Wintery morning after wintery morning, I shuffled through the chilly hallways of the county hospital and encountered the same scene: my patient, a 24-year-old woman, reclined in her bed, nearly buried in a mountain of dusty yet colorful stuffed animals brought in by her mother. I was a third-year medical student coming from the large academic center next door, but without the many resources available there.
My patient had a bizarre case of catatonia likely related to her advanced lupus cerebritis. This meant that she was mostly frozen in bed when I visited, except one special morning when I saw her slowly tap her phone screen to skip a YouTube ad. How human, I thought.
I had learned that lorazepam was first-line treatment for catatonia. However, IV lorazepam was in shortage, and we were running out of options because my patient could not safely swallow oral medications. Even after we managed to obtain and administer IV lorazepam, the patient remained frozen. Electroconvulsive therapy was the next best option, but unavailable at this county hospital, and my patient’s insurance coverage created barriers to transferring her to my home institution next door.
Days passed, and I felt uneasy visiting my patient each morning. Before her lupus progressed, this patient was a young woman in her early 20s who went to work, had friends, and loved her mom—not so different than me. When I realized my lack of power to help this person whose life had been like mine, I felt dejected. Physically, I experienced increasing fatigue, and I found myself looking forward to this psychiatry rotation less and less. I was aware of the rising rates of physician burnout—from 38% in 2020 up to 63% at the end of 2021 according to a recent study cited by the American Medical Association.1 Was I experiencing the phenomenon of “burnout” I had been warned about early in medical school, or was this something else?
Medical students are taught the importance of building a broad differential diagnosis because, “if you don’t think about it, you won’t diagnose it.” With respect to the crisis of physician and medical trainee burnout in our country, our “diagnosis” of burnout is imprecise and therefore our “treatment plan” is inherently incomplete.
In a seminal opinion article published in 2018, Drs. Wendy Dean and Simon Talbot introduced another potential contributor to the syndrome of burnout: moral injury.2 They posited that “burnout” operates on the individual level and implies a failure to be resilient. On the other hand, they argue, moral injury is a result of the smaller conflicts of interest that mission-driven physicians and trainees face in an increasingly profit-seeking business model of health care. One such conflict—my patient lying motionless in bed day after day when a reasonable treatment option existed a few hundred feet away—was transpiring before my eyes.
Medical students are constantly reminded to appreciate our patients’ humanity. As a novice, I am equally struck by the humanness in myself, my residents, and my attendings. I remember the frustration expressed by my psychiatry attending at the lack of options for our catatonic patient. In his decades of work with underserved psychiatric patients, this was not the first time he faced tension between his clinical judgment plus moral intuition and the limitations of the system. He is a survivor of chronic moral injury.
To acknowledge and address moral injury, we must first acknowledge our humanity and examine the conflicts of interest we have at work. Like my patient, we as physicians sometimes find ourselves frozen in response to moral conundrums. In these moments, going on our walks, talking to our therapists, and having that occasional grounding coffee meeting with a colleague may not be enough. We need to examine the extent to which our systems are aligned with our core values, our purpose as physicians. And if you, like me, conclude that they are not, this is largely because they were not designed to be. As human beings who chose to enter a field with moral underpinnings, we are at risk of injury not only because of the number of hours we spend training and working, but also because we work within the boundaries of a system that does not share our values. The only option, then, is to leverage our voices as people who took a special vow to protect humanity in medicine, including our own.
In the case of our young woman with catatonia, we researched the evidence, created a presentation, and ultimately appealed to the humanity of an ECT provider at my home institution to get our patient transferred there. This led to inter-department conversations as well as eventual administrative support, and our patient ultimately received the treatment she needed, though not without hurdles. Through this experience, I learned that first-line treatment for moral injury is advocacy, and that we are uniquely positioned to advocate together as physician-humans in diverse settings across this healthcare system.