My new normal moral injury

Whatever we call it—burnout, moral injury, disillusionment, work fatigue, hopelessness—these did not appear to apply to me before the COVID-19 pandemic. I tried to keep up on discussions about how moral injury is a pervasive and destructive force leading health care workers to feel helpless, leave medicine, or, at worst, become suicidal. I tried to educate myself about the forces behind moral injury, such as lack of control of work, unnecessary bureaucracy, and other controlling factors limiting our ability to effectively do our jobs. Being a younger attending, I wanted to learn more about these issues so I could try to avoid becoming a victim of medicine’s dark side. Also, being in a dual-physician family with young children was always challenging, but it came with a sense of purpose and satisfaction that if I worked hard to find a balance between work and family, I could live a dream life that was shielded from moral injury. Things were going well in this regard. Then the COVID-19 pandemic hit.

As I walked through the inpatient units lined with many sick patients infected with the novel coronavirus at the peak of the pandemic in the Spring of 2020 in New York, I expected to find chaos and general unease. What surprised me most was the camaraderie, teamwork, and determination of all the staff involved in caring for these patients. Death was something shared acutely and simultaneously across the health care system. These moments of hope in a sea of despair were uplifting, and it is the victims of COVID-19 that are on my mind more than anything. Nevertheless, I know that one of the several predisposing factors for moral injury is lack of work-life integration and stress. Even on my worst days at work, before the pandemic I at least knew my kids were being taken care of in school, my spouse was able to do her work without fear of infection, and if my kids needed to stay home, we had backup plans.

COVID-19 obliterated these loosely structured foundations. Who would help take care of our kids if both parents became ill? Can we both work on COVID floors and risk bringing home the virus? Can we risk inviting backup childcare into our house? How the heck do to upload my child’s preschool drawings onto the school’s virtual platform while I finish my charting at home? These personal and professional frustrations that were not an issue in my pre-COVID world order were now erupting without warning and with no solution in sight. With the new school year on the horizon, many parents like me are having to make difficult decisions and weighing our children’s wellbeing with the obligation to work. For now, there do not appear to be any ideal solutions.

As our office begins to return to pre-COVID operations, it has been uplifting to have a relative sense of normalcy, even though morale seems to be reduced. It is difficult to promote team building and improve morale when everyone has to maintain social distancing. I would love to go out for a meal with my staff, hug my patients, and lecture our trainees face-to-face in a classroom. While the hope is that all of these distancing measures are temporary, avoiding despair is another layer added onto an already heightened level of stress. I think all of us in medicine who have survived the pandemic thus far are grateful, even as we mourn the tremendous loss of life. There are signs that we can overcome this new normal moral injury involving fear, stress, and work-life imbalance. Several things that were burdensome pre-COVID such as licensing regulations, charting requirements, being unable to do telemedicine, for example, all were revised in some positive way as a result of the pandemic. In the same way that protests for social justice are rising, so are voices in medicine that will hopefully use this time of uncertainty to potentially change and improve health care systems. As we continually provide hope to our patients, perhaps there is hope for our profession to improve when we come out of this challenging time.

Marc Braunstein is a hematology-oncology physician and can be reached on Twitter @docbraunstein.

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