Burnout & Moral Injury

In my last blog post, I used the term “burnout”. From it has ensued a thought-provoking debate on Twitter about whether this word is now outdated and we should be calling it “moral injury”. I have carefully considered some of the points that were raised, and I aim to share my own views as well as justify my use of certain words. I don’t want to get into an argument over definitions, because that takes away from the overarching issue; that we have a serious problem in the medical profession of poor mental health amongst our doctors.

I believe burnout and moral injury are actually two separate entities, although they are not mutually exclusive. I understand the issues that people have with the word “burnout”. Using the word “burnout” has the potential to shift the blame to the victim because, as the word describes, it is like the individual has burned all of their fuel. It suggests that maybe that person lacks tenacity, when in fact a lot of people who experience burnout are actually quite resilient. So what is burnout?

There are many definitions of burnout. It is a broad term that encompasses a spectrum of poor mental health experienced by an individual due to work. The word is criticised because it is “too broad”, but for me that’s the point. Individuals experience work-related distress in a large number of ways, but the central theme connecting these presentations is that it is caused by a failure of the work environment in which he or she is in. Some argue that by having such a broad definition, we cannot have specific interventions. I’d argue that solutions such as regulating work hours would lead to a reduction in burnout in all of its forms.

Yes, we need clearly defined terms when we talk about research and evaluation. In order to collect data, we need to know what we are studying first. Thence we can use that information in a meaningful way to come up with conclusions and recommendations. I don’t deny that we need solutions to “burnout” but for my own purposes, I use this word to talk about my lived experience rather than use it in an academic manner.

Yes, I also do have other diagnoses that fit into the DSM criteria as a result of my “burnout”, but when I blog, I use the word “burnout” because it captures many of my symptoms, and people know what is means – it is a term that is more accessible to the wider audience. Physician burnout has been recognised and studied for a long time and is characterised by exhaustion, a sense of reduced accomplishment, and depersonalisation (or loss of personal identity). However, it is not recognised by the DSM-V as a mental illness, although those who suffer from it may then become unwell with sequelae such as depression, anxiety, or PTSD which do have formal diagnostic criteria.

I myself believe that I have suffered from both burnout and moral injury. Whilst I consider my physical, mental, and emotional exhaustion as burnout, it could have occurred simply from the sheer number of hours I worked, without necessarily suffering from moral injury. “Moral injury” is often used in the context of military service, whence a soldier may find him or herself in a situation where they must take actions that go against their moral code. This leads to feelings of guilt and/or shame.

In the medical profession, moral injury can interfere with doctors’ altruistic intentions. Many doctors hold the belief that it is not just a job, but a calling in which they have a moral obligation to provide a high standard of care to patients. When a system is unsupportive and poorly resourced, it can lead to moral injury whereby a doctor feels that he or she is unable to carry out this moral imperative.

When I found myself sleep-deprived to the extent that I felt my ability to care for patients was affected, I did feel guilt. When I expressed this concern to my hospital, it was ignored and I continued to work inhumane hours – a moral transgression. In this way, I suffered from moral injury, which occurred concurrently to my experience of burnout and shared several characteristics.

Whilst more people are becoming aware of the concept of “moral injury”, it is still “burnout” that dominates research into physician mental health, as well as public discussion. I think that it’s important to separate the two terms as they are not the same thing, and use them appropriately. However, punctilious use of appropriate language shouldn’t get in the way of getting to the core of the issue: the health system needs to change. Junior doctors, particularly unaccredited registrars, need to be protected from exploitation, unsafe hours, and inhumane treatment.

Take care,

Miko xx