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Military Surgeons Deployed to Combat Environments Face Moral Injury, Distress - U.S. Medicine
"Moral distress—characterized as overwhelming feelings of being powerless to do what is believed to be right—and moral injury—trauma from an event generates significant dissonance with the individual's belief system and worldview—are topics of increasing interest and research in civilian health care professionals and combat soldiers."
Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq
https://jamanetwork.com/journals/ja...01742/ryu_2023_oi_230032_1676399882.20722.pdf
“He was young…had isolated facial injury. There was nothing that would have killed him other than his airway. You think about things that you could have done differently…you think, we should have more securely tied down his tube or should have done an airway. Maybe then that wouldn’t have happened.”
"Several surgeons mentioned that they did not have the necessary prior caseload experience to prepare them for deployment from their military hospital experience back home. They felt that the teams were not given enough time to prepare together before deployment and, often, they felt that the ancillary personnel were improperly or incompletely trained to support the
operation, leading to substantial frustration and diminished patient outcomes."
"Furthermore, surgeons said that they were not trained to do some operations that were required of them, which led to second-guessing of decisions made before and during surgical procedures."
"Measure of Moral Distress for Healthcare Professionals statements Score, median (IQR)
Watched patient suffer because of a lack of practitioner continuity 8.5 (3.3-16.0)
Was unable to provide optimal care due to pressures from administrators or environment to reduce costs and save resources 7.5 (4.0-11.3)
Experienced compromised patient care due to lack of resources, equipment, or bed capacity 6.0 (4.0-11.3)
Was required to work with other health care team members who are not as competent as patient care requires 5.0 (3.0-11.3)
Witnessed low quality of patient care due to poor team communication or team training 4.0 (1.3-6.0)
Experienced lack of administrative action or support for a problem that is compromising patient care 4.0 (4.0-9.0)
...
Was pressured to avoid taking action when I learn that a physician, nurse, or other team colleague has made a error and does not report it 3.5 (1.0-6.0)
...
Felt unsafe or bullied among my own colleagues 3.0 (0.0-4.0)
Worked within power hierarchies, in teams or units that compromise patient care 2.0 (0.3-4.0)
...
Witnessed a violation of a standard of practice or a code of ethics and not feel sufficiently supported to report the violation 1.5 (0.0-4.0)
Felt required to overemphasize tasks and productivity or quality measures at the expense of patient care 1.0 (0.0-4.0)
Was required to care for more patients than I can safely care for 1.0 (0.0-2.3)
Feared retribution if I speak up 1.0 (1.0-4.0)"
...
Brief commentary:
At first, I kept reading the word "morale". By "moral" they mean what I would call "existential" or "mental/emotional/spiritual".
I get that military members at all levels (not just surgeons) accept that suffering some level of PTSD from the horrors of warfare is just par for the course, and were aware of this when they raised their right hands. However, this study reveals that many of the stressors surgeons and others experience in country are directly due to the dysfunctional military medical system itself.
What is striking in the commentaries (table 3, page 7) is how many of the stressors these surgeons experienced were created by their incompetent/unreasonable commanders and/or inadequately trained/experienced co-workers, rather than the exigencies of combat patient care per se. Having your clinical decisions questioned after the fact by higher echelons of care that have CT-scan capability, for example, seems pretty demoralizing.
Even when they returned home, the after-effects of their moral damage didn't stop. In the article one surgeon discusses his "worst complication of [his] career" because he was rusty from not doing the kinds of cases his civilian practice required of him.
I think prospective military physicians should be directed to this kind of article so that they understand exactly what they are signing up for: a system where the smart and competent few are led, assisted, and second-guessed by the dumb and/or inexperienced many.
In related news:
Harvard researcher says he reversed his aging with these 4 steps
4. Reduce stress and avoid "idiots"
Stress and annoyance from being around "idiots" can reduce someone's life expectancy, Sinclair said, since it can lead to chronic stress and increased inflammation. The latter of these consequences can raise one's risk for heart disease, obesity, sleep problems and accelerated aging.
Sinclair's solution is to set aside "quiet time" each day and avoid working with idiots.
"Moral distress—characterized as overwhelming feelings of being powerless to do what is believed to be right—and moral injury—trauma from an event generates significant dissonance with the individual's belief system and worldview—are topics of increasing interest and research in civilian health care professionals and combat soldiers."
Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq
https://jamanetwork.com/journals/ja...01742/ryu_2023_oi_230032_1676399882.20722.pdf
“He was young…had isolated facial injury. There was nothing that would have killed him other than his airway. You think about things that you could have done differently…you think, we should have more securely tied down his tube or should have done an airway. Maybe then that wouldn’t have happened.”
"Several surgeons mentioned that they did not have the necessary prior caseload experience to prepare them for deployment from their military hospital experience back home. They felt that the teams were not given enough time to prepare together before deployment and, often, they felt that the ancillary personnel were improperly or incompletely trained to support the
operation, leading to substantial frustration and diminished patient outcomes."
"Furthermore, surgeons said that they were not trained to do some operations that were required of them, which led to second-guessing of decisions made before and during surgical procedures."
"Measure of Moral Distress for Healthcare Professionals statements Score, median (IQR)
Watched patient suffer because of a lack of practitioner continuity 8.5 (3.3-16.0)
Was unable to provide optimal care due to pressures from administrators or environment to reduce costs and save resources 7.5 (4.0-11.3)
Experienced compromised patient care due to lack of resources, equipment, or bed capacity 6.0 (4.0-11.3)
Was required to work with other health care team members who are not as competent as patient care requires 5.0 (3.0-11.3)
Witnessed low quality of patient care due to poor team communication or team training 4.0 (1.3-6.0)
Experienced lack of administrative action or support for a problem that is compromising patient care 4.0 (4.0-9.0)
...
Was pressured to avoid taking action when I learn that a physician, nurse, or other team colleague has made a error and does not report it 3.5 (1.0-6.0)
...
Felt unsafe or bullied among my own colleagues 3.0 (0.0-4.0)
Worked within power hierarchies, in teams or units that compromise patient care 2.0 (0.3-4.0)
...
Witnessed a violation of a standard of practice or a code of ethics and not feel sufficiently supported to report the violation 1.5 (0.0-4.0)
Felt required to overemphasize tasks and productivity or quality measures at the expense of patient care 1.0 (0.0-4.0)
Was required to care for more patients than I can safely care for 1.0 (0.0-2.3)
Feared retribution if I speak up 1.0 (1.0-4.0)"
...
Brief commentary:
At first, I kept reading the word "morale". By "moral" they mean what I would call "existential" or "mental/emotional/spiritual".
I get that military members at all levels (not just surgeons) accept that suffering some level of PTSD from the horrors of warfare is just par for the course, and were aware of this when they raised their right hands. However, this study reveals that many of the stressors surgeons and others experience in country are directly due to the dysfunctional military medical system itself.
What is striking in the commentaries (table 3, page 7) is how many of the stressors these surgeons experienced were created by their incompetent/unreasonable commanders and/or inadequately trained/experienced co-workers, rather than the exigencies of combat patient care per se. Having your clinical decisions questioned after the fact by higher echelons of care that have CT-scan capability, for example, seems pretty demoralizing.
Even when they returned home, the after-effects of their moral damage didn't stop. In the article one surgeon discusses his "worst complication of [his] career" because he was rusty from not doing the kinds of cases his civilian practice required of him.
I think prospective military physicians should be directed to this kind of article so that they understand exactly what they are signing up for: a system where the smart and competent few are led, assisted, and second-guessed by the dumb and/or inexperienced many.
In related news:
Harvard researcher says he reversed his aging with these 4 steps
4. Reduce stress and avoid "idiots"
Stress and annoyance from being around "idiots" can reduce someone's life expectancy, Sinclair said, since it can lead to chronic stress and increased inflammation. The latter of these consequences can raise one's risk for heart disease, obesity, sleep problems and accelerated aging.
Sinclair's solution is to set aside "quiet time" each day and avoid working with idiots.
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