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.