Fighting COVID-19 Leaves Many in Health Care Suffering Moral Injury

Patient Care recently spoke with Michael Myers, MD, an expert in physician mental health, about the unprecedented psychic and emotional challenges faced by front line clinicians caring for patients infected with the SARS-CoV-2 virus.

The public has witnessed, through broadcast and social media, the humanity of so many of these clinicians, as they describe doing every day everything they have been trained to do--and still losing the struggle against COVID-19.

Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their long standing, deeply held commitment to healing.

Of course the scale and scope of the pandemic have overwhelmed the health care system. But, Dr Myers explains, the feeling of impotence against illness combined with the daily expectation that they make choices that transgress a life-long, deeply held commitment to healing--the toll this exacts on clinicians is not simply exhaustion and not "burnout;" it adds up to moral injury. He discusses in the video that follows.

The following transcript has been edited for clarity.

Patient Care. I would think that even, because of the unprecedented nature, A, and, B, the scale of this that even physicians, even emergency room physicians—I interviewed actually an open heart surgeon from Long Island early on, and his heart transplant OR had been turned into an ICU and, and even these guys, who really look like Gibraltar, we're just sort of melting towards the end of the day or towards the end of a week because of the unrelenting pace and that sense of, “I've done everything I can and it still didn't work.”

Michael F. Myers, MD Professor of Clinical Psychiatry, immediate past Vice-Chair of Education and Director of Training Department of Psychiatry & Behavioral Sciences , SUNY-Downstate Medical Center, Brooklyn, NY.

Dr Myers. You’ve probably heard of the term moral injury. That's the very important work of two individuals, Dr. Wendy Dean, and Dr. Simon Talbot. And they actually have a whole sort of organization, moral injury website or something like that. But that really fits what so many of the physicians were experiencing, especially in situations where perhaps there wasn't enough PPE or they were having to reuse their dressing gowns, or their masks, things like that. They're having to make a decision as to who gets a respirator—having to deal with so many people having so much difficulty breathing on oxygen; when would they get a respirator, right? And then, of course, the separation from their loved ones. And if they're not able to be at their bedside and [clinicians] having to stand in for the relatives outside. Those are the kinds of things that Dr. Dean and Dr. Talbot have been really studying that, that this is really about a healthcare system that needs that needs revamping, it needs to make major changes so that physicians and other health professionals aren't put into those kinds of conflicts.

Patient Care. I think it's interesting, too, that I've been thinking as I've watched physicians, nurses, even people who do the housekeeping staff in hospitals, that the face, the implacable face that we associate with health care providers very often, we've seen it melt on TV, we've seen our health care providers begging and pleading with the community to wear masks, we've seen probably nurses and doctors in tears on television. And, and so even as we say, this is a broken healthcare system, we're also seeing a totally different side of our providers. And what I'm wondering is whether this is affecting health care providers – to actually see themselves in this light? Is it affecting their sense of efficacy, or I guess, power, professional power? And maybe that’s a little bit what you were talking about with the moral injury?

Myers. Wonderful question. I think it's a good thing, quite frankly, that this has gotten play in some respects. I think it is. It's our humaneness, of course, in the face of tragedy, in the face of a pandemic. And yet, in my mind, it doesn't take away at all, from the advanced training, the expertise, integrity, skill, etc, of our highly-trained frontline health professionals. This is just another piece of them. It's the human part that is expected at one level to you know, to absorb what they are facing. Now, of course, this has to be watched, though, because individuals still have to have proper rest, they still have to have proper food. They have to make sure that they're getting breaks. They can’t just be, in a sense, workhorses.

In fact, many physicians even before the pandemic, had felt that they have been sort of used and abused, that they're just a cog in a wheel. And that's been some of the contributing factors to that huge cohort of physicians who have felt burned out, and who Dr Dean and Dr Talbot would say, that's an example of moral injury. Because, why some people recoil at the term “burnout” because they feel that it blames the health professional even though it's occupationally induced, and they feel sometimes equated with a sort of lack of resilience. And it's not that at all; it's their inability to really practice the craft and the way that they were trained. In fact, I remember in the first couple of weeks, hearing a couple of physicians say that the work they were doing in the ICU had actually at one level made them feel better. They said, “I was feeling kind of burned out before the pandemic hit. But now I'm, I feel I'm doing the work that I'm trained to do. I wish I was saving more lives. But I feel I feel value that this is, you know, I feel I'm a I'm a I'm a doctor, I'm a physician. This what I was trained to do.”

For more information on the work of Drs Wendy Dean and Simon Talbot:

Web site: Moral Injury of Healthcare

Dean W,Talbot S, Dean A. Reframing clinician distress: moral injury, not burnout. Federal Pract. 2019;36:400-402.

Talbot S, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT News [First Opinion]. July 26, 2018. date. Accessed January 10, 2021.