What COVID-19 reveals about physician moral injury

The figurative ills of the nation are made manifest in our health care. COVID-19 has laid bare the fractures and injustices in the systems that serve people at their most vulnerable. It reveals that the financial framework of care depends inordinately on elective procedures and that a splintered, privatized health care system fares poorly when coordination is paramount.

Our collective failure to invest in public health and preparedness means the nation, as a whole, is unprepared for the coronavirus crisis. Everyone is at risk. But it exacts the highest tolls in places and populations already challenged by scarce resources and least able to protect themselves by isolating — low-income areas, those chronically underserved with social services and health care, and communities of color. For too many, these challenges overlap and compound one another.

Physicians watched the first wave approach, helpless to stop the devastation they read about in China and Italy. They were angry that the disparities and skewed priorities they had known and fought against for decades were putting individual patients and populations they care deeply about in serious danger. They are watching, helpless again, as the country opens up and unmasks, failing to heed the dire warnings sent mere weeks ago from overwhelmed hospitals in New York City, New Jersey and Seattle.

COVID-19 hit health care systems already in crisis. Nearly half of clinicians in the U.S. reported at least one symptom of distress last year. Trust had eroded between health care staff and organizations as financial constraints cut staffing, supplies and space to the bone; staff members were micromanaged and hypermonitored to drive optimum efficiency; and leadership offered tea carts, lunchtime yoga and mindfulness meditation as reparation.

Those offerings, though well intentioned, were often perceived as either performative or patronizing. The pandemic is highlighting the vulnerabilities in health care organizations, increasing tension with staff and sometimes devolving into painfully public breaks in decorum.

Resource constraints also foist unimaginable choices onto clinicians: How are scarce resources such as ICU beds or ventilators allocated? Such discussions are anathema to U.S. health care, and clinicians, therefore, are not well-versed in applying the principles. Most are not psychologically prepared to engage in those ethically charged decisions. Physicians are left taking responsibility for those exquisitely painful decisions alone.

At the same time, tens of thousands of physicians were sidelined as elective procedures shut down. Those clinicians struggled with what one called an identity crisis. How could their exceptional care, the dramatic improvements in quality of life they offered patients, be so readily abandoned? They struggled with the prospect of closing long-standing practices, furloughing staff and coping with personal financial devastation. The deep irony of health care workers facing job insecurity in the midst of a pandemic was not lost on them.

The language of clinician distress has shifted in recent years from burnout to moral injury, as clinicians have adopted a framework that better expresses their experience. Jonathan Shay, M.D., Ph.D., in his book “Achilles in Vietnam,” defines moral injury as a “betrayal of what’s right, by a person who holds legitimate authority in a high-stakes situation.” Shay’s definition applies to soldiers in combat, but the COVID-19 crisis neatly fits that definition and has propelled the adoption of the term, as evidenced by the crude metric of Google alerts. Those alerts have gone from an average of one or two articles several times a week to three to five articles nearly every day during the pandemic. Clearly, the concept of moral injury resonates in the context of COVID-19.

Clinicians are bombarded with daily evidence of brazen betrayal at every level — local, state and federal. Hospitals failed to heed warnings about the massive need for personal protective equipment (PPE). When those predictions came true and stores ran low, safety standards quickly shifted from optimum to minimum, and federal guidelines supported the shift. Clinicians wade into the breach without sufficient protection, even as their pay is cut, their protests gagged and their employment threatened and as they watch their colleagues and friends fall ill. No longer is there a question about the harm done to clinicians, patients and the nation at large by the financial framework of health care. The evidence is everywhere.

Now, in the wake of the response to the coronavirus’s proverbial shot across the bow, physicians are reckoning with all they have observed and experienced, personally or vicariously. They see what the virus can do firsthand, read the accounts or talk to doctor friends in epicenters. If they have not seen it yet, they know it is only a matter of time before they do. They are doing the hard work of integrating the risk posed by this virus with the cavalier disregard exhibited by too much of the public and too many public figures — yet more betrayal and moral injury on top of that already perpetrated.

They are struggling with a litany of losses — patients, colleagues, personal safety, job security — and the prospect that this may be just the beginning of a brutally long campaign. Ideally, this is an opportunity for leadership to recommit to doing the right things for staff and patients: ensuring enough PPE, providing professional support for psychological recovery, working together to address operational challenges and easing up on those who are in the thick of COVID-19 care. But, at the very least, most clinicians would happily trade hero worship for universal masking in public until this is truly over.

Wendy Dean, M.D., is a psychiatrist and the president and co-founder of Moral Injury of Healthcare.