• Fresh Perspectives

    Teetering on the Edge of the Moral Injury Cliff

    February 2, 2022, 8:00 a.m. — Looking back, I realize now I thought not only that I knew burnout, but also — naively — that I had beaten it. I thought I knew compassion fatigue and had overcome it. I even thought I had figured out a way to survive as a physician in a dysfunctional health care system during a pandemic. I honestly thought I was coping appropriately with the stress of early 2021 until it literally stopped me in my tracks.

    woman looking over cliff

    Seven years is all it took to break me. I completed residency in 2014 and was fortunate enough to have a job I loved, in a community I enjoyed serving, working for an organization that actually valued me and my patients. I was meeting productivity goals while making measurable improvements in my patients’ health. I was not just exercising but training for another marathon. Life was great.

    The onset of COVID-19 obviously brought setbacks and frustrations, but by early 2021, I thought we had reached a turning point, with vaccines becoming available to fight the virus. But as I continued to see patients who had access to the vaccine but were refusing to take it, I gradually began to feel defeated. And soon after that I just got mad. To say I was mad at the individual patients is not quite right. I continued to have what I genuinely felt was a therapeutic and effective impact on my patients’ other diagnoses. The only part of their health they did not trust me with was COVID. So, I wasn't ostracized or even ineffective at my job in their eyes. If you were to run an analysis on my preventive care and diabetes management, you would likely see that I continued to improve outcomes. However, the cumulative weight of the COVID betrayal was causing irreversible moral injury, even though I was blind to it for a very long time.

    I knew I needed to take better care of myself and deal with the anger I felt. I worked on leaving the office earlier, even if it meant I had notes to do in the evening, because it allowed me more time away from the stressful setting of the office. I ran almost every day after work, sometimes for an hour or more. Running was the thing I started to hang on to like a life raft. Not only did the actual time running feel like an escape, but afterward I felt the day’s stress was gone. The problem is it came back too quickly. I was working five days a week; I’d worked holidays and multiple weekends, often without a day off for two weeks, but I convinced myself it was manageable.

    A week before I ended up in the hospital, I knew something had changed, but it didn’t seem like a big deal: I couldn’t run farther than seven miles. I literally could not do it. My legs wouldn’t move past that point. I didn’t stop running, I just ran shorter distances. I did realize, however, that I needed to be evaluated for this. That workup revealed my blood pressure was high. Not just a little, but a lot. I also felt different. Each day I felt a little worse, had a headache earlier in the day, had more palpitations than usual — but I still went to work until I couldn’t do that anymore, either. Finally, I called in to work, canceling 20 patients (which I hate doing and have always avoided at all costs) so I could see the person who would become my cardiologist because my blood pressure was 230/115. We talked about how much I was working, how I needed to make changes, and he made me promise I would call if I ever had a blood pressure that high again. He had worked with me as an intern so knew my personality. He also knew how dedicated I was to the patients that we shared, and that I wasn’t taking my health as seriously as I took my patients’.  I thought I was just going to take some blood pressure medicine and go about my normal life; he knew I was going to need further testing. He was right, because 24 hours later, I was in the intensive care unit.

    April 17, 2022, will be one year since I walked into the emergency room, barely able to see, very short of breath, with a blood pressure of 250/125. I did keep my promise from the previous day and called my cardiologist. I had a run of ventricular tachycardia shortly after I arrived. In retrospect I felt it a few times that day before heading to the hospital. My cardiac enzymes were significantly elevated. I argued with the team who wanted to put me on a heparin drip. I argued more when they wanted to do a cardiac catheterization. My office’s answering service called me three times while I was in the cath lab. My husband took my phone away, and my cardiologist was trying to take me away from my job (for a bit). Everyone around me knew I wasn’t coping or managing my stress as well as I thought I was. And now my heart had put it front and center for all to see — especially me.

    My cardiac cath showed Takotsubo cardiomyopathy — more colorfully known as broken-heart syndrome — with an ejection fraction of 35%. When I saw the look in the cardiologist’s eyes as they moved from the screen showing my paralyzed myocardium to my face — that was the moment it really hit me: I did this to myself. This was avoidable.

    The first emotion I felt was actually anger — the very thing that brought me to this cold, hard table. Quickly the anger faded, and I felt utterly mortified. It has taken me almost a year to tell my story because of the embarrassment I felt about my diagnosis. Because I wasn’t tough enough to follow the path I’d set myself on. No one put me in this position. I applied to medical school, I sought a job in rural primary care, and I poured my identity into it. Takotsubo’s is typically caused by severe acute stress, something traumatic and abrupt. Mine was just from going to work every day and seemed super lame to me in the moment.

    After four days in the hospital, I went home, where I barely got out of bed for another five days. I couldn’t eat; I was exhausted by the time I finished brushing my teeth. I almost missed my son’s birthday by being in the hospital, and I did abandon him at a chess tournament as I headed to the emergency room. I was told I couldn’t go back to work for at least four weeks. In retrospect, I needed more than four weeks, but I still was too embarrassed to give in to what my body was screaming it needed. It wasn’t until I went back to work and realized I could not do what I used to that I accepted that I could have died because of my job, and not due to anyone else’s expectations of me but my own.

    Why had I said yes to doing so many home visits? Why did I work so hard to make food accessible in this town that I don’t even live in? Why didn’t I at least take a weekday off when I worked the weekend? Why was I even working weekends? Why did I agree to see patients whenever they walked in instead of at their scheduled appointment times, making my whole workflow rushed and awkward? Why was I letting any of my vacation time expire at the end of every year? Why did I keep saying yes to everything anyone asked me to do? I still don’t have answers to those questions. I know on the surface it was because I was too invested in my patients to prioritize myself. And I think that maybe the anger I started to feel as patients accused me of things like making up COVID was really anger at myself for feeling I’d failed them.

    Moral injury didn’t just lead me to burnout, it almost killed me. I could not have put more effort into my job, yet my impact started to feel insignificant. On my way home from work I pass a busy gas station. I would, and still do, see patients walking through its doors — maskless — who I knew had COVID and were supposed to be quarantined. As family doctors, we are accustomed to patients not making the lifestyle changes we suggest, not going for tests we order, not taking medicine we prescribe, and all while we navigate the obstacle course insurance companies put in our way. And we persevere. Sure, it gets frustrating, but it is nothing compared to feeling that your medical advice is going completely unheard. The patient with diabetes who continues to drink Mountain Dew and not use insulin knows that there are consequences to those choices and knows that what I would prefer they do is actually better for them. I don’t feel I’ve failed that patient — they are failing themself. But when it comes to the COVID-positive teacher going to work in a classroom of unvaccinated children, I feel the weight of every case that results on my conscience for some reason, even though I did not walk through the classroom door — they did.

    So how do I move forward, make my student loan payments and send my kid to college? My long-term plan was obviously not to retire after seven years, and I am still trying to figure that out. First, I have changed my approach to patient care. I see far fewer patients, and I actively work on leaving the exam room burden-free. I won’t say I always succeed, but at least now I try to handle stressful patient encounters with an attempt at forgiveness. Forgiving myself for having boundaries, saying no sometimes. Forgiving patients for being offensive when they never intended to be.

    My biggest “ah-ha” moment was in realizing that what I thought broke me was my overflowing compassion, when in reality, it was that I had checked my compassion at the door. I had stopped taking a compassionate approach to patient care. I was entering exam rooms with armor (and anger). This is common with burnout. We think if we go in to just do the job, the bare minimum, rush through our notes and get out the door, that it will protect us from burnout. But if we shut down the opportunity to process the encounter from a place of compassion, we shut down our own ability to sustain ourselves.

    I am shifting my focus toward helping other physicians learn from my mistakes, which means I have to actually tell my story. To do that effectively, I have to be accountable. Last week, I should have stayed home one day when my blood pressure was high, but I went to work anyway because I didn’t have internet at home. I was honest with my co-workers, telling them that I didn’t feel well, and I moved two commitments to the next day. I am definitely a work in progress, and I am always on the edge of a cliff, at risk of jumping back into being angry and putting myself in a position to be hurt again. But at least now I know there is a cliff. Before April 2021, I didn’t know I could run over the edge.

    Escapism might help us briefly step back from the edge of the cliff of critical moral injury, but it won’t make the cliff go away. We need time off, time away, time with zero clinical obligations. We need supportive work environments and fewer administrative hurdles. Escapism can help us recover from the annoyance of an ever-replicating inbox, but it won’t undo years of disappointment and true depression. A week at the nicest resort with the most gorgeous view will not prevent your downfall the following week; it might help you move Monday-level stress tolerance to Wednesday, but the stress is still looming. Living our lives with a vulnerability on/off switch for work survival isn’t effective. We have to be genuinely human inside the exam room and at the dinner table to thrive.

    We have to approach our professional responsibility with grace and forgiveness. We have to be in a mindset of truly caring, having compassion, for the patient in front of us but also for ourselves. Because if we are able to feel compassion for them, then by default we are emotionally in a place where they can’t hurt us. It has taken me a very long time, and a lot of work, to not only see this but to believe it. We all know how it feels to reach the point where the patient has made us mad, and we just want to get out of the room. And it’s no surprise to any of us that we don’t feel any better once we do. The worst-case scenario is that we take that anger into the next room. By the end of the day, we feel defeated, and the patients leave knowing we weren’t entirely present for them.

    Multiple studies show that both the patient and physician have better outcomes when the physician provides more compassionate care. As scientists, we don’t want this to be the case. We want to think that if we order the same tests, prescribe the same medications and give the same advice — whether in a robotic monotone or the warm voice of a kindergarten teacher — the outcomes will be the same. But that’s not the case. The bottom line is that patients are more likely to comply with medication advice and preventive screenings, have shorter hospital stays, experience less physiological stress and even report less pain if the interaction with their doctor was more compassionate. The win for the doctor is that we actually perceive that we have more time in our day when we are delivering more compassionate care. We feel less rushed, make fewer errors, and show improvement in burnout inventories when we provide more compassionate care. So, if it is a win all around, why are we not doing it?

    We think we don’t have time to do anything new or extra or even to learn about something outside of actual advances in medicine, much less trying to wedge it into our crazy packed days in the office. Practicing medicine is a double full-time job in itself, and we tend to be rigid when it comes to questioning anything about our sacred time in the exam room. However, what we are doing is not working for us. I really thought it was working for me, and I almost died. We are all on different compassion continuums. Some of us simply need to set our intention for the day. Some of us need to sign up for formal longitudinal courses in compassion. But most of us need to do something to build a firm barrier zone between ourselves and the moral injury cliff instead of an emotional one between us and the exam room.

    I can’t help but wonder if my heart, and my life, would still be normal if I had taken just a fraction of my time to change my mindset, because now, I’ll never run that marathon. If I told you doing something one hour per week would increase your patients’ cancer screening rates by 20%, you would do it without hesitation. What if I had dedicated an hour per week to improving my own well-being, or even my compassion skillset? We all have an hour, but we choose to fill it with different things and pretend it isn’t accessible. I would encourage you to fill that hour with something that will invest in your sustainable success as a health care professional.

    Keep in mind, though, that just as data shows compassion is important, interventions to bolster physician happiness or prevent burnout only work if you are actually invested in seeking help. Modules mandated by Human Resources are the nails in our collective professional coffin. But if you are at a point of acknowledging you need an intervention, then that intervention is likely to be groundbreaking for you.

    One final thought: If you’ve decided it’s time to seek help, do it now — on the upside of the cliff — because doing it after you fall over the cliff is miserable and painful. My heart failure has improved, but it has not resolved, and that has made the journey far harder. I have to say no to more things than I’d like because I’m simply not well enough to do them, which in turn perpetuates some of the moral injury that pushed me over the edge in the first place.

    Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.

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