Is this physician experiencing burnout or something else?

A 35-year-old intensivist feels powerless and guilt-ridden. At times, her senses are heightened, and at other times, she feels numb. Sometimes when she is speaking with patients’ family members, she feels like she is no longer present in her body.  She currently has a patient who is dying of liver failure, and despite multiple phone calls advocating for transfer, and a direct conversation with the transplant hepatologist, the patient is not going to receive a liver transplant because of an elevated BMI. The intensivist assumes that she is experiencing burnout – it has been a rough stretch of days, on top of a challenging year. Looking forward to her day off tomorrow, she does not speak with her colleagues about these feelings.

What words best describe her experience?

A. Moral distress
B. Burnout
C. Moral injury
D. Compassion fatigue

Answer: A&C 

This intensivist is suffering as a result of her emotionally charged, heavy, and at times, disturbing work. She is not facing a moral dilemma as the decision is out of her control. She is experiencing an erosion of her moral integrity: believing the system is broken and being unable to change it leads to moral distress, while continuing to care for the patient as she continues to decompensate leads to moral injury. Moral distress emerges when one’s ability to act morally is constrained by external factors like hospital policy, administration, and legal confines, and one’s feelings are heightened by internal factors like powerlessness, threatened values and thwarted moral actions (Čartolovni et al.). Moral distress causes psychological disturbances, including self-blame, self-criticism, and guilt (Čartolovni et al.). Moral injury describes the harm suffered when someone witnesses or participates in events that contradict their ethical beliefs. Moral injury is a “deep emotional wound unique to those who bear witness to human suffering” (Čartolovni et al.).

In contrast, burnout and compassion fatigue are the result of compounding experiences in the workplace over time. Burnout is a syndrome of “emotional exhaustion, depersonalization, and diminished personal achievement” that is caused by chronic workplace stress (Epstein et al.).  It is defined by some in medicine as a part of a continuum of clinician distress and is criticized by others for suggesting that the problem lies within the individual rather than in a broken system (Dean et al.). Compassion fatigue is a state of exhaustion caused by prolonged exposure to people who are suffering. Ongoing empathy with the pain and suffering of others can eventually lead to a diminished capacity to show compassion or empathy.  Burnout may be best addressed by focusing on changes in the workplace environment, such as reducing workload or improving job resources.  The focus in addressing compassion fatigue is often on developing self-care practices or seeking support from colleagues or therapists.

Bottom line, recognizing the variety of personal consequences of working as a medical provider is an important step in both caring and advocating for yourself in your workplace. Acknowledging symptoms of burnout and compassion fatigue may allow you to take a step back from your day to day work and reorient yourself to what brings you fulfillment. Naming the more specific experiences of moral distress and moral injury may provide the impetus to change the current work culture and status quo.  While medical care is rife with moral dilemmas, our places of work should ideally facilitate medical decision making that does not erode our own morality.

References

Čartolovni, Anto, et al. “Moral Injury in Healthcare Professionals: A Scoping Review and Discussion.” Nursing Ethics, vol. 28, no. 5, Aug. 2021, pp. 590–602. DOI.org (Crossref), https://doi.org/10.1177/0969733020966776.

Dean, Wendy, et al. “Clarifying the Language of Clinician Distress.” JAMA, vol. 323, no. 10, Mar. 2020, p. 923. DOI.org (Crossref), https://doi.org/10.1001/jama.2019.21576.

Epstein, Elizabeth G., et al. “Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community.” AACN Advanced Critical Care, vol. 31, no. 2, June 2020, pp. 146–57. DOI.org (Crossref), https://doi.org/10.4037/aacnacc2020285.

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