Wellness: Of dreaming in blood and the ‘moral injury’ contained in a healthcare setting

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Dawn M. Coleman

Have you ever “dreamt in blood”? A vivid, waking nightmare that reminds you of exsanguinating hemorrhage that can’t be stopped? I have. An Iraqi war fighter who sustained catastrophic explosive lower-extremity and truncal wounds and required far-forward damage control resuscitation with an emergent aortic cross clamp and diverting colostomy in a dirty, fly-infested surgical tent visits me periodically. My boots still bear his blood. A ruptured supra-renal aneurysm patient with coagulopathy, another with profound ischemia-reperfusion and hepatic insufficiency following aortic endarterectomy for acute on chronic mesenteric ischemia… thankfully, my civilian list is short.

Ironically, the compounding burden that keeps me awake at night is the patients that I can’t help: The out-of-state pediatric patient whose insurance provider won’t authorize necessary aorto-visceral reconstruction out of network despite multiple lengthy peer-to-peer review calls and appeals; my homeless patient that lacks the physical, financial or emotional means to comply with medical treatment of his cardiovascular comorbidities and now faces homelessness as an amputee; the ruptured aneurysm patient sitting in a small, rural hospital with back pain that I can’t accept and treat because our hospital is full.

Frontline

Vascular surgeons continue to serve at the frontline of healthcare, frequently responding to crisis and balancing life and limb. As chair of the Society for Vascular Surgery (SVS) Wellness Task Force, and a busy vascular surgeon, I am acutely aware of our collective resilience.

We have self-selected ourselves for the privilege of this vocation, perhaps blissfully ignorant to the rising challenges thrust upon us (not limited to excessive electronic medical record-keeping, regulatory compliance, billing mandates, adherence to standardized practice guidelines and public reporting) by a medical system that isn’t prioritizing the “physician experience.”

The concept of “moral injury” was first described in service members returning from the Vietnam War with symptoms that vaguely complied with a diagnosis of post-traumatic stress disorder (PTSD), but which did not respond to standard PTSD treatments.1,2 These soldiers had “experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings.” Moral injury occurs when we perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs.

As physicians, our deeply held moral belief is the Hippocratic Oath—put the needs of patients first. “So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate,” reads the translation from the Greek medical text, by Michael North, at the National Library of Medicine, 2002.

Routine

The moral injury of healthcare is not the offense of killing another human in the context of war, but is being unable to provide high-quality care and healing in the context of healthcare.3 Every time we are forced to make a decision or treatment omission that transgresses our patients’ best interests, we feel moral injustice which amasses with repetition into moral injury.

This routine experience of suffering hurts providers and the repetitive betrayals of patient care and trust represents Lingchi (a “slow process,” or “lingering death”). Essentially, a “death by a thousand cuts”—in that any one injury, delivered alone, may heal but the incessant and continuous incidents culminate into the moral injury of healthcare. Moral injury is discrete from burnout, and the treatment for such remains challenging as moral injury degrades an individual’s view of themselves in relation to society. Therapy aims to restore a sense of worthiness and self-esteem.4 Prevention must be prioritized.

Simon Talbot suggests: “Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.”3 He follows that “the simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers.” Leadership and healthcare must allow for self-regulation and patient-directed care; thoughtful and compassionate care must be prioritized.

This requires high-level intentionality—to match the wellness of patients with that of providers. There is a well-described business case to address physician burnout, financially incentivize clinician satisfaction and an urgent need to re-establish a sense of community among clinicians.2,5

I am deeply committed to our SVS membership; the SVS Wellness Task Force will continue to work and advocate for our members. Please look forward to our April Peer Support module on SVSConnect, “Moral Injury,” and consider joining one of our future live calls or webinars in collaboration with the SurgeonMasters coaching team.

References

  1. J. S. Moral Injury. Psychoanal Psych. 2014;31(2):182–91
  2. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019;36(9):400–2
  3. Talbot SG, Dean W. Opinion S-F, editor. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/2018
  4. Jones E. Moral injury in time of war. Lancet. 2018;391(10132):1766–7
  5. Shanafelt TD, Dyrbye LN, West CP. Addressing Physician Burnout: The Way Forward. JAMA. 2017;317(9):901–2

Dawn M. Coleman, MD, is an associate professor of surgery and pediatrics at the University of Michigan, Ann Arbor, Michigan, where she serves as the program director for the Integrated Vascular Residency Program and Fellowship.

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