What COVID-19 reveals about physician moral injury

The figurative ills of the nation are made manifest in our health care. COVID-19 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.

Wendy Dean, MD

Physicians watched the first wave approach, helpless to stop the devastation they read about in China and Italy. They were angry at the disparities and skewed priorities they have known and fought against for decades that put individual patients, and populations those clinicians 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 healthcare systems already in crisis. Nearly half of clinicians in the US 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 were micromanaged and hyper-monitored to drive optimum efficiency, and leadership offered tea carts, lunchtime yoga and mindfulness meditation as reparatives.

Those offerings, though well intentioned, were often perceived as either performative or patronizing. The pandemic is highlighting the vulnerabilities in healthcare 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 US healthcare, 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 personal financial devastation. The deep irony of healthcare 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 new framework that better expresses their experience. Jonathan Shay, 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 applied 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 went from an average of one or two articles several times each week, to 3-5 articles, nearly every day during the pandemic. Clearly, the concept of moral injury resonated in the context of COVID.

In fact, 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 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, 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, to patients, and to the nation at large by the financial framework of healthcare. 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 seen 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 were in the thick of COVID 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, MD, is a psychiatrist and president and co-founder of Moral Injury of Healthcare.