Moral Injury


To start the terms moral injury or burnout, are powerful and emotionally charged words that do have standard definitions, but still experienced in different ways by different people.  These words can be powerful enough to even stop discussions.  Probably a healthier way to think about moral injury and burnout is that they are the opposite of engagement; anti-engagement.  When we are engaged at work, everything is so much better, even if it’s hard.  To put it simply, engagement is the antithesis of burnout and we should strive to increase our collective engagement. 

In orthopaedic surgeons, Shanafelt (Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag JA. Burnout and career satisfaction among American surgeons. Ann Surg. 2009 Sep;250(3):463-71. doi: 10.1097/SLA.0b013e3181ac4dfd. PMID: 19730177.) has found that about 50% of orthopaedic surgeons meet criteria for burnout.  Occupational burnout has 3 components:

  • Emotional exhaustion
  • Depersonalization of patients
  • Perceived lack of personal accomplishment 

The personal effects of moral injury/burnout include broken relationships, alcohol and substance abuse, depression and too often suicide.  The professional effects include decreased quality of care, increased medical errors, decreased patient satisfaction, decreased productivity and professional effort and increased physician turnover.  This is a pretty bleak picture, especially when on average half of us suffer from burnout during our career. 

So, what causes burnout?  There are 7 drivers of burnout/engagement for physicians.  If drivers are optimized then higher levels of physician engagement occur.  If the drivers become less optimized, then less physician engagement occurs.  This is what can be called burnout.  The 7 drivers are listed below:

  • Workload and job demands
  • Efficiency and resources
  • Organizational culture and values
  • Social support and community at work
  • Work-life integration
  • Control and flexibility
  • Meaning in work

In the past (and maybe in the present), hospitals and health care systems and proactive groups operated with the idea that individual physicians are responsible for engagement and this led to the use of narrow solutions.  Think of things like stress management workshops or individual mindfulness training.  Many of the primary drivers of burnout are organizational in nature and can only be addressed at that level.  In fact, there are 4 scales to consider for physician engagement:

  • Individual factors
  • Work unit factors
  • Organization factors
  • National factors

Now you can make a matrix of the 7 drivers and 4 scales to make a large chart that can give an insight into the complexity of making these changes. For example, changes in the reimbursement structure would have one effect while changes in your work unit would have another.  It’s beyond the scope of this discussion to go into more depth.  Please read the papers below to find out more. 

  1. Daniels AH, et al.  “Orthopaedic Surgeon Burnout: Diagnosis, treatment and Prevention.”  J Am Acad Ortho Surg 2016; 24: 213-219.  This is a review paper with details regarding the incidence and factors that are related to burnout in orthopaedic surgeons.
  2. Shanafelt TD, Noseworthy JH.  “Executive Leadership and Physician Well-being; Nine Organizational Strategies to Promote Engagement and Reduce Burnout.”  Mayo Clin Proc 2017; 92(1): 129-146.  This is a sensational paper to read.  It details the causes and 9 strategies that organizations can engage so that improvements in physician wellness can be realized.