Moral Injury, The Sequel | AMA 24

There was a lot left unsaid in my first video on "burnout" and moral injury, so now I gotta get some of it off my chest.

[LaSmoocherina]

Love this! Today was crazy at work. We had a 16 year old vocational CNA student on my unit and she passed out. (A super awesome tech caught her) It was hard to get her to come around. When she finally did, she had tears s streaming from embarrassment. I held her chin up (mostly because I didn’t want her to look down and pass out again). And I wiped her tears and said, “you have nothing to be embarrassed about. Sometimes in healthcare, we get sick or dizzy or nauseous or we cry, but that’s the part of us that’s human. It’s the same thing that allows you to have compassion. You can be a robot and have no compassion and never get faint at the sight of blood, but being human is way better. You did nothing wrong here.” She just nodded and we got her instructors. But my techs thanked me so much for what I said to her. Other people were like, “well, this isn’t the job for her!” I said, “not true. I had a strong gag reflex for about 3 years and definitely when pregnant, but that almost never happens to me now. We don’t give up on 16 yr olds that want to care for people.”

[doug]

ZDogg, I have to firmly disagree with your last point. Burnout does not just start when you are an attending physician.


The medical education system is broken. From huge examinations that determine the very fields you are able to enter prior to even seeing patients, to monthly examinations that require extended amounts of time to prepare for, with quantifiable impact on residency placement, there is a reason students are less engaged while on the floors. That coupled with medical legislation, EMRs that require residents to treat the computer and exclude student learners, subjective grading systems and literature reviews that are almost never relevant to the information tested on exams, is there any wonder why students this generation are more jaded than prior? There is no longer the space for them that there once was in the age of paper charts and verbal orders.


Now add that to what you have stated. These students know they have the monumental hurdle of residency facing them and hear from their mentors how broken the system is. They have already lost hope. What may have called them to medicine gets hit by reality in those four years of graduate education and beyond, and it shows in the residency choices these students are making; they want a future with better hours, less paperwork, more patient interaction. Giving up your 20s and 30s is only worth it if the system takes care of you on the other side, and that bitterness can start as early as medical education.

[anniee]

"So they don't put in the work and passion that proves to their mentors that this is a frickin' calling." I'm just beginning my 4th year but I have already heard attendings tell residents that divorce is to be expected and they have no business making time for their spouse. I've watched residents work 12 hour days, 12 days in a row, with a wife and infant at home before getting the "golden weekend" that is expected in every other field. How is this just? We shouldn't have to personally suffer through burnout before we get the right to say that this system is inhumane! Work hard, yes. But I reserve the right to fight for my health and my relationships outside of medicine before (not after) they are broken. This system isn't designed for education, it's designed to profit from the cheap labor of residents.

[vettejakes]

Whew chile... as a nurse working the battle field for 37 years, ( worked in various in patient settings )you’ve said what I’ve felt all that time in 4 minutes. Daily I have to remind myself why I chose to be a nurse. Times have changed so much. My saying is that it’s gone from healthcare to health business and I did not go to business school.

[laurasmith]

LOVE your stuff! Thank you for your voice. Yes AND on what you've said on moral injury: I'm a chaplain in a 1, 100 bed teaching hospital that's a Trauma 1 Center, Transplant Center, with 12 ICU's. Nurses have my heart. What they do for 12 hours seems impossible. I'm seeing a LOT of "burnout" caused by moral injury. I'm working hard with Nurse Managers to provide better support for all caregivers (docs, techs, etc), although focus is often nurses. We're finding that the cause of moral injury is so complicated. Everything you've said and this too: Pt acuity is crazy high--people who 10 years ago would not have even survived to get to the hospital. The patients are often younger, which really tugs on the heart strings--people who have young children, expecting many more years of life. Families can now basically live in the ICU room. All of this results in caregivers becoming closer and more attached to patients and families--not in an unhealthy boundary crossing way, just reality of the situation. Add to that the fact that our technology CAN do things that many of us are not sure we SHOULD do to people. A culture that seems to promise miracles and is death avoidant, creating totally unrealistic patients and families. (One of my personal soap boxes: News flash folks: WE ALL DIE.) MD's who have their own culture of wanting to "cure, " their own pressure of insurance, numbers, statistics, etc. Not throwing docs under the bus here, just recognizing all the pressure they are under as well. I work a lot with our Palliative Care service, so I echo Dr. Suri's thoughts on the inability to have difficult conversations, which results in unrealistic expectations, etc. (She's amazing!! Everything she said and wrote!) All of this often results in the medical team taking care of basically a corpse, and nurses are on the front line of that, dealing with family hope, but knowing the inevitable outcome. Add the old school nurse culture of compartmentalizing, just internalizing and moving to next patient, etc. We can do better!

[kathygaddy]

I know this is about docs, but I am a second career nurse. I got into this thinking I was going to change things. But now I believe in the "Starfish Theory" which is if I can help one person then I am doing the best I can. It is unsatisfactory on so many levels, but that, plus being on of your followers (doc's aren't exactly known for compassion) keeps me going. But I see those people every day, uncaring nurses, docs that give me the orders "I want" without knowing the patient. Come on I'm a f**king nurse, I'm calling you in the middle of the night because my patient is in pain, vomiting, freaking out, I don't want to call you, and yes I probably know what you are going to order, but I'm not a freaking doctor. Burn out also happens when a doctor says "and you are calling me at one o'clock over constipation?" and you have to explain 3 calls and 3 interventions were done during the day but the patient is still bloated, painful, and vomiting feces smelling stool. I want to say WTF all I want is an order for an NGT that should have been ordered 12 hours ago. So it is not just the system it is also the healthcare team.

[PH-xwri]

ZDogg - when you went through med school, the tests were way easier and you weren't 500K in unforgivable debt. Don't shit on an entire generation.
Signed,
Resident doc

[bigdavid]

I don't think current attendings understand the massive debt medical students/residents are being forced to sign/delay paying. It was a nice deal 15-20 years ago but now its a crappy pool to wade through after finished.
From a fellow IM compatriate.

[nduval]

First time I'm going to have to disagree with the ZDogg. Since healthcare systems bought most of the private practices and therefor 'own' most of the healthcare providers, there is a hefty imbalance of power. For us to make change we need to crawl, hat in hand, to administration. Example. . . . doctor burning out. . .. asks for a scribe in order to spend more time with his patients. Administrator, under pressure from the board then says doctor can have scribe only if he sees 3 more patients per day. Negating the purpose for the scribe to begin with, ie extra time we hope to use for patients now spent generating profit. Provider doesn't get to make that call, . . . . administrator does. They win because they have the power. We will see patients whether they get us the scribe or not. We have a moral obligation and they know that. No control over our own fate, . . . . the match that lights the fuse of burnout.

[semao]

Being a sheep and perpetuating a clearly broken system was never my calling.

[goldilocksbears]

“Healthcare is a tribe!” Unless your a resident/fellow.

[soulsaver]

As a Patient Advocate and advisor to the CMA, my moral injury is doubled. I am still a patient, but I have full awareness of the system and where it’s at. You are correct about the admins, but it’s the politicians and policy creators who need a hardy kick in the shin.
However, when I mentor medical students I tell them to not forget about their heart and to always bring it along.

Here’s a recent quote of mine the CMA (Canadian Medical Association if you are unaware) used:

“My hope for the next wave of health care providers is to have more time and psychological safety in the workplace so that they can stay grounded in the true purpose of the profession: their oath and commitment to authentically listen, partner with patients and support patient-oriented health outcomes.“ – Elke Hutton, CMA Patient Voice Member

[TheStitchinDietitian]

As one of many I'm sure who've been on the receiving end of "those entitled little pieces of sh!t", thank you. I will respect you Doc with as much respect as you give me.

[lenak]

Hmmm it sounds like you backed down from the original message. Made it sound soft. I was inspired but now I see it will not happen.

[Shinybadguy]

I take responsibility for myself and my own struggle with PTSD after decades in critical/emergency care settings. Sorry but hospital administrators that are responsible for protecting and perpetuating a broken system aren't going to get any sympathy from me. They seem to enjoy collecting the big bucks while pushing meat through the grinder and there is no sign at all that anything will change...Ever.

[kritika]

Z dogg your videos are insightful. Love it.

[tiaregraves]

AMEN! As a nursing administrator working in risk management, I too become a second victim! Thanks for that truth, tell 'em ZDoggMD!

[farc]

I am a big fan of yours and our world needs you to be the voice for healthcare. However, I strongly disagree with your position regarding students and residents. Never before has medical school been so expensive and useless when it comes to actually TEACHING the students. Medical students are purchasing a medical degree and teaching themselves everything. The current resident climate is such the hospitals treat them like NURSE PRACTITIONERS. The hospitals care more about making the dollar than educating the residents. You are actually part of the older generation of physicians and it seems like you have a hard time understanding the younger generation. Please take more time and energy to listen to the younger physicians and let them share with you their troubles so that maybe you will have a better understanding and so you won't be so dismissive with their issues.

[lookingleasuretime]

I like listening to you, as I am waiting for the last of my left brain cancer and then hopefully what treatment I get to start tomorrow or Wed. Thank-you for your clear information.

[countesscalypso]

Entitlement. I’m a nurse, and yes today is me being an Rn one year. One of the residents complained about a perfectserve message (nurse to dr communication), saying it was “all day long”. My response “welcome to the next 40 years of your life”. The look on his face I can’t describe. This resident started with me, so he listens to me. I said “your nurse is your eyes, don’t be mad when your eyes see something. “