by Dr. Scott Armistead

Physician burnout is a major issue in the U.S., receiving attention in medical education, medical specialties and at various government levels. Moral injury, in my professional and teaching experience, is a significant and growing challenge to physician wellness. Moral injury happens when one’s personal convictions are unwelcomed and one is pressured to think, be silent, speak, act or not act in a way that compromises one’s conscience.

I graduated from the VCU School of Medicine (formerly Medical College of Virginia) in 1991, trained in family medicine and served in a mission hospital in Asia for 16 years. In 2015, I transitioned to a Virginia university practice and became heavily involved in the lives of medical students.

In the time that had passed since I was a medical student, I found the environment of medicine and medical education had significantly changed. One area of change was the emergence of the “provider of services model.” “Provider,” a relatively new term at the time, is now commonplace.

In my training, we were formed as “professionals.” Though we provided a service — as does one providing a latte — there was a broader vision in our professional formation than I see now. Implicit in professionalism was that we professed something. Philosophically, we professed the goal of health as an objective good, not a subjective one. There was an inherent objective goodness, even excellence, of the embodied human. Our calling was to maintain and restore health as much as was within our power and expertise. The Hippocratic Oath offered a moral framework in which to live out the profession of medicine.

In current medical education, I see an increasing lack of clarity, even confusion, about what we profess. I observe a redefining of health into a subjective, not objective, category. Perceptions of health increasingly reflect a dualistic or divided view of humans, disintegrating them into categories of mind vs. body.

Traditionally, we spoke of an integrated “whole-person medicine.” Now we predominantly speak of patient autonomy, with the center of the autonomous patient in the mind and will, not the body, and often disconnected from the body. In this disintegrated anthropology (understanding of what a human being is), the body suffers a grave reduction in status, reduced to a degree that interventions are done in U.S. medicine to normal human bodies that were unthinkable two decades ago.

This “provider of services model,” wedded with the ascendance of patient autonomy and a subjective view of health, can result in the physician providing whatever patients desire based on their subjective views of health.

As the body’s status has suffered, so has the physician’s status as a human moral agent. In any ethical relationship (physician-patient included), there are two persons, two autonomies, both deserving of respect. The present hegemony of patient autonomy is accompanied by an increasingly anemic view of professional autonomy. Physicians’ convictions and principles, what they “profess,” are to be abandoned in this imbalanced view of the relationship. The physician simply “provides” services.

Medical students tell me that they will be expected, if not obliged, to provide legal and broadly accepted services requested, regardless of their convictions. Students who hold to moral traditions that profess an integrated anthropology, view the body as intrinsic to the whole person, and profess an objective view of health feel increasingly unwelcome in the present medical education system. They can be coerced into silence or acquiescence. I have walked with such students through the stressful journey of an educational culture that pressures them to be formed in a way that conflicts with their deepest convictions.

Moral injury is increasingly a significant factor among our physician wellness challenges. Our institutions must assess reigning models, clarify confused definitions, decide what the profession of medicine actually professes, protect the autonomy of both patient and physician, and welcome the rich, diverse moral traditions we have inherited from the past. Only then will we see a flourishing of the next generations of medical professionals.

Dr. Scott Armistead is a board certified Family Medicine physician who grew up in Hanover County and attended William and Mary for college and the Medical College of Virginia for medical school. He and his family served for 16 years at a mission hospital in Pakistan. Since returning to the U.S. in 2015, he has been working both in primary care and in student ministry through the Christian Medical and Dental Association’s VCU chapter. He has led medical students on short-term medical missions trips to Africa and Asia and to work among the under-served in Richmond. Dr. Armistead is a family physician at Garden of Eden Health Center in North Chesterfield. This column originally appeared in The Roanoke Star and is reposted here with permission.

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15 responses to “Moral Injury Is Driving Doctor Burnout”

  1. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    I think the point the author is trying to make is a significant one. However, his argument is too abstract. A few specific examples of what his is lamenting would be helpful.

  2. LarrytheG Avatar

    Not entirely clear what the good Doctor is getting at. Seems to be making a general complaint but the specifics of which in his case are not really articulated.

    We, as individuals, have choices about what to do or not especially if such choices involve conflict between one’s personal views and what the work consists of and involves these days.

    And it’s not just health care. It can and does involve decisions that affect peoples lives in other ways.

    We as individuals can’t change big institutions but we can associate with other individuals to form groups that can and do influence how entities function.

    As someone who does receive services from health care “providers”, I’m well aware of the role of diagnostic codes in determining what the provider can provide or not – and get compensated for it and the disconnect between two (or more) providers providing their services to you without real collaboration and consultation between them over a more integrated approach – of which there are apparently no diagnostic codes that “fit”. Apparently a position known as a “Hospitalist” does have some latitude if you are hospitalized. I’m not sure if any in this paragraph relates directly or indirectly to the good doctors complaint but that’s what I thought of in reading some of the passages.

  3. Nancy Naive Avatar
    Nancy Naive

    Uh yep, maybe. Moral conflict can, and surely does, lead to a sense of burnout in a diverse field of endeavors, and not just in medicine. Technology has made so much possible that one should continuously ask, “What should be possible?”

    But the goal of healing is the patient’s wellbeing, not the physician’s. I suppose that’s the sacrifice a physician must be prepared to make for his craft.

    If, for example, in these times of morality, legality and motherhood, a physician is incapable of setting aside his moral, or equally his legal, fears for the benefit of his patient then perhaps podiatry should be his calling.

    I can certainly name more than one doctor who has placed his beliefs before his patient’s health. It didn’t end well.

    “The question is not Can they reason?, nor Can they talk?, but Can they suffer?” — Jeremy Bentham, jurist and philosopher (15 Feb 1748-1832)

  4. Eric the half a troll Avatar
    Eric the half a troll

    “…that interventions are done in U.S. medicine to normal human bodies that were unthinkable two decades ago…”

    Breast implants….??

    1. LarrytheG Avatar

      hip and knee replacements?

    2. Nancy Naive Avatar
      Nancy Naive

      Nah, those have been around for a long time. Now, putting them in the buttocks… that’s new!

  5. DJRippert Avatar

    My doctor talks about “Internet MDs” among his patients. While he is happy that people research and understand their ailments online he gets nervous when they start self-diagnosing and especially nervous when they start self-healing by telling him what drugs they want prescribed in what dosages.

    1. Nancy Naive Avatar
      Nancy Naive

      Internet? Watched TV lately? I believe the US is one of the few, if only, country that advertises prescription drugs directly to the public. Perhaps that explains the cost and the less than sterling life expectancy.

      1. Dick Hall-Sizemore Avatar
        Dick Hall-Sizemore

        What confounds me is that many of these ads for prescription meds leave me asking, “What condition is that for?”

        1. DJRippert Avatar

          There is some rule that requires a list of potentially adverse symptoms if the ad describes the medical purpose of the drug. So, some ads do describe the purpose and some don’t. At least, that’s my understanding.

          I especially like the ads which do describe the purpose and then warn, “Don’t take XYZ if you are allergic to XYZ”. Seems like good advice.

        2. Nancy Naive Avatar
          Nancy Naive

          Yes! Lately, there have been more those. I guess you have to figure it out from the side effects. What gets me are those that do say what they cure also list the condition they cure as a side effect, and the ever present, “If you’re allergic to New Miracle Cure, don’t take New Miracle Cure.” (Translation: take New Miracle Cure, if you suffer anaphylactic shock, don’t take it again.)

          1. Among the side-effects listed in one TV drug advertisement was: “An urgent need for bowel movements and an inability to control them.”

            I can’t remember the name of the drug but I’ll never forget that side effect.

          2. Nancy Naive Avatar
            Nancy Naive

            Age is not determined in years but by what has dried up and what has begun leaking.

          3. LarrytheG Avatar

            ugly but true.

          4. DJRippert Avatar

            The plumbing is always the first to go when a house starts to deteriorate.

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