLC, 1130 Creek Rd, Carlisle, PA 17015 (wendykdean@gmail.com).

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.

References
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Schuster  DG.  Neurasthenia and a modernizing America.  JAMA. 2003;290(17):2327-2328. doi:10.1001/jama.290.17.2327PubMedGoogle ScholarCrossref
2.
World Health Organization. ICD-11: implementation or transition guide. Geneva, Switzerland: World Health Organization; 2019. https://icd.who.int/docs/ICD-11%20Implementation%20or%20Transition%20Guide_v105.pdf. Accessed November 18, 2019.
3.
Rotenstein  LS, Torre  M, Ramos  MA,  et al.  Prevalence of burnout among physicians: a systematic review.  JAMA. 2018;320(11):1131-1150. doi:10.1001/jama.2018.12777PubMedGoogle ScholarCrossref
4.
Schwenk  TL, Gold  KJ.  Physician burnout: a serious symptom, but of what?  JAMA. 2018;320(11):1109-1110. doi:10.1001/jama.2018.11703PubMedGoogle ScholarCrossref
5.
National Academies of Sciences, Engineering, and Medicine.  Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: National Academies Press;2019.
6.
Kvalnes  Ø.  Moral Reasoning at Work: Rethinking Ethics in Organizations. 2nd ed. Oslo, Norway: Palgrave MacMillan; 2019. doi:10.1007/978-3-030-15191-1
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Epstein  EG, Hamric  AB.  Moral distress, moral residue, and the crescendo effect.  J Clin Ethics. 2009;20(4):330-342.PubMedGoogle Scholar
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.2009.07.003PubMedGoogle ScholarCrossref
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Dean  W, Talbot  S, Dean  A.  Reframing clinician distress: moral injury not burnout.  Fed Pract. 2019;36(9):400-402.PubMedGoogle Scholar
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Talbot  SG, Dean  W. Physicians aren’t “burning out:” they’re suffering from moral injury. STATNews. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Published July 26, 2018. Accessed November 27, 2019.
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    6 Comments for this article
    EXPAND ALL
    Do Not Obfuscate Burnout
    Edward Volpintesta, MD | Private Physician
    I respect the author’s taxonomic talents, but subdividing burnout into four categories -- moral dilemma, moral distress, moral residue, and moral injury -- risks confusing more than clarifying what doctors understand when they complain about burnout.

    We would do well to concentrate on what has been identified as the most important “pain point” in physician burnout in a recent study: the distraction and fatigue caused by the intrusion of electronic records into health care (1), which so far add little to patient care and can actually lead to medical error.

    Stratifying burnout into different categories is interesting but
    let’s not confuse lawmakers and policymakers. 
    They must understand clearly without any qualification at all that electronic medical records are the prime cause of burnout among doctors—and that that is where their efforts must be directed.

    Reference

    1. Hawkins M. 2018. Survey of America’s Physicians: Practice Patterns and Perspectives. 2018
    CONFLICT OF INTEREST: None Reported
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    Absurd
    Victor Ettinger, MD, MBA | Retired Physician - Endocrinology
    Burnout is NOT a moral dilemma; it is a socio-financial burden on the ability to practice medicine in the best possible way for optimum outcomes as the available knowledge base allows. Making a decision to discontinue care, to operate or not, to treat or not is a medical decision, not a moral one. If a physician is unsure of what the 'right' choice of care is then they (in the singular, using current terminology) should turn over the patient's care to someone who can choose wisely for the best outcome whether it is death or amputation or whatever else may be available. If we start floundering in what is the morality of the decision, we will never accomplish anything and healthcare delivery will become more debased than the health plans, insurers and governments have already made it.
    CONFLICT OF INTEREST: None Reported
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    Focus on the Root Causes of Burnout to Pursue Effective Interventions
    Paul De Chant, MD, MBA | Management Consultant
    While I respectfully disagree with the basic premise of this Viewpoint from Drs. Dean, Talbot, and Caplan, I strongly agree with one sentence in the next to the last paragraph: “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.”

    Attempting to differentiate between moral dilemmas, moral distress, and moral injury risks misses the most significant opportunities to reduce burnout.

    According to Maslach, “Burnout is a sign of a major dysfunction within
    an organization and says more about the workplace than it does about the employees.”

    The drivers of burnout are work overload, lack of control, insufficient reward, breakdown of community, absence of fairness, and conflicting values.

    Exhaustion is closely related to work overload, which is a result of the chaotic, time pressured clinical work environment with poorly designed workflows exacerbated by insurance and regulatory requirements to enter data into the EHR, which is so poorly designed that physicians spend two hours documenting for every hour of direct patient care.

    Depersonalization is closely related to the other five drivers, which result from a dysfunctional management system and culture that does not recognize physicians for the highly competent knowledge workers that they are, instead treating them more like production line workers in a factory.

    The stakeholders who have the greatest opportunity to improve both clinical workflows and the management system and culture are the health system executives who control budgets and operations. Making a significant impact on burnout requires their active engagement in efforts to reduce the drivers of burnout. There is significant opportunity for greater leadership engagement in most provider organizations.

    Moral challenges are inherent in patient care and are increasing as societal changes such as income inequality and gun violence increase. They deserve proper attention but should not distract from the significant opportunities to fix the root cause drivers of physician burnout – poorly designed clinical workflows and dysfunctional management cultures.
    CONFLICT OF INTEREST: None Reported
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    The Road To Burnout Is Paved With Moral Injury
    Peter Shah, MB ChB MA FRCOphth FRCPEd | University Hospitals Birmingham NHS Foundation Trust
    Language enables us to access the real worlds we inhabit on a daily basis, and describe our experiences to others. As such, the language of 'moral injury' is going to become increasingly important. With any injury, we have the ability to intervene and enhance self-healing in the early stages, before chronicity and irreversible structural and functional changes occur. Failure to address the unmet need of help for clinicians with moral injury will have serious consequences for clinicians, the communities we serve and society.
    CONFLICT OF INTEREST: None Reported
    Burnout is Wider Than Moral Injury
    Steve Iliffe, FRCGP, FRCP; Jill Manthorpe | Emeritus Professor of Primary Care for Older People, University College London (Iliffe); Professor of Social Work, Director of the NIHR Health & Social Care Workforce Research Unit, King's Col
    We agree with Dean and colleagues (1) that clarification of the language of clinician distress is necessary, but framing distress in terms of a moral spectrum, from dilemma to injury, has provoked dissenting voices in both the US and the UK (2). Moral distress – an experience of cognitive-emotional dissonance arising from acting contrary to moral requirements - is a common feature of the clinical landscape (3), but moral injury and burnout are not the same. Burnout can be seen as a consequence of demand exceeding supply, poorly designed clinical workflows and dysfunctional management cultures; it a feature of a dysfunctional system that tells us more about the workplace than about individuals.

    Burnout is a non-specific idea (1), but so is morality, which has its own influential critics (4). When we use the word ‘moral’ we may mean knowing right from wrong, manifesting high principles, learning from experience and espousing standards of behaviour. Compromising any of these meanings is not the same as experiencing depersonalisation or having profound doubts about the worth of one’s clinical work, as with burn-out, although as Dean and colleagues point out (1), moral injury can lead to burnout. The difference in view may become clearer if we consider that morality has nothing to say about what ought to be done, but concerns only how we decide what ought to be done (5). What is moral to some is not to others. In a homogeneous profession or mono-cultural society morality may be widely shared but even then there will be dissenters in private if not in public. Few professionals have as great an input on ethics as the medical profession. If clinicians become muddled in their decision-making about what is to be done in the situation they are in, as distinct from the one that they would like to be in, they are likely to be harmed.

    We argue that there is an emerging educational and research agenda; clinicians may wish to engage with the moral distress or dilemmas perceived by patients and caregivers and seek to establish what is meaningful support or empathy in changing times. While for some patients and caregivers this may relate to single decisions, for others there is repeated potential distress or kaleidoscopes of complexity. Pre- but especially post- qualifying education may offer educationalists and researchers opportunities to listen to clinicians and then help build up skills and foster workplace support.

    Steve Iliffe, Emeritus Professor of Primary Care for Older People, University College London, s.iliffe@ucl.ac.uk

    Jill Manthorpe, Professor of Social Work, Director of the NIHR Health & Social Care Workforce Research Unit, King's College London jill.manthorpe@kcl.ac.uk

    REFERENCES
    1) Dean W, Talbot SG, Caplan A Clarifying the language of clinician distress JAMA January 31st 2020 doi: 10.1001/jama.2019.21576

    2) Parker J Moral injury and burnout are not the same BMJ 2019 https://blogs.bmj.com/bmj/2019/06/06/joshua-parker-moral-injury-and-burnout-are-not-the-same/

    3) Berger JT Moral distress in medical education and training J Gen Int Med 2013; 29(2):395-8

    4) Leiter, Brian, Morality Critics. The Oxford Handbook of Continental Philosophy, B. Leiter & M. Rosen, eds., Oxford University Press, 2007; U of Texas Law, Public Law Research Paper No. 114. Available at SSRN: https://ssrn.com/abstract=952771

    5) King M Clarifying the Foucault-Habermas debate Philosophy & Social Criticism 2009;35(3): 291
    CONFLICT OF INTEREST: None Reported
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    Please Do Not Redefine the Obvious
    Kamal Kishore, MD, MBBS | Illinois Retina and Eye Associates, Peoria, IL
    Physician burnout is real, affecting about half of US physicians according to a recent Medscape survey. The dimensions of burnout, emotional exhaustion, depersonalization and lack of personal accomplishment have already been defined by Christina Maslach in 1981. Authors' attempt to redefine it into moral dilemmas, moral distress, moral injury and moral residue are flawed and unnecessary.

    Emotional exhaustion is brought upon by long work hours, complexity of patients, needless regulations including demands for preauthorization, chart audits, coding and billing related addendums, and unnecessary clicks to satisfy MIPS requirements, and not due to moral dilemmas. Every doctor is doing
    the best she or he can for a patient and physicians are able to obtain a second opinion or treatment guidance from experts when they need it. There are no new moral issues now compared to what we faced two decades ago. But burnout is a relatively new phenomenon.

    Depersonalization is the result of falling reimbursements and constant pressure from administration to
    "process" more and more patients with fewer and fewer staff using highly inefficient EHR systems with endless clicks to find any useful information and, not to forget, constantly flooded email inboxes from a variety of sources-coders, managers, liaisons, colleagues, labs, and patients, forcing a doctor to continue to work long after his or her already long day of work in the face of immediate retribution from managers, and, in this age of social media, from patients being crushed between the grindstones of "doctor didn't spend enough time, was short and rude" and "I waited too long."

    Similar factors and not morals issues are responsible for high burnout rates in American nurses (1)

    Reference

    1. https://www.mededwebs.com/blog/well-being-index/how-will-nurse-burnout-affect-the-medical-industry-in-2018
    CONFLICT OF INTEREST: None Reported
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