Becker's Hospital Review

52 CMO / CARE DELIVERY Viewpoint: Physicians aren't burning out; they're suffering from 'moral injury' By Megan Knowles D espite widespread conversations on physicians experiencing burnout, ex- hausted providers oen face an un- recognized threat to their well-being — moral injury, Simon Talbot, MD, a reconstructive plastic surgeon at Boston-based Brigham and Women's Hospital, and Wendy Dean, MD, a psychiatrist and senior medical officer at the Henry M. Jackson Foundation for the Ad- vancement of Military Medicine, wrote in a STAT op-ed. Here are eight insights: 1. Moral injury is oen mischaracterized, portrayed as burnout among physicians, the authors wrote. "But without understanding the critical difference between burnout and moral injury, the wounds will never heal, and physicians and patients alike will con- tinue to suffer the consequences." 2. Burnout includes exhaustion, cynicism and decreased productivity — and over half of physicians report at least one of these symp- toms, the authors wrote. "But the concept of burnout resonates poorly with physicians: It suggests a failure of resourcefulness and resil- ience, traits that most physicians have finely honed during decades of intense training and demanding work," the authors wrote. 3. e authors called burnout a symptom of the nation's broken healthcare system. "e increasingly complex web of providers' highly conflicted allegiances — to patients, to self and to employers — and its attendant moral injury may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience," they argued. 4. "Moral injury" was first used to describe how soldiers responded to what they did during war, defined as "perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations,' the authors wrote. "e moral injury of healthcare is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the con- text of healthcare," the authors wrote. 5. Dr. Dean and Dr. Talbot discussed how most physicians choose medicine by fol- lowing a calling, entering the field with a desire to help people while facing lost sleep, lost years of young adulthood, financial in- stability and disregard for personal health. "Each hurdle offers a lesson in endurance in the service of one's goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one's patients," the authors wrote. "Failing to con- sistently meet patients' needs has a profound impact on physician well-being — this is the crux of consequent moral injury." 6. As the healthcare environment becomes in- creasingly business-oriented, physicians must consider various factors outside their patients' best interests when making treatment deci- sions, the authors wrote. Financial consider- ations of hospitals, insurers and patients, for example, oen lead to conflicts of interest. EHRs also overwhelm busy physicians with tasks outside of having high quality face-to- face interactions with their patients. "Navigating an ethical path among such intensely competing drivers is emotion- ally and morally exhausting," the authors wrote. "Continually being caught between the Hippocratic oath, a decade of training and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand." 7. Healthcare executives must recognize and acknowledge this is not an instance of physician burnout to ensure compassionate, engaged physicians are leading patient care, Dr. Talbot and Dr. Dean said. "Physicians are the canaries in the healthcare coalmine, and they are killing themselves at alarm- ing rates (twice that of active-duty military members) signaling something is desperate- ly wrong with the system," they wrote. 8. Leadership must be willing to acknowl- edge the human costs and moral injury of the competing allegiances physicians face, and then minimize those competing de- mands, the authors argued. "A truly free market of insurers and pro- viders, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care," the authors write. "These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of healthcare." n Johns Hopkins creates opioid guidelines for 20 common surgeries By Harrison Cook A panel of healthcare provid- ers and patients from Balti- more-based Johns Hopkins Medicine developed the country's first set of opioid prescription guide- lines for 20 common surgeries. The researchers outlined their pro- cess for creating the guidelines in a study published Aug. 14 in the Jour- nal of the American College of Sur- geons. The panel included 30 health- care professionals from the Johns Hopkins Health System, including surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists. The procedures included a combi- nation of invasive and noninvasive surgeries across eight specialties, in- cluding thoracic, orthopedic and car- diac surgery. The panel recommends patients use over-the-counter-painkillers before asking their physicians for opioids. When opioids are necessary, the pan- el recommends physicians prescribe one to 15 opioids tablets for 11 of the 20 procedures, 16 to 20 tables for six of the 20 procedures and zero tablets for three of the 20 procedures. "Prescriptions for pain meds after surgery should be custom tailored to the operation and a patient's needs and goals, but the hope is that these guidelines will help reset 'defaults' that have been dangerously high for too long," lead author Martin Makary, MD, professor of surgery and health policy expert at Baltimore based- Johns Hopkins University School of Medicine, said in a press release. n

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