Moral injury in medical school

I’ve been searching for a way to describe my experience as a third-year medical student until recently, when I stumbled upon two new terms: moral injury and emotional labor. Moral injury is a phrase coined to describe an insult to a person’s moral conscience or values. It happens as a result of actions that transgress his or her “deeply held moral beliefs and expectations.” It was originally used to describe the effects of war on combat veterans but has recently been applied to health care workers. When these transgressions happen, they can produce a wide range of emotions like guilt, shame, sadness, betrayal, or anger.

Emotional labor refers to the “enhancing, faking, or suppressing emotions” to fulfill the requirements of a job or situation. Translation: Looking calm while you’re anxiously awaiting getting pimped by an attending, keeping a smile on your face after getting yelled at by residents, or the cumulative emotional toll of always being “on” throughout rotations. Maybe these two phrases combined are why I feel so tired all of the time.

Moral injury is the term for that feeling I’ve had on so many occasions throughout my rotations when I wished a patient received better treatment and when I felt powerless to do anything about it. It’s the anger that I felt when an attending told me the best way to “deal” with our patient was to remove his diet orders; a manipulative move to get a “difficult” patient to leave the hospital. It’s the stomachache I got when a resident labeled our patient as malingering, when maybe a little more patience, communication, and open-mindedness would have found a better answer for the unusual symptoms he complained of. It’s the sadness, anger, and resentment I feel every time I hear, “I like it better when the patient is asleep because then you don’t have to talk to them.”

I think we all signed up for this job to be healers, to help people, but something got lost along the way. In the first and second year of medical school, we spend a lot of time talking about treating the “whole patient,” about empathy, and about the human side of medicine. Now in the third year, I feel like we’re encouraged to quickly adopt a new reality: the dehumanization of medicine. We check boxes, treat lab values, and objectify patients instead of learning how to effectively communicate with them. Maybe a better term for this is “moral whiplash.”

These experiences all have an emotional toll. Every time I try to treat my patient from a place of empathy and compassion, only to be made to feel bad or embarrassed about it. (“You’re being too nice.” ”This guy is a waste of our time.” “You’ll learn that patients like this can’t be helped.”) I feel a tiny piece of my morality, my soul, fracture, splinter off, and fall away. I wonder if these residents were like me once, full of optimism to make human connections and help people. I wonder if this is what happens to a person after repetitive moral injury? Am I destined to end up like this, jaded and cynical? Questions like these are constantly playing in my head, along with, “Did I make the wrong choice going into medicine?” and, “Should I continue to go down this road?”

This is where the emotional labor comes in. Being constantly subjected to the inhumanities and indignities of medicine while keeping a good attitude and smile on my face is exhausting. Add on the expectation to be constantly studying and the guilt that ensues when I’m too tired to do so, and it’s a recipe for depression and anxiety. If I once wondered why mental health among medical students and physicians is so poor, I don’t anymore.

I’m not sure how to solve these problems. I’m not sure how to stave off the burnout I feel creeping in so soon in my young career. So, for now, I’ll try to be optimistic about medicine and my place in it. I’ll keep treating patients like human beings: with empathy, compassion, and respect. And maybe I’ll take a nap (though I really should be studying). After all, I’m just a tired med student.

The author is an anonymous medical student.

Image credit: Shutterstock.com 

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