Responding to Burnout and Moral Injury Among Clinicians

As the COVID-19 pandemic wore on, multiple surveys and news reports described rising levels of burnout and fatigue among clinicians on the front lines. Among the many nurses and physicians reporting they were stressed out and overwhelmed, some said they were ready to leave their jobs. While it’s unclear how many clinicians have quit practicing, workforce shortages continue in some regions.

Burnout can be defined as having too much work and not enough time or resources to do it. In the context of health care, researchers often ascribe it to factors such as increased patient acuity, heavier caseloads, and having insufficient time with patients. The burdens of documentation and performance reporting and barriers like prior authorizations — what are sometimes referred to as administrative harms — can also leave clinicians feeling exhausted and unwilling to continue.

But, increasingly, clinicians are rejecting the term “burnout.” They say they’re not overworked or frustrated, but are instead demoralized by a health care system that puts profits ahead of patients. Nearly every day since Wendy Dean, M.D., and Simon Talbot, M.D., published an op-ed describing physicians’ distress as a form of “moral injury” in Stat, in 2018, they’ve heard from physicians who’ve faced systemic problems that keep them from helping patients. One, an emergency department (ED) physician, had for years warned hospital administrators about the dangers of understaffing. Eventually, a patient died in the ED while he was covering an emergency in an inpatient ward.

Eric Reinhart, M.D., who published “Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System” in the New York Times, in February, says some clinicians have begun to question the role they play in a health care system that accepts inequitable access to care and fails to address the root causes of disease. “Many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine,” he writes. Discontent is now bubbling up among health care providers in ways not seen since the spread of managed care — including efforts to unionize by physicians and medical trainees.

In this issue of Transforming Care, we explore the manifold causes of burnout and moral injury among clinicians and identify ways in which health care leaders have begun to respond. “Burnout, demoralization, and administrative harm are much more than hot topics of the day,” says Joseph Betancourt, M.D., the Commonwealth Fund’s president and a practicing physician. “They are a clear and present danger to the future of health care, and we ignore them at our own peril.”

Surfacing Problems and Developing Peer Supports

From long nights of training to long days treating patients, clinicians pride themselves on their ability to shoulder heavy workloads and thrive amid stressful situations. But this can work against them if they fail to care for themselves or unfairly blame themselves for problems. “Everyone goes into health care knowing that they're going to work long hours, that they're going to see really hard things. You see people on the worst days of their lives,” says Dean, a psychiatrist who cofounded Moral Injury in Healthcare, a nonprofit that, alongside education, research, and advocacy, works with health systems to identify and address moral injury in their workforces. “But understanding what those unavoidable situations are and separating them from what the avoidable situations are is what's critical.”

Some health systems have developed programs to help clinicians care for themselves — and to identify problems that may be avoidable and may require organizational or policy solutions.

Mayo Clinic’s COMPASS

Colin West, M.D., Ph.D., directs the Mayo Clinic Program on Physician Well-Being in Rochester, Minn., and has been researching clinician burnout and its causes for two decades. Together with colleagues at Mayo, West developed COMPASS (Colleagues Meeting to Promote and Sustain Satisfaction) as a way of encouraging clinicians to reflect on what gives their jobs meaning and share strategies for addressing job stressors and promoting work–life balance.

Over the course of six months, physicians meet in small groups (six to 10 people), typically over lunch, to explore the virtues and challenges of being a physician and to brainstorm solutions to common problems. Mayo provides a $20 voucher to cover meals, with the only stipulation that for the first 15 minutes participants discuss one of the suggested topics (e.g., using creativity to solve work-related problems — a format designed to prevent meetings from devolving into complaint sessions. “The groups have told us they’re surprised that doesn’t happen. What they find instead is that their colleagues have similar challenges but different ways of approaching them. Realizing they are not alone and learning from one another keeps the spark of the meetings going,” West says.

A randomized controlled trial found that participating in COMPASS groups helped reduce overall rates of burnout and some depressive symptoms, with participants reporting a lower likelihood of leaving their current practice within the next two years. Nearly half of Mayo’s 5,000-plus physicians have taken part, and the approach has been promoted by the American Medical Association and adopted at many other institutions.

West’s long-term goal is to expand Mayo’s COMPASS groups as a way of strengthening the sense of community — within departments and across the institution — and reinforcing the importance of pursuing both individual and structural approaches to burnout. “In framing solutions to promote well-being, we’ve got to have shared responsibility,” West says. “Yes, we need to be able to bring our best selves to our work, not wallow in negativity. We also need to expect that our practice environments are places where an individual doesn’t have to be a superhero to succeed.”

OSU’s Brief Emotional Support Teams

As a faculty member in the psychiatry department at Ohio State University’s Wexner Medical Center, in Columbus, Kenneth Yeager, Ph.D., was frequently called in to support health care workers after traumatic events, such as the sudden death of a colleague on the job or the tragic loss of a patient on a medical floor. Once, he supported a housekeeper who was haunted by images of blood that drenched the walls and floors of a trauma bay. She’d been told to clean it up after the arrival of a college student who’d been hit by a dump truck.

Realizing he couldn’t respond to the level of need in a health system as large as his, Yeager developed Brief Emotional Support Teams (BEST) to train more people to help. BEST team members are nominated by clinicians as well as administrators and receive a half-day of training on ways to offer basic comfort and practical advice. Among other supports, BEST staff provide education to help staff to recognize that hypervigilance, avoidance, and the exertion of control are all normal responses to trauma, and to know when to seek additional help.

In 2009, Yeager trained the first 12 BEST team members. In the years since, more than 1,000 staff have been trained for the role. They respond to an estimated 2,000 events each month, Yeager says. About a third involve the emergency department and other high-risk units, such as oncology and intensive care. After being debriefed by BEST teams, most people return to their shifts and about 7 percent to 10 percent receive follow-up counseling.

The health system’s risk management teams have begun to lean on the program to determine the level of support a clinician may need when being interviewed about significant events that may, for example, involve a patient’s death or severe harm. Such interviews are a critical part of a patient safety process, but when not accompanied by support they can be especially detrimental to clinicians who are inclined to blame themselves and may do so in an effort to recover a sense of control, Yeager says. The anesthesia department has found the teams so helpful that it built a tool in the electronic medical record to notify the BEST teams when there is an unforeseen event.

Johns Hopkins’ Mindful Ethical Practice and Resilience Academy

Because nurses typically spend more time at a patient’s bedside than physicians, many face prolonged exposure to complex ethical issues, patient suffering, and death. During one of the peak waves of the pandemic, in 2022, half of nurses said they’d experienced an extremely stressful, disturbing, or traumatic situation just in the past two weeks; many also said they’d experienced violence, bullying, or other harms.

At Johns Hopkins, Cynda Rushton cocreated the Mindful Ethical Practice and Resilience Academy in 2016 to give nurses tools to meet ethical challenges in ways that preserve their sense of integrity and well-being. The curriculum, a mix of experiential and didactic training, helps nurses develop moral resilience but also communication and ethical discernment skills. Rushton and colleagues found that the program, initially delivered to 192 frontline nurses from 2016 to 2018, enhanced nurses’ ability to confront the ethical challenges they faced in clinical practice. “The goal is not to fortify nurses to tolerate what may be unacceptable conditions,” says Rushton. “Instead, we want to help nurses develop protective resources so they can be agents of change in their workplaces.”

Reducing Cognitive Load

In describing the pain points of their jobs, clinicians often point to electronic medical records, not just because the systems can be time-consuming and clunky but because documentation requirements get in the way of spending time with patients. One study found that physicians spent two hours every day on documentation for every hour spent with patients.

Ranjit Tamaskar, M.D., an internal medicine physician, is president of Atrium Medical Group, an independent physician group in Northeast Ohio. He practices in what he describes as the “traditional way,” seeing patients in his office and following them into hospitals or nursing homes; since he’s known many of his patients for years, they trust him when he recommends treatments or preventive procedures. Still, as performance measures and reporting requirements have increased in number, he finds himself overwhelmed. “I’m interested in quality care, and these measures are important,” Tamaskar says. “But during visits I have split focus: I’m listening to what patients are telling me, but I’m also thinking about checking all the boxes in the short time I have with them.”

James Innes, an adviser for the Institute for Healthcare Improvement’s Joy in Work initiative, an effort to address clinician burnout, and an improvement director for the U.K.’s National Health Service, describes the growing number of treatment protocols, documentation requirements, and other complex information as placing “cognitive burdens” on clinicians. “It swamps your brain,” he says. While clinicians in the U.K. struggle with similar issues, the payment system in America adds yet another layer of burden, he says.

Several projects are in place to reduce clinicians’ cognitive burdens, including the federal Meaningful Measures Initiative, which since 2018 has reduced the number of performance measurements reported for Medicare patients by 18 percent. The American Medical Informatics Association has released a toolkit to guide health care organizations in reducing the burdens of electronic medical records and is partnering with technology vendors to highlight priorities. In 2018, a Hawaii health system launched Getting Rid of Stupid Stuff (GROSS), an effort to reduce administrative burdens on clinicians by asking them to report things they do in the electronic medical record that they see as unnecessary or poorly designed. The approach has been used by health systems around the country to review documentation, training, risk management procedures, and other processes.

Using Ethics Committees to Resolve Conflicts

When looking for causes of burnout and moral injury, some point to the consolidation of health care organizations into mega systems, and the decision by many physicians to become employees of large and bureaucratic systems. “In larger organizations, a practicing clinician could be five levels down from anyone who could make a difference,” says Joseph J. Fins, M.D., professor of medical ethics and chief of the Division of Medical Ethics at Weill Cornell Medicine in New York City.

Fins says that ethics committees, which most large health systems convene, can be mechanisms for clinicians and health care administrators to work through conflicts and elevate problems that require systemic solutions, such as those relating to the allocation of scarce resources or efforts to respond to misinformation or mistrust.

Ethical conflicts may arise when physicians’ professional autonomy runs up against workplace restrictions. For example, physicians may resent when their contractual obligations require them to refer patients to other clinicians within their health system, rather than to an outside specialist they think is best equipped to treat a particular patient. “What should prevail is what’s best for the patient,” says Fins, “but the doctor may have signed a contract or may be in an employment situation where it’s stipulated that you refer inside. So, you put your doctor at moral jeopardy.”

In these situations, Fins suggests that ethics committees could have a process in place whereby requests to refer patients out of the health system are assessed against agreed-upon criteria. “A good ethicist is aware of the contingencies and can be an agent for change within an institution,” he says.

Creating Alliances Between Administrators and Clinicians

Rothman Orthopaedics is a private practice with 230 physicians, including 96 who have an ownership stake and thus a say in running the business. Founded in 1970, the practice has thrived by attracting physicians who want more control over their work lives than they’d get in most large health systems. But as the practice has grown to 40 locations across four states, it’s had to strike a balance between being clinician-led and having a centralized administrative structure and some common protocols, says Ed Tufaro, Rothman’s senior vice president of operations.

Tufaro describes his role as “building bridges” between clinicians and administrators. Every week, he visits a different office to hear in person from care teams. “Sometimes I hear about something very specific that requires a discrete response,” he says. “And sometimes I sense a pattern and an opportunity for us to think differently about what we're doing.”

In 2019, Tufaro and the organization’s physician leaders created a burnout committee to have a dedicated forum for clinicians to discuss their challenges and report them to the board directly. Frustration over prior authorizations for imaging services emerged as a significant problem. (Prior authorizations are used by health insurers that require approval and sometimes justification before covering certain services). Clinical teams were spending hours tracking down the status of authorizations, submitting documentation, arranging calls between insurers and physicians, and responding to frustrated patients. Rothman’s surgeons also felt their professional judgment was being questioned. “It’s a respect issue,” Tufaro says, noting that authorization decisions were sometimes made by physician employees of health plans who had no orthopedic expertise. In response to clinicians’ request, Rothman created a centralized team to manage imaging authorizations.

Implications

While the volume has been turned up on conversations around clinician burnout and moral injury, there is still much to learn about the causes and potential ways to respond. But it’s clear that we need much more than culture change within individual health care institutions to address the problems. In his advisory on clinician burnout, U.S. Surgeon General Vivek Murthy called for systemic responses, involving governments, health care leaders, insurers, technology vendors, training programs, and patients themselves.

The examples above suggest ways for health systems to act now.

Develop structured processes for soliciting input from clinicians.

In convening the “burnout committee” at Rothman Orthopaedics, Tufaro said he and other leaders needed to be willing to have uncomfortable conversations. “Sometimes it’s hard to acknowledge that we’re imperfect as an organization. In health care, we don't want to believe that we may be creating these scenarios that are challenging for patients and providers,” he says. “You have to really be open to where the conversation goes.”

While the era of health care consolidations has resulted in a reduced number of physician-led organizations, there may be ways to embed this approach into large health systems. In her book If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard to Put Patients First, Dean calls for more widespread use of the dyad model of health care management, in which physician leaders are paired with administrators to promote joint decision-making grounded in patients’ needs.

Organizations may also need ground rules when asking clinicians to identify problems and advocate for change. Many physicians are at-will employees, carrying large student loan debts, and speaking up can risk job loss, while admitting to mental health struggles may put their credentialling at risk. Nurses, too, may feel disempowered and need peer and leadership supports.

Make it easier for clinicians to seek mental health support.

The Dr. Lorna Breen Health Care Provider Protection Act of 2022, named after an emergency medicine physician who died by suicide in 2020, aims to expand access to mental health care and treatment for health care providers, in part by funding health care organizations to develop and spread programs that promote mental health and resilience. It also funds the Workplace Change Collaborative, a technical assistance center that supports 44 organizations — among them health care systems, universities, professional associations, and nonprofits — that are testing a wide array of individual- and system-level strategies for creating more supportive workplaces and learning environments in the health care and public safety fields. Some are focused on expanding access to mental health care and reducing suicide risk within their institutions.

But persuading clinicians to take advantage of professional help can be a challenge because it requires people to disclose on credentialling forms that they’ve sought mental health treatment. To get around this, Ohio State University’s employee support programs are purposefully defined as wellness activities.

Acknowledge the inequities of the health care system and advocate for change.

Clinicians risk moral injury when they prescribe medications or treatments their patients can’t afford, see the high costs of treatment causing suffering on top of disease, or do things like repeatedly discharge unhoused patients back to the street. A 2022 survey found that 61 percent of U.S. physicians feel they have little to no time and ability to address their patients’ social determinants of health.

In a Health Affairs blog post, Elliott Fisher, M.D., M.P.H., director of the Dartmouth Institute of Health Policy and Clinical Practice, and George Isham, M.D., a senior fellow at the HealthPartners Institute, exhorted clinicians to consider their role in a health care system that prioritizes financial interests over public good. “The public impression that health care is largely about making money undermines the legitimacy and trust upon which we depend,” Fisher and Isham say.

They and other advocates point to a range of policy changes that could help, from Medicaid expansion to deploying teams of community health workers and building up addiction treatment and social services. But they also suggest that clinicians start within their own institutions, wielding the power they have by taking on leadership roles and engaging in collective action to advocate for things like fair billing practices and meaningful use of community benefit dollars.

“As health care changes, as it inevitably will change, we need to figure out ways to perpetuate the ethos of service to the patient that was so important to medicine from the beginning,” says Fins of Weill Cornell Medicine. “When that doesn’t happen, that leads to the moral tension, the burnout, and the stress.”