Moral Injury
Authors: Venktesh R. Ramnath
Journal: Annals of Internal Medicine (2021)

On Being a DoctorSeptember 2021Moral InjuryFREEVenktesh R. Ramnath, MDVenktesh R. Ramnath, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-0997 Audio Reading - “Moral Injury” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads “Moral Injury” by Venktesh R. Ramnath, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail National headlines relentlessly delivered jolts to the psyche: funds channeled to border wall construction to enhance national security while the porousness of airports and crumbling roads and bridges went unaddressed; suggestions of equivalence in Charlottesville between peaceful protesters and violent multitudes bearing Nazi insignias and carrying torches; thousands of children separated from parents, housed in immigration detention centers, awaiting judgment promised expeditiously but realistically delayed for years; a political insurrection—the likes of which had never been witnessed in U.S. history—to obstruct an election; the repeated denials of science, discrediting of public health authorities, and erratic approvals and disavowals of the FDA; and the unnecessary deaths of Heather Heyer, George Floyd, Officer Brian Sicknick, and others.Then there was COVID-19. The dimensions and scale of costs of the pandemic still escape comprehension. Despite all that modern medicine offered, people died at unprecedented rates, making COVID-19 the leading cause of death in the United States and a global catastrophe. As societal lockdowns uprooted local economies and cultural ways of life, nationalistic blame games heightened geopolitical tensions and embroiled “essential” workers in a vicious cycle of poverty, public stigma, and person-to-person disease spread. Societal divisions seemed to widen almost daily.Although they were woefully incomplete, available statistics unmasked other truths. Health care disparities were undeniably linked to class, race, and socioeconomic strata across countries and continents. Those who did survive COVID-19 continued to suffer from a poorly understood “long-haul” syndrome that prevented a return to full health or work. In the United States, decades-long ferment from fragmented systems disinclined to collaborate now burst forth with a vengeance, as the number of deaths from COVID-19 in smaller hospitals with fewer resources tripled those of larger hospitals and attention to non–COVID-19 illnesses dwindled. Hospitals clung to business models predicated on short-termism that collapsed like a house of cards, losing billions. Medical education reeled, as trainees struggled to learn bedside skills through contrived Zoom facsimiles. Even hopes for efficient, equitable access to a novel vaccine that was developed in record time fell headlong into chaotic distribution channels and fractured global supply chains.Describing the total emotional cost to frontline health care workers is difficult. My own capacity to process human suffering ultimately ruptured under the weight of what I saw daily. Distraught family members pressing their faces against dirty hospital windows for a glimpse of dying loved ones. The voice of a mother of three children, begging me to save her life. The words of a grandfather who said, “I trust you, doc,” before quickly deteriorating on my watch. The hours seemed endless and cruel, filled day after day with dying patients and desperate and angry families constantly demanding why. My thoughts turned to images of war-weary soldiers adapting through depersonalization and numbing. I could not shrug off the gnawing dread while driving to the hospital, devolving into utter helplessness as I walked through the ICU, knowing that most of my patients would die no matter how intense my efforts.On rare days off, I was plunged back into the world of the living. I reclaimed the roles of husband and father and walked with my family in my neighborhood as the blue ocean sparkled, the birds sang in warm morning sunshine, and flowers spilled over pots in front of doorways. Children rode bikes, neighbors walked dogs, and couples chatted over coffee at the cafe. It all seemed so tantalizingly “normal.” However, most did not wear masks, and my throat would suddenly clench with Pavlovian precision. Did they not see what was happening? On television, on Facebook, from friends in the community? Was wearing a mask simply too much, even if only to declare solidarity with their medical “heroes”? I lived in two incongruous worlds—one of life and one of death—and I felt helpless in both. I wondered about the countless others across the world similarly trapped in this purgatory.The result? A black stain upon our collective humanity. Our societal and individual morality, grounded in what should happen, had drowned in the quicksand of what actually did happen. The mettle of physicians, nurses, and other essential personnel was shattered by the magnitude of human injustice. Our families and friends, inadvertently subsumed in our plight, magnified the psychological toll. All of our morals had been tested, distressed, and then finally injured. This was not just burnout, a condition of stress and fatigue from overextension causing reduced workplace productivity. No—this was deeper and more pernicious: a gross assault on our core ethics and morals as human beings in a world no longer rational or reasonable.How could we reconcile the layers of injustice laid bare before us? Patients and their families did not understand our tortured predicament—how could they? Did anything make sense anymore? Could anyone be trusted? Did we not see this coming? Yes … well, maybe. The signs were there; yet, as a society, we stood dumb and effete. For months, I stared at intubated patients, wondering if, how, and why they believed in me to answer their supplications now silenced by the endotracheal tubes. In my mind, our failure was absolute.In the midst of this turmoil, I saw rays of hope. My team of critical care intensivists became confidants with whom to work through personal and professional challenges. We shared stories and leaned on each other long after applause from balconies and “hero” monikers had faded. Relationships I made with local hospitalist, emergency department, and specialist physicians and administrators deepened, and several of them became very good friends. Finally, my division supported one-on-one sessions with trained psychotherapists to navigate some of the feelings and tribulations of our experience. Although not complete or perfect, these resources offered comfort.The pandemic has forced a radical acceptance that moral injury and mood disorders in physicians are a cancer demanding a definitive plan for eradication.First, we need regular access to professional counseling and coaching sessions, such as our institution's Healer Education Assessment and Referral program, which conducts one-on-one sessions between clinicians and licensed psychologists.Second, institutional leadership must encourage physicians to participate in practice-based individual and group sessions led by supervisors. Under proper conditions, workplace settings can offer safe spaces for support, growth, and targeted interventions when warning signs (such as communication difficulties between staff, unprofessionalism, and performance dips) appear.Third, physician engagement in restorative activities should receive financial support and public recognition to destigmatize these “soft” practices. Furthermore, institutions should visibly champion physicians and leaders who commit to improving well-being.Fourth, physicians need easy and reliable access to ethics and palliative care services when meeting with patients and families. This would prevent physicians from relying solely on themselves to manage the psychosocial complexities of shared decision making.Finally, institutions must motivate more frontline physician leaders with public policy and other experience to engage directly in institutional strategy rather than viewing us as a monolith lacking understanding of operations, finances, and managerial sustainability. Our involvement would be a salve against currently pervasive feelings of disempowerment, disposability, and devaluation.We cannot wait for Thomas Hardy's President of the Immortals to end his sport with us. Rather, we must discard petty weakness of heart and confront this plague with deliberate and uncompromising purpose. No bowing down in submission, complicit in silence, or pursuing affirmation. Our call to duty mandates systemic change for no other reason than this: It is merely logical. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: UC San Diego Health La Jolla, CaliforniaCorresponding Author: Venktesh R. Ramnath, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, 9300 Campus Point Drive, La Jolla, CA 92037; e-mail,[email protected]ucsd.edu.This article was published at Annals.org on 29 June 2021. PreviousarticleNextarticle Advertisement Audio Reading - “Moral Injury” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads “Moral Injury” by Venktesh R. Ramnath, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics Cited byMoral Injury Among Frontline Long-Term Care Staff and Management During the COVID-19 PandemicSophocles’ Philoctetes and Moral Injury in the COVID-19 Pandemic September 2021Volume 174, Issue 9Page: 1325-1326 ePublished: 29 June 2021 Issue Published: September 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...