Tackling Physician Burnout and Moral Injury

But why do some physicians develop burnout, moral injury and long-term mental health conditions, while others don’t? Why is America losing a doctor every day to suicide? And what can be done about it?

The health care system surrounding today’s clinicians encompasses much more than just providing care. Clinical work is part of a much larger picture that often includes electronic medical record management, office and insurance paperwork, highly complex regulatory requirements, satisfaction reviews, quality improvement and cost reduction responsibilities, continuing education, and multidisciplinary collaboration for complex patients. Clinicians are asked to accomplish more and more, often with no extra time or resources provided.

“Clinicians are increasingly torn by competing priorities, and they report they are constantly making trade-off decisions: having to choose between getting their administrative duties completed and providing more or better patient care,” says Brandon Kozar, PsyD, MBA, director of leadership coaching and development at Nationwide Children’s Hospital. “These are individuals who are in medicine because they want to help people, so this constant battle is demoralizing, guilt-inducing and makes them feel they aren’t in control of their professional lives. They lose the joy of practicing medicine.”

Resourcefulness and hard work cannot solve this dilemma, and their resiliency plummets. Over time, clinicians who feel that these forced trade-offs infringe on their ethical duties — that they are unable to uphold their entrenched moral desire to put patients’ wellbeing first — experience “moral injury,” a significant predictor of other serious mental health concerns, such as clinical depression, substance abuse, anxiety and suicidal ideation.

Burnout — a more common phenomenon, where emotional and physical exhaustion result from constant exposure to stressors and a decreased ability to cope with daily duties — and moral injury have important implications beyond the wellbeing of the affected individual clinicians. These problems may negatively impact patient care and outcomes. When doctors are exhausted mentally, emotionally and physically, they cannot provide optimal care. They become more likely to make mistakes. Substance abuse, sleep deprivation, anger control issues, relationship troubles and other problems arise, further increasing the risk to physicians and their patients.

Unfortunately, physicians and other health care workers often feel they have nowhere to turn for relief.

Historically, clinicians have been known for a dogged commitment to their patients and their work, often at their own expense. Acknowledging emotions and troubles, admitting to being overwhelmed, and seeking help have been tantamount to inadequacy or unprofessionalism, and thus have carried a stigma.

Even in recent years, clinicians with depression or substance use disorders have faced loss of licensure, increased supervision, restriction of hospital privileges, and loss of privacy — making admission of difficulties a potential threat to their livelihood and status. And in part because of the profession’s reticence on the idea of mental health concerns affecting their own, suicide among physicians is believed to be underreported by pathologists trying to protect their deceased colleagues’ reputations.

To further complicate matters, many hospital program and department leaders are clinicians themselves, rather than business experts trained in human resource management and administrative processes. Running a business unit with significant fiduciary, regulatory and supervisory responsibilities may come naturally to some clinical directors, but others struggle to create environments that both support morale and enable engaged productivity. Emotional intelligence — the ability to recognize and empathetically respond to the emotions of the people around you — is perhaps under-appreciated in the selection of leadership, and clinicians and other staff pay the price.

“Some departments have greater rates of burnout and poor mental health than others, and the differences are not best predicted by workload,” says Dr. Kozar, referencing literature on emotional intelligence and clinical staff performance. “Instead, just the perception of being socially supported by peers, superiors or the organization dramatically influences how health care providers cope. Positive and supportive work environments that foster a sense of support and collegiality result in more productive work, more accurate differential diagnoses and less burnout.”

This goes beyond creating a feel-good culture to fostering an environment that systematically embraces a genuine concern for clinicians and other employees both in the adoption of workplace expectations and in the everyday manner of interpersonal interactions.

There is no cut-and-dry solution to the problem of overwhelmed and under-supported physicians. But that has not stopped many institutions from trying to take an active step toward identifying burnout and distress, helping physicians in need, and preventing the problem in the first place.

At Nationwide Children’s, for instance, Dr. Kozar’s existence on staff is a primary example of the hospital’s intentional decision to protect its people. His role was created partly in response to the hospital’s Zero Hero program, designed to eliminate preventable harm, such as overtired staff and emotionally depleted clinicians. In addition, it was an attempt to formalize programs and a cultural shift toward de-stigmatizing mental health concerns, supporting employees and equipping them with resources and outlets to address their needs.

Dr. Kozar directs the hospital’s YOU Matter program, which offers emotional and mental health support to both clinical and non-clinical staff faced with work-related and potentially traumatic stressors, such as a patient death. The program has several components, including a peer support initiative, a critical response team, on-site Master’s-level clinical counselors exclusively for staff (focused in high-acuity settings such as the emergency department and intensive care units), and hospital rounds focused on discussing psychosocial impacts of participants’ work. In addition, hospital employees are eligible for confidential counseling sessions at no cost.

“It might be due to the increasing visibility of mental health needs in society at large, but I think clinicians are becoming more accepting of the need to speak up and speak out about salient issues of burnout,” says Dr. Kozar. “The trick is to avoid framing all stress as evil. Stress actually can have many benefits both professionally and personally, and it isn’t realistic to totally eliminate it. Distress, however, is overwhelming and negative and needs to be reduced.”

Further efforts at Nationwide Children’s have included the implementation of business coaching for clinical department leaders to help them run better-organized programs and alleviate burnout. Stress management training for staff — in which the distinction between good and bad stress is emphasized — also reinforces the hospital’s culture of confronting the issue and treating each other with compassion. Staff trained as peer support personnel are taught to pay attention to the work experiences of their colleagues and to reach out to others on a regular basis.

“Human beings are social creatures — we do better when we work and operate in an environment where we are cared for,” says Dr. Kozar. “Instead of an environment where there’s nothing but a time crunched, task-oriented day where clinicians are drawn in every direction with no time to look out for each other, we’re focusing on building deliberate and strategic social support systems that can cultivate resiliency.”

The widespread problems of burnout and moral injury will not disappear overnight, but Dr. Kozar is confident that personal and institutional steps to counteract these problems can equip clinicians with the support and competencies they need in order to maintain resilience and protect their psyches.

“These are high-performing individuals,” Dr. Kozar says. “When you teach them to do something, they can implement it very effectively. You just have to make sure that you’re not training them to quash problems in one area only for them to pop up in another. The approach has to be comprehensive, which means it’s oriented at the institution’s programs and personal resiliency, not just workload.”

As many as a dozen hospitals per year come to Nationwide Children’s to learn about and implement programs similar to those managed by Dr. Kozar.