It's Not Burnout, It's Moral Injury | Dr. Zubin Damania on Physician Burnout



It’s time to stop the victim shaming…and call it like it is. We use the term “burnout” when that’s just the end-stage result of chronic moral injury. Links and more at …

46 Comments

  1. A lot of people have invisible injuries that are not "moral" injuries in the way he described it. That doesn't invalidate their illness or injury, it just means not everybody fits into the same check box. If we misdiagnose their legitimate injury by calling it moral, when it's something else, they will never receive the appropriate care for that injury. How many different types of heart attacks are there? How many different types of fractures are there? Legitimate medicine gets as specific as possible when dealing with the illness, and mental health/psychological/invisible injuries are as legitimate as cardiac.

    We need to stop trying to rename illnesses. In the past century we've seen what we now call PTSD re-named a half dozen times. As a result there is confusion which results in delayed treatment and stigma. I appreciate that the intent is to try and reduce stigma and shame, but it seems to be more harm than good in the long run. Why "disorder" is a good term is because it gets people's attention to something that needs care. What gets your attention faster "heart attack" or "myocardial infarction"? One results in you getting to a doctor ASAP, and the other finishes washing the dishes and folding the laundry before you give it a second thought. "Disorder" may not be stigma reducing or a nice sounding word, but it is a pretty good call to action which is often the biggest issue with treating these illnesses. Invisible injuries need to be addressed immediately the same way a stroke or heart attack does. They do not heal on their own (despite notions like "time heals all"). We just develop bad new habits to cope and compensate which make the problem worse.

    I appreciate what he is doing in trying to bring understanding to these injuries, why they happen and the stigma associated. The spirit of this is something we should absolutely take and run with.

  2. 9 years going on 10 years as a nurse, was a nursing assistant for 4 years before becoming a nurse. Worked at a nursing home for almost 8 years (specialized in Alzheimer’s, Dementia and behavioral health) and ultimately left because we didn’t have enough staff to feed our patients who were dependent on us to feed them. When I asked for more help, the ADON, came in to “assess the need” (while I was off) and said there was no need for assistance.

    Went to a small hospital for 5years going on 6, from the CDU to PCU to CVICU, thinking it would give me more opportunity to care and get to know my patients and help them through their illness. Ratio was too high and barley had time to get the bare necessities done let alone address the patient’s and family’s emotional needs.

    Now I’m at a big university hospital, moved my entire family, hoping to be able to just take care of patients holistically and not just get bare minimum tasks and care done. I’ve been here 3 months and am now realizing it’s the system and doesn’t matter what facility I work for.

    I’m discouraged and disheartened because I never feel like I do enough for my patients. I miss my lunches to care for them (and I don’t mind) but get talked to about missing lunches (which sometimes cannot be avoided) and they offer no solutions for me. I’ve been telling my husband I’m burnt out in a field I truly do love, but you’re right. It’s moral injury.

    I just want to take care of my patients.

  3. Been a nurse for 10 years. I don’t know how doctors experience their work but for a nurse it’s a low self esteem job. Would love to try a different type of industry but it’s not easy. I’m 46 years old. The older you get the harder it gets to switch to a different industry. And then when you do you are starting at the bottom of the career ladder and there are not that many productive years left. I think low self esteem has been the biggest problem in this industry. “Too stupid to hack medical school”.

  4. I bet moral injury is, to a degree, also to blame for all the police officer suicides that are happening. That, bad PR and a bunch of rotten apples that do the wrong thing in a society where everyone is being watched and scrutinized at every moment. No room for mistakes or errors anymore especially in the climate of critical professions like doctors and law enforcement.

    I have a hunch that we would have seen more suicides in the past if the social pressures and shame from accidents were as compounded with guilt as they are now. It does seem to only be getting worse with no signs of the pressure letting up. As technology and business become more powerful and integrated so too does depersonalization. Adapting to this may take a VERY long time. I don’t think society will be the same. Perhaps this is the natural course of our evolution. For better and for worse.

  5. Not bad. Nice and wordy. Lots of semantic juggling. I'd stray away from millenial words like "resonate" though. They are pretty obvious.

  6. Very interesting. I'm a patient who.always worries about her doctors and nurses. I don't know how any of you do what you do.

    Reading the comments below, that speaking up solo just gets you punishment, can anyone tell me, have doctors organized? Do MDs or NPs have unions?
    I would much rather be seen by someone who has a good work/life balance, not for my own sake, but because that is my provider's right.

  7. Thank you Z. As a child psychiatrist in an overburdened, over-bureaucratic and under-resourced mental health care system, this spoke volumes to me. Our agency just bought a crappy computer record system (so poor I won't even call it an EMR), and is talking about "peer-review" and trotting out a bunch of micromanaging moves to address "burnout" while not-so-subtly blaming us and offering "more training" to get "comfortable" with our new system, instead of actually working on program and service development.

  8. This applies to the tech industry too. "Burnout" is a very popular term here, with hospitalisations due to stress being easy to come across. I've been there myself. We are worked like dogs and propagandised with fanciful notions of 'changing the world' and 'passion' – it's all about money. And we're the lucky ones. Amazon's warehouse workers are barely a step up from slaves.

  9. Absolutely right on! Twenty years in automotive industry as machinist, engineering and was always putting accuracy and precision first. Thought nursing would be a good fit. Ten years in as an RN and all I can say is : this occupation is about as accurate and precise as Taco Bell! It's all about the money period! Staffing and nurse mental health is non existent! I have known three nurses that have committed suicide because of this system. It's a shame, I once was a happy carefree person who looked forward to the future, now I dread every single second of existence as a nurse. Once you get in its impossible to escape this hell on earth! God help anyone who enters this field.

  10. Divorce hospitals and medical care from the rule of the insurance kingdom and this would easily remedy 50% plus of what you speak. Medicine is broken because it is corrupted under the control of the Insurance Industry. Doctors should be the voice for getting insurance out of the doctor-patient relatio and out of medicine. Sadly, we never hear doctors advocate for this.

  11. As a retired Claims Benefit Specialist I can say first hand, I agree with Dr. Z. one hundred percent! My job was all about production, to the point it was ridiculous and at times I lost hope and felt like giving up and for the same reasons stated by Dr. Z! Our hands were tied by "the system" as well! Analyst often get to (most do) work closely with doctors and/or other medical staff and as a result, get to see inside the circle of care and trust me, the system is not working for them! They work for a system that demands production, not compassionate care! Dr. Z. is telling the truth! It will be a sad day for us all, when we no longer have caregivers that have a moral compass, who leave the system or worse, never enter it. The system is broken and has been for a very long time! Medical care is all about production and we are a product on the assembly line! It is time for change, there is no question about that! Thank you Dr. Z!

  12. Oh my goddess…… This. I have been feeling this all my damn career in healthcare. This puts words to all my turmoil. What a relief and total validation.

  13. Love the video… too true. However, you mentioned 3 goals. 1. Financial security. 2. Family and work/life balance. 3. Providing excellent medical care to your patients. Pick 2. You cannot have all three as a primary care physician. The horrible changes in medicine that have occurred are irreversible and will continue as outsiders continue to "improve" our health care system. A dismal outlook, I know, but true.

  14. This is right on. I practiced as an FNP for 28 yrs in Family Practice before getting out. I couldn't do it anymore. I had a boss who was all about revenue and wanted me to do things to meet measures that was not good medicine. I went to school and went into practice to help people, not practice insurance. I loved my patients- I had 5 generation families- took care of the mums, then the daughters thru pregnancy, took care of the babies, the parents, the grandparents. I miss every one of them still- 3 yrs later- but I couldn't sustain when faced with the things in this video. Even more depressing- I find the younger Providers are all trained to practice to the test- all about measures, what insurance covers what- not what is best for the patient. They aren't the slightest bit bothered when the patient can't have what they need. That's the way it is. Add in the EMR which is so cumbersome people don't write real notes and no one reads them because no way you can search thru multiple windows, see the patient and document in 15 min. Wish this video was there to see when I finished. When I got out I was a mess. Took me months to look at the world with any sort of hope. I might miss my patients but I found myself when I stopped trying to tell myself this all had to be OK. (In the last 3 yrs 6 of my friends ~more if you count colleagues/acquaintances~have gotten out. All of us are before retirement age.)

  15. Great.!!!! This is not fir just our healthcare heroes.Our teachers are " teaching to the test" like the stupid SOLs, with students graduating who can't THINK.

  16. I would have more sympathy for doctors if this current situation hadn't been true for OVER a decade. Anyone that becomes a regular MD now is either clueless or arrogant and greedy. Doctor Z also glosses over the fact that the "scientific evidence based" medical system depends on pharmaceutical companies and virtually ignores the vast anecdotal evidence that good nutrition and herbs can probably help the majority of people. This leads to expensive healthcare that doesn't actually address the underlying problems. Doctors that don't follow the money are part of the problem.

  17. I work in dialysis on the equipment. The policies change every week, they constantly tighten the rules to the point a sinless perfect human could not possibly obey all the rules and procedures. I have seen them put planned obsolessence parts on the machines, parts that never tore up before, then just started tearing up, just to sell more parts. The machines were down graded in quality just to sell more parts, which resulted in more work for us, and resulted in interrupted treatments for the patients. It's sickening. We've had a massive increase in turnover in all positions, people who gave 10 years of their life to the company just gave up. I personally went through a year of panic attacks. I put on 50 pounds since coming there. The clinics are just factories to the big wigs. We tell them there's too much to do, the process is not doable, they know the turnover rate is out of control, and all they can do is push another project on us with a deadline, or add another checklist or responsibility to keep up with. They've got RN's so bogged down, all they can do sit at the computer documenting every little minute detail, instead of focusing on the patient. They've got us checking every little piddly insignificant screw or knob in the building to the point we don't have the time or patience to give the machines the TLC they need to stay as close to new and trouble-free as possible. They promote who they like. The people over my head have minimal to no experience in my position. The higher ups took away gas efficient company cars from people who needed them and used the money to buy themselves 3/4 ton pickup trucks and gas cards to haul their suitcases to the office. It's just a big racket used to give upper management, executives, and shareholders the good life while they kill everyone in the clinics trying to keep the patients alive. I only stay because the pay is good and the benefits are good.

  18. Very passionately put. That being said, I don’t necessarily agree with you. Lets start with the simple parts I don’t agree with. First off, terms like ‘burn out’ are only victim shaming if you let them be. You can make the same argument with regards to your preferred ‘moral injury’ nomenclature. We need to see things like ‘burnout’ rather than something that happened to us, as a self reflective, self analytical state. “I’m getting close to burn out, I need to look at the reasons why and do something about them”. You’ve identified a few problems you see, but havent expressed what you want done in an actionable state. For example —you talked about patient care systems behaving like cash registers. Ok, fine, how do you want them to work? Put it down in a concrete plan, and get it developed.

  19. I'll tell you something. As I watched the RW destroy teaching as a profession, I predicted that doctors would be the next line of attack. I find my prediction quite accurate actually.

  20. I shared. It's not as if I hadn't thought about what our system is doing to my doctors who happen to be people I like very much. I'm not even afraid oy own doctors. Just new ones I haven't met before.

  21. The American healthcare system is an anomaly that not only puts us behind the rest of the 3rd world countries but harms both healthcare professionals and patients alike.

  22. We also need a lot more doctors. Just like with law, the profession has gotten bloated with credentials and entry requirements that diminish the labor pool.

    Hospital administrators can't make 100 doctors stretch over 10,000 patients without having a bad ratio. Having more licensed hospitals and more mid and low level licensed medical practitioners would give more face-time with patients and let the current best-of-the-best who are allowed to work actually spend quality time with each and every case that reaches their level.

  23. no-burnout is the correct word. they get tired of doing a job they hate. it has nothing to do with some kind of moral injury. stop trying to make yourself a victim to gain some kind of entitlement. doctors need to just say, hey im sick of doing this job cause I hate it and I quit. doctors are not forced to be doctors, they are not victims of choosing to endure their workplace conditions

  24. Oh. BULLSHIT. IT'S all about forced vaccinating by the corporations to keep your job. I walked away in 2012 and sad I had to lose my patients, but kept my HIPPOCRATIC OATH. TODAY, most don't take that oath. It's all about the money and not caring to find the root of the health problem. Managing symptoms, makes money. Curing health problems doesn't.

  25. All you've said rings true to my ears, Dr. Z. I couldn't change any of the dysfunction on the unit where I worked at the VA. After mediation, grievances, meetings, and more BS, I finally left. No good person should have to go through what I, and other PAs, had to go through in the VA system. The "moral injury" you speak of leads to resentment and heartache. I cannot, in good conscience, recommend the PA profession to anyone. And, I would certainly tell anyone thinking about getting a job in the VA system to think again.

  26. Thank you for this. I would also add other professions to this: social workers, cops, EMS, teachers, and some attorneys.

  27. That's exactly the same if you work as a teacher. If you take your job seriously trying to give the best to each individual you'll collapse sooner or later becaus the whole system is wrong. If you have groups of 28 – to 30 kids and about 80 percent of them have serious learning or language problems you can't do a good job and it draines all your energy. Every day a little bit until you break. But the authorities are very good in telling you that the problem is you and that you need to have 'your' problems fixed. This is what makes people even more sick.

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