In addition to the medical risks of COVID-19, the pandemic’s occupational hazards are numerous for health care workers. The threat of walking into the clinic or hospital and being exposed to the increasingly contagious novel coronavirus is a now-familiar reality for the many physicians caring for patients. It is astounding to think about these surreal conditions as the pandemic approaches its one-year mark. As doctors, we have met this new clinical situation with the same idealism and standard of care as we have any other clinical duty placed before us—our path forward led by the ethic to “first do no harm”.
In the health care systems in which we practice, our patients’ health can often come before our own. This is a dynamic of selflessness and heroism that has carried on throughout the history of medicine as a field. The obligations physicians face are both explicit and implicit. The learning we complete in medical school prepares us for clinical care, years of studying medical knowledge that dictates our treatment of patients. But there is a cultural learning that underlies the formal knowledge of caring for our patients—the hidden curriculum of doctoring that also affects the care we provide for patients. In the setting of COVID, moral injury represents a threat to the way doctors deliver care and is a hazard, not only to physicians’ health but also to their patients.
Moral injury can occur when “clinicians are … expected, in the course of providing care, to make choices that transgress their longstanding, deeply held commitment to healing.” We are all susceptible to this type of emotional transgression when we violate our values or personal code of ethics as individuals—almost a psychological conflict of interest. Bearing witness to death and disability has an impact on a person’s psyche that challenges our innate nature to protect one another. Day after day of internalizing grief and suffering can lead to disconnection from one’s sense of self-efficacy, ability to care for others, and can impact our feelings of belonging, meaning, and even competence. In a fragmented health care system, under the strain of a months-long pandemic, moral injury is a reality that many clinicians face. Burnout and moral injury are related phenomena. While moral injury is not a DSM-5 diagnosable illness, it is a concept that can be helpful to better understand the psychological plight of health care workers today.
Physicians around the world have been required to make health care decisions that threaten their value system and potentially undermine their oath to patients and themselves. Decisions have been made about the use of resources to treat populations — but also on the very individual level of triage decisions and visitation with dying family members. Additionally, the policy limitations and potentially lack of adequate resources (not only PPE, ventilators, and ICU beds, but also unavailability to treat patients with medical issues unrelated to COVID and our own fears of becoming infected) can lead to doctors’ care falling short of their ideals. These changes can be unsettling and represent a mental and emotional challenge.
In July 2020, the American Psychiatric Association released guidance for dealing with moral injury among health care workers caring for patients during COVID. This document provides health care leadership and administrators tools to combat and intervene when encountering moral injury. There is data that identifies burnout as a factor associated with adverse health outcomes. Additionally, recent research suggests that burnout is related to increased unconscious bias, among resident trainees, potentially leading to disparate care of our patients who are from racial and ethnic minorities. Medical errors are costly in terms of patient morbidity and mortality and in terms of health care dollars. Our ability as doctors to identify burnout and mental health challenges, and to have support to seek appropriate treatment, is imperative to our patients’ health. The long-used cliché compares caring for one’s self by putting on our own oxygen masks on airplanes before putting on a child’s mask. The difficulty with this perspective and this emphasis on self-care puts the onus on doctors to prioritize themselves, when historically the medical care system has devalued physicians’ senses of well-being.
In order to affect real change, the identification of moral injury and burnout must be supported by cultural shifts— by actionable steps. The APA document describes: promoting discussion about moral injury and educating physicians, supporting decision-making, teamwork and cohesion as potential steps to decrease risk of moral injury. Health care administrators and leaders can create spaces for education and dialogue related to concepts of moral injury, well-being, and burnout prevention. The COVID crisis offers health care leaders an opportunity to support physicians by being pro-active about the risks of moral injury and burnout.
Brennin Brown is a psychiatry resident. Susan Hatters Friedman is a reproductive and forensic psychiatrist.
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