Moral Injury: Physician Distress in the Era of COVID-19

For years we have followed the reports of increasing physician distress — the high rates of exhaustion, depression, substance abuse, and even suicide. We’ve called it burnout, suggesting overwork. And it’s been tempting to see the COVID-19 crisis as the climax of that narrative, with overworked doctors now forced to put in even longer hours serving patients desperately ill with a challenging and mysterious new disease.

But, in my experience, doctors like working hard. They’d never have survived medical training if they didn’t. They also like caring for patients with complex conditions, and they like solving medical mysteries.

They just need the time and resources to do it.

Though burnout is real, it’s a diagnosis that applies to individual doctors and offers up individual solutions. Yet much of the growing physician distress we see is systemic. It’s called “moral injury,” and what COVID-19 has exposed is the extent of the moral injury doctors suffer as they toil away in our broken, fee-for-service healthcare system.

What is Moral Injury?

In 2009, researchers proposed the phrase “moral injury” to describe trauma suffered by Vietnam War veterans that seemed to go beyond Post-Traumatic Stress Disorder, or PTSD. Forced to perpetrate or witness acts that violated their moral beliefs, some came to question their own morality, and the long-term impact on their psychological and spiritual (and even physical) well-being could be devastating.

For doctors, medicine is a mission and a calling, and moral injury among physicians has been described as “the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice.” When a healthcare system does not allow doctors to provide the care they know how to provide — and believe it is their life’s purpose to provide — the impact on their psyches seems much deeper and more complicated to address than burnout.

One of the most chilling things I’ve heard was from a young primary care physician who had already come to believe that it was futile to express an opinion about their own patients’ needs if they wanted to stay in their job at an academic medical center. They told me that they were going to have to accept “learned helplessness.” It scared me because primary care doctors are the closest to patients and it’s vital that our voices be heard. Further, this doctor is helping to teach the future primary care physicians we will all depend on, so for this doctor to feel so beaten down so early in their career is quite concerning.

How Value-Based Care Protects Doctors from Moral Injury

I joined ChenMed nearly four years ago because the company’s value-based care model allows me to practice the kind of medicine I was trained to provide — something I no longer felt I could do in the fee-for-service model.

When I first started in medicine some 30 years ago, we’d get recruitment ads from healthcare systems promising that administrators would take care of business and free us up to treat patients. But as Medicare and insurance company reimbursements failed to keep up with the rising cost of healthcare, profit margins dwindled, and administrators were continually introducing cost-cutting measures. These saved pennies in the primary care physician (PCP) offices but generated many dollars downstream in the emergency department or hospital. For example, many practices no longer stock IV fluids in their offices. This means a patient who needs fluids ends up in the emergency room, which is prohibitively expensive — though we have to remember that one person’s cost (the patient’s) is another’s profit (the emergency room’s). Primary care physicians in the fee-for-service arena are not allowed to leave room in their schedules to see sick patients when patients need immediate care because the system gets reimbursed for the volume of patients seen, rather than how well the population of patients is managed, and therefore PCPs are always booked solid. They’re forced to tell a patient who might have something that can be easily diagnosed and treated in the office to, once again, go to the emergency room.

The fee-for-service model misses the forest for the trees. I remember one woman who was confused about a change in medications prescribed by her cardiologist. She was worried because her heart rate was low and asked me to send a nurse to her home to help her figure it out. But Medicare won’t pay for a nurse’s visit to help you sort out your medicines and therefore it is not a service provided by most integrated health systems. Yet if you have a heart attack or stroke as a result of that confusion, it will cover bypass surgery or a stint in the ICU.

At ChenMed, we assume full risk for our patients, and it’s our job to keep them healthy, happy, and at home. We don’t make more money by seeing as many patients as possible or referring them to specialists or ordering unnecessary tests or procedures or medications. We do well financially when our patients get well and stay well.

So, we have small patient panels (450 per physician as opposed to 2,500 in a typical fee-for-service system) and a team of professionals who collaborate to provide care. This means we have time to develop a relationship with each patient, see them a least once a month instead of once a year, and really focus on those face-to-face encounters — instead of spending the visit filling out their electronic health records and worrying about how to code the visit for reimbursement. Crucially, we have the time to focus on preventive care. And we have the luxury and responsibility of considering a patient’s health in holistic terms, factoring in social determinants of health, which can range from food and housing security to literacy and the financial ability to pay for medications.

Doctor-Led Decision Making

The best antidote to moral injury among doctors is to support us in doing what’s best for our patients, and to afford us the autonomy to decide what’s best — decisions informed by our medical training and experience and an intimate knowledge of each patient’s situation and goals.

A 2018 article in The Annals of Family Medicine concluded that while primary care physicians report especially high levels of distress and burnout, doctors whose scope of practice is broader and less dependent on specialists do better. Happy primary care doctors are not just referral machines or drug-dispensing machines bowing to the demands of the system.

Physicians who practice medicine in a full-risk, value-based system are not forced to defer to formulaic procedures dictated by distant administrators. And they get to practice medicine to the full extent of their training.

Learn more about the impact of value-based care on physician burnout in our eBook, Value-Based Care: Rx for Physician Burnout.