New Book Review! What is Moral injury?
What is
moral injury?
Victor O. Kolade, MD | Board of Directors, Programming
Committee and Committee on the Integration of Academics & Quality (CIAQ)
I first heard
about moral injury when Wendy Dean, MD spoke at the Guthrie Clinic’s P.A.U.S.E. Summit. In her book with collaborator Simon Talbot, MD1,
she differentiates moral injury from burnout thus: ‘… burnout is an incomplete
diagnosis, and we must expand our understanding of distress to encompass the betrayal,
distrust, and ruptured relationships that lead to moral injury’ (p. 282).
Moral injury
is a new term in healthcare.2 Most
recently, Dr. Dean and colleagues argue that there is a ‘fundamental conflict
between the integrity and values of healthcare workers, and the way health
resource distribution is decided and enacted, or what are called the structural
determinants of health.’3
The book1
includes several stories of physicians and healthcare leaders whose work and/or
personal lives were altered by work circumstances they could not control –
including a suicide. She offers strategies to mitigate moral injury, including
increasing clinician time in hospital boardrooms and increasing the exposure of
hospital leaders to clinical work so that both teams have a better working
knowledge of the challenges each faces.
What
stands out for me? Two Observations
The ask for
clinicians to switch out of scrubs and into suits for board meetings reminds me
of our AIAMC push for National
Initiative teams to align their project work with institutional strategic priorities
and to develop clear talking points for the C-suite to engender buy-in and
continuous support. Personally, I believe participating in the administration
of education of medical students and residents is protective against severe
moral injury. For example, it was personally gratifying to mentor two senior
internal medicine residents in a podcast-style Grand Rounds discussion of
burnout and moral injury recently. Fittingly the presentation was done on the
first IMG Well-Being Day introduced by Intealth: Intealth: IMG Well-being
Day Hosted by Intealth.
My second, related
observation is that moral injury can occur in non-clinician healthcare staff,
some of whom work in healthcare for the opportunity to serve others. When working
in teams for the National Initiative and related projects that include non-clinician
staff, recognizing their input can go a long way to validate these individuals.
Not to
worry, If I Betray These Words1 is written in simple
prose so it can easily be followed by non-clinicians and clinicians alike!
References:
1.
Dean
W with Talbot S. If I Betray These Words: Moral Injury in Medicine and Why It's
So Hard for Clinicians to Put Patients First. Lebanon, New Hampshire:
Steerforth Press; 2023.
2.
Dean
W, Morris D, Llorca PM, Talbot SG, Fond G, Duclos A, Boyer L. Moral Injury and
the Global Health Workforce Crisis - Insights from an International
Partnership. N Engl J Med. 2024 Sep 5;391(9):782-785. doi:
10.1056/NEJMp2402833.
3.
Dean
W. Avowing and mitigating moral injury calls for courage and community. J
Epidemiol Popul Health. 2024 Dec;72(6):202793. doi: 10.1016/j.jeph.2024.202793.
About Victor
Kolade, Professor
of Medicine & Regional Clerkship Director for Internal Medicine, Geisinger
College of Health Sciences and Core Faculty for the Guthrie Robert Packer
Hospital Internal Medicine Residency program.