Whether a disease is afflicting the mind or body, causes and symptoms are common links for diagnoses. Trauma is no exception; events resulting in physical injury, mental, or emotional stress present physicians with the information they need to deliver a diagnosis. Post-traumatic stress disorder (PTSD) is an example of trauma following an emotionally-terrifying event — either through experience or by witnessing it — and the symptoms manifest themselves in scary, uncontrollable ways. Changes in mood, physical and emotional reactions, and suicidal thoughts, just to name a few.
So if at least half of all physicians are suffering from burnout — and symptoms or consequences can include depression, lower patient satisfaction and care quality, a higher rate of medical errors, and more than 400 physician suicides a year, to name a few — should the medical community start diagnosing and treating clinician burnout the same way as trauma?
In PCP’s Elizabeth Métraux’s personal account in STAT about her experience with trauma and PTSD, she says yes, it’s time. I asked Matt Lewis, PhD and a strategic consultant at Primary Care Progress, to examine Métraux’s plea to start calling burnout trauma and for all of us to come to the aid of our providers.
How does the description of events and her symptoms align with what you’ve learned during your scholarship of veterans and moral injury?
There are two separate yet intersecting narratives of trauma braiding Ms. Métraux’s article: I experienced trauma working in Iraq. I see it now among America’s doctors.
First, there is the corporeal and somatic return — “the uncanny”, to use Freudian language — of memories that arrive without warning, overwhelming Ms. Métraux. The descriptors she emphasizes in this moment are tactile: flip-flops on pavement mist from a fountain, and fireworks. This is textbook PTSD.
Second, there is story of what’s happening in healthcare today. The physician Ms. Métraux mentions that served in Iraq describes his trauma in healthcare by underscoring that, for him, medicine has become a profession that lacks purpose. The descriptors she emphasizes here: loss of meaning, work inconsistent with your values, tiny betrayals of purpose, and the undoing of character. This language, this narrative, speaks to the experience of moral injury.
In her article, Métraux analogizes the trauma associated with physician burnout to PTSD. Is that also how you see it?
In my research, I’ve learned that the experience of Ms. Métraux’s reliving of a traumatic event is often associated with anger and/or anxiety. PTSD focuses on the primal scene — for her, the eruption of gunfire in Baghdad while she walks across a granite platform. Moral injury, however, considers the betrayal of ideals, ethics, values, and the disruption in an individual’s sense of what’s right.
The factor that distinguishes the emotional content of moral injury is the persistent feeling of shame and/or guilt. An individual may have symptoms accurately categorized as PTSD and also grapple with moral injury. Sleep disturbance, suicidal ideations, and re-experiencing traumatic events — all common signifiers of traumatic brain injury and PTSD — can also represent the presence of moral injury, but they may not be signs of moral injury.
Perhaps the question is not if it is correct to analogize the trauma associated with physician burnout to PTSD; rather, we should ask if this approach generates a new perspective regarding the challenges endemic to healthcare.
As many as 400 physicians commit suicide each year, a rate second only to America’s armed forces. What are some of the biggest similarities you’ve found between veterans and clinicians with mental health challenges?
I believe that in many respects, veterans and clinicians both suffer from moral injury but in different ways. The traumatic reality of physician burnout Ms. Métraux vividly animates in her article — a loss of trust in medicine as a profession; feelings of guilt and shame because clinicians are unable to serve their community consistent with their values; and trauma resulting from witnessing the disintegration and degradation of system that they are a part of and cannot fix — all point to moral injury, not PTSD.
During the Moral Injury Conference at Syracuse University in 2015, Andrew Miller, a contributor to the Moral Injury Project and an Army veteran, articulated one of the functional differences between PTSD and moral injury:
The conversation that we hear about PTSD fails to include the same afterthoughts and worries that are characteristic of moral injury...And so we have work to do. We have arrived in this room today for a conference on moral injury and I hope the term remains unshackled by the DSM [Diagnostic and Statistical Manual of Mental Disorders] so the bearers of morally injurious burdens will experience a more permissive and inviting culture.
My research has shown that a byproduct of the way we talk publically — and try to understand PTSD — can unintentionally stymie how veterans talk about wartime injuries. In DSM we find a clear definition of PTSD symptoms — a definition of what is and what is not traumatic. Moral injury widens the contextual frame, allows for new dialogical and emotional analysis, and approaches for treatment, in ways that veterans and clinicians can benefit from for seeking treatment.
Métraux concludes her article by asking patients to do our part and heal our doctors. As a big healthcare advocate yourself, how do you think you can help physicians manage triggers and navigate treatment for trauma?
Remarks by clinical psychologist Dr. Joe Currier — whose scholarship largely focuses on quantitative measures of moral injury, particularly within military populations — provides an instructive point of view in this regard:
The predominant emotions for what we might call Moral injury are not necessarily anger or anxiety [as it is with PTSD] they are instead guilt and shame. Some of the soldiers I have worked with describe experiences in which they, or someone close to them, violated their moral code...Others are haunted by their own inaction, traumatized by something they witnessed and failed to prevent.
Again and again scholars of moral injury highlight the need for community engagement. The refrain from these thinkers acknowledges that conversation about trauma is very difficult. In the end, this is not an issue only for them (the military and physicians), but also for us (civilians and patients). All too often, those untouched by moral injury gaze across the divide to those who have invisible wounds and conclude that the outsider simply can’t know, understand, or address territory so far away from their known world. This assumption — that there will always be an insurmountable psychic/emotional gap — produces silence and misunderstanding.
To quote Dr. Rita Brock on moral injury and soul repair, “this is not a problem just for Veterans Affairs, but the whole community.” We must actively and daily reframe the issue. Whether it’s a veteran or physician feeling alone, it will require a community of empathetic experts and confidants to help facilitate healing. No one can (or should) do the healing work alone.
Should the medical community start diagnosing and treating clinician burnout the same way as trauma?