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The term ‘burnout’ has become prevalent in both discussion of the healthcare delivery environment and in medical literature.

It is vitally important and threatens the stability of our healthcare system, and most importantly our primary care practices across the country.  Burnout most generally refers to providers (especially physicians, nurse practitioners and physician assistants) but can impact anyone, and is described as a loss of empathy as a consequence of an environment in which resources are not matched to the tasks expected of providers, new tasks are added on a regular basis, there is a shifting role for providers and there is little control over the amount and pace of work we face on a day to day basis.  The loss of empathy then results in cynicism, fatigue and a failure of engagement with each patient and with the full embrace of the management of a panel of patients, and the consequences for quality of care can be profound.  Most alarmingly, burnout rates for family doctors are estimated to be over 50%.  As you might imagine, healthcare organizations must attend to this challenge and that attention should be urgent.  Here at PCHC we have had a Joy in Medicine workgroup tackling this for the past 18 months and our scribe pilots, the standard primary care schedules, and efforts at increased staffing and reducing desktop documents have resulted from that endeavor (which is ongoing).

But a recent article raises the possibility that the situation may be more nuanced than burnout alone.  The authors, Dr. Simon Talbot and Dr. Wendy Dean, writing in STAT magazine argue that there is an unrecognized threat to provider wellbeing and they label it as “Moral Injury”.  They assert that moral injury is mistaken for burnout and that risks misapplied and ineffective solutions.  They go on to make these points:

  • The complexity of the work that we undertake and the myriad of interests (patient, employer, payers, self, etc.) involved create highly conflicted allegiances on the part of providers and it is this conflict that robs us of our resilience.
  • The ongoing moral injury in healthcare is being unable to provide high quality care and healing in a consistently reliable fashion due to financial concerns, limited or no insurance coverage, and the overwhelming impact of electronic health records.
  • Most providers feel called to their work, and have sacrificed a great deal of time, energy and money in order to train to do that work. Leaving training and entering a work environment that is as rapidly changing and challenging as healthcare creates an ongoing tension that is difficult to manage and “Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting”.  I would argue this is most dramatic in primary care.

So in addition to providing support and resources, leaders of healthcare organizations must consider these “competing allegiances”, strive to mitigate their impact, and advocate for public policy and organizational innovations aimed at creating an environment in which the best interests of the patient are paramount.  I’m all in.

Noah Nesin, MD

Dr. Nesin, Vice President of Medical Affairs for PCHC, is a family doctor with 30 years of experience.

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