It's Not Burnout—It's Moral Injury
The suicide rate for doctors is significantly higher than for the general population, including people with similar academic training who are not physicians. For women doctors, the rates are over 250 percent higher and about 70 percent higher among men versus the general population. An estimated 300 to 400 doctors die by suicide each year, approximately 28 to 40 per hundred thousand. That’s more than double that of the general population (page 15).
Dr. Pamela Wible is a family practice doctor who has spent over a decade on not only studying physician suicide, but also excelling in her commitment to actively decrease the suicide rate for physicians. She uses the term moral injury instead of burnout. I believe moral injury more accurately describes the assault physicians face on a daily basis in their working environment.
Lip service is paid to organizations for physicians who seek help. Often these programs are part of the problem. Ask Dr. Pamela Wible. If we have a CEO, for example, who doesn’t like us because we might blow the whistle on substandard or fraudulent practices, we can be sent for 3 to 6 months of "treatment." There is no insurance to cover these treatments, which could be several hundred thousand dollars. That in itself would be enough to keep most physicians flying under the radar.
Burn-out is an older word implying some kind of weakness or defect in the person, while moral injury and similar terms such as moral harm or moral assault imply a systems problem.
"Moral injury is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct."
The Moral Injury Project
The problem for physicians is that we aren't allowed to object to harmful practices whether it's differences in opinion about patient care or the COVID vaccine. Physicians are no longer allowed to have differing opinions for fear of losing their licenses.
Whenever we encounter a prior authorization, denial of medical care, denial of the best medical care, a mandate to participate in substandard care, a mandate to be responsible for the outcome of substandard care caused by an insurance company, or the time-consuming electronic medical record (EMR) which requires all kinds of recoding for the Centers for Medicare and Medicaid Services (CMS) mandated information—we struggle with moral assault.
In a 15-minute visit, we are probably going to spend 7 or 8 minutes on the EMR, three minutes listening to the patient, and another 15 minutes completing the chart after the patient has left the clinic. Those 15 minutes times 10 office visits often mean not having time to eat and spending your evening hours completing charts. Moreover, the Medicaid fraud unit can come in four, five or six years later and declare something wrong with your chart note and accuse us of Medicare fraud because some AI program has found a chart note it didn't like. It's time to stop relying on AI to generate fraud claims. No human actually reviews these AI generated complaints. Indeed, as Malcolm Sparrow says about Medicare and Medicaid fraud claims, CMS uses the term "audited" in relation to their fraud claims, but this is a misuse of the term. Genuine audits of claims issues require a human being to contact the patient involved and ascertain that the medical services were actually received.
"A Medical Review audit (which accepts all documents as "true" and focuses on their medical significance) would seldom reveal claims as false. Only a more rigorous fraud audit could do that. A fraud audit would have to include at a minimum, substantial efforts to contact patients or their relatives to verify that services were delivered." (p. 93)
Of all the above problems, the thing that weighs most heavily on us is being forced to provide substandard care, and then being held guilty for the bad outcomes. Unfortunately, I don’t see any solutions for this in the near future, because the dysfunctional medical system which has evolved is impervious to physician and patient needs. This perverse equation is essentially untouchable in our dysfunctional healthcare system.
Time to let go of the burnout chorus and call the assault on physicians what it really is: moral injury. The high rate of suicide for male and female physicians is due to external factors much more than internal factors such as depression. Going to a psychiatrist is not going to change the burden of prior authorization, of the missed meals, the missed family time, or the awkward necessity of being forced to provide substandard care.
About 35 years ago Diane and I wrote a book called Modern Medicine. What You’re Dying to Know. Even then, I wanted to discuss the idea of moral injury. Many people advised me that nobody wanted to listen to a doctor whine. And I thought maybe if we talked about moral injury in the physician workplace actually being transferred into patient harm, that notion would be more palatable. The idea of avoiding patient harm was the message of the book. Out-of-control patient harm coupled with rapidly spiraling healthcare costs are precisely the cause of the healthcare mess we have today.
Being held responsible for the irresponsibility and greed of others creates one of the largest moral dilemmas ever. We wrote Modern Medicine to bring to the surface the idea of course correction. The situation has not improved, but rather gotten worse.
While I don’t agree with the shooting of Brian Thompson, UnitedHealth's actions are without defense. Current UnitedHealth CEO, Andrew Witty, is quick to defend his company's 30 percent rejected claim record. The doctors working for UnitedHealth sign off on these rejections without reading them. The reviewers who reject the most claims get rewards. Mr. Witty claims they will continue to “combat unnecessary care.” Mr. Witty ignores the problem that to reject 30 percent of all claims without reading them doesn't define the care as being unnecessary. How does anyone know what is “unnecessary” or "necessary" when the requests are not read? This is a classic example of public relations avoiding the real point, as described by Darrell Huff in his book How to Lie with Statistics:
"What comes full of virtue from the statistician's desk may find itself twisted, exaggerated, oversimplified, and distorted-through-selection by salesman, public relations expert, journalist, or advertising copywriter." (p.103)
Mr. Witty himself made $23,534,936 in 2023...that’s 352 times the median salary for a UnitedHealth employee in 2023. Of course, that pales compared to Moderna CEO Stephane Bancel, at $398,000,000. These CEO salaries drain a lot of money out of the healthcare budget each year.
In summary, is there a solution? Not really. We will continue to see physician suicides increase and physicians retire early or change careers mid-life. Our medical schools and residencies will be harder to fill and will eventually remain unfilled. Medical corporations see AI, NPs, and PAs as a solution to increase their profits rather than flip a switch to retain physicians and decrease the moral assault being delivered to practicing healthcare providers. In time, I suspect PAs and NPs will get tired of moral assault too.
For physicians, the best way to avoid moral injury is to become a direct primary care provider. Critics of direct primary care try to portray this form of practice as concierge medicine. Direct primary care is not concierge medicine. Of course all payers and owners of private equity healthcare companies object to direct primary care because interlopers can't siphon off billions of dollars. If you are interested in locating a direct primary care practice near you, the direct primary care organization provides a map to help users locate practices near them.
As I wrote earlier in this post, I do not believe the current healthcare dysfunction causing moral injury to providers will change because the needs of providers and patients are not in any way addressed in the current dysfunctional healthcare system. It appears what we as providers and patients will see is a dual healthcare system develop where corporate medicine continues to rape and pillage the healthcare system, and an alternative healthcare system of direct primary care providers will evolve.
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