Moral Injury

[pgg]

Someone else posted this over in my other home, the anesthesia forum. Seemed relevant here too. All of medicine seems broken to some degree.

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[Cooperd0g]

Medicine has a lot of ridiculousness.

Younger students pursuing a career in medicine are not always shown the realities of the profession. Happiness (or sadness) is the difference between Expectations and Reality. I think for a lot of people who enter medicine naive to realities have a negatively balanced equation. There just isn’t as much truth in advertising as their should be. Having said that ZDogg is very right because the equation shouldn’t be so negatively balanced.

And don’t get me started on medicine as a HRO and being “evidence based.”

 

[Gastrapathy]

Some of it is just burnout. No matter how fulfilling a job, too much work is too much. The moral injury part can decrease resilience but no matter how perfect a job, doctors just work too much.

And yeah, if I hear one more aviation metaphor, I’ll lose my mind.

 

[narcusprince]

Since you posted this twice. I will say this. Whats lost in some practices is the ability to truly make an impact. The replacability of knowing in the end all we are is an fte can be demoralizing. No matter all our training our time away from our families in the end we are an fte no more no less. What has given me some satisfaction mid career is truly being in service to those you work with. You have to find happiness outside the skills of just being and fte. Those that are happiest are the ones engaged in duties beyond our primary role. Do I get paid less yes, am I necessary to those I work with yes. Those things give me satisfaction. Find out what really makes you happy and go with it.

 

[militaryPHYS]

How do we validate the right balance? Most specialties (even non-surgical) are dependent on volume/acuity, repetition/consistency. But we realize that time off is vital to sanity. How are we supposed to know that we've spent enough time in the hospital learning our skill and can now spend more time at home or off? There aren't enough docs to spread the wealth of call/shifts/clinics most places. Training and group-sessions can't fix burnout, those things just takes more hours away from the physician who is struggling to find balance. We need more docs, we need efficient EMR's and we need ancillary staff to take away some of the administrative load.

 

[FlowRate]

ancillary staff to take away some of the administrative load

The astounding thing is how difficult it is to find people to do things, of any sort, quickly and accurately, with minimal downtime, the further down you go in the pay scale. Being surrounded by physicians takes you out of the reality that most people spend like 50% of their day just screwing around at work, doing nothing productive in particular.

 

[CheGuevaraMD]

The astounding thing is how difficult it is to find people to do things, of any sort, quickly and accurately, with minimal downtime, the further down you go in the pay scale. Being surrounded by physicians takes you out of the reality that most people spend like 50% of their day just screwing around at work, doing nothing productive in particular.

Is it really that astounding? If you can't find anyone reliable at a certain pay rate, offer higher pay.

 

[FlowRate]

Is it really that astounding? If you can't find anyone reliable at a certain pay rate, offer higher pay.

No I mean literally the pay range for "ancillary staff" as a whole, not "low paid ancillary staff."

 

[BlackFrancis33]

I am sick of lectures on burnout that give sage advice like 'exercise more' and 'spend more time with family'. I like it even better when some professor emeritus that sees patients once a month gives his keys to not burning out, because not having any real responsibility anymore makes you an expert. I also love physician wellness events during the midst of the work day that are supposed to decrease burnout, like massages, meditation classes etc. that are announced with short notice during our clinic days. Stop bringing in grand rounds speakers that are experts in 'physician burnout' and consider some small changes that might make physicians lives a little bit better. A physician lounge in a closet open from 1000 to 1400 that had coffee and saltine crackers would be an easy place to start. The gesture means as much as any small change sometimes. I feel like this video is getting at some of these frustrations.

 

[absolutdokta]

At least we got National Doctor’s Day coming up!!! That always gives me warm fuzzies

 

[Fpg1245]

The whole wellness movement in healthcare was essentially a load of nonsense from the start. It was a by product of a broken system defined by the loss of dignity, respect, and autonomy for the providers. All the BS wellness retreats, stupid team building exercises, irrelevant free therapy sessions, relaxation rooms was all a bunch of garbage designed to distract you from the truth: that they were being squeezed from all sides to do more work for less money. The practice of medicine was and continues to be challenging but there is a difference between the challenge of a clinically tough patient to treat and challenges by a health system that treats you like a criminal the second you touch a patient or one that plays shell games with your livelihood. A stress ball and therapy session will never quite cover it.

 

[DrMetal]

Meditation with lavender essential oils...is that really a thing? I prefer the spa and sports book a Caesars Palace

 

[John1513]

Happiness (or sadness) is the difference between Expectations and Reality.

I really like what @Cooperd0g wrote about happiness and balancing expectations and reality. For a young doctor coming into Miltary Medicine, this is vital. Expectations need to be calibrated not only for being a physician, but as an Officer working in a military structure, and calibrating our family values as well. This is why actively seeking out mentors is so key.

 

[haujun]

During locum work I see 15-20 patients and drive 2 hours daily. I am much more burned out at end of the day after seeing mere 8 patients in the Army hospital dealing with greater amount of military and patient admins with much less ancillary support. I am not even allowed to use printer in my room.
Change the system...I love those words. I doubt the system would significantly change for the military doctors. Those who end up staying in the military just embrace the system

 

[militaryPHYS]

During locum work I see 15-20 patients and drive 2 hours daily. I am much more burned out at end of the day after seeing mere 8 patients in the Army hospital dealing with greater amount of military and patient admins with much less ancillary support. I am not even allowed to use printer in my room.
Change the system...I love those words. I doubt the system would significantly change for the military doctors. Those who end up staying in the military just embrace the system

"The System" is what weighs on every physician. Military or civilian. Unfortunately, in the military we have the standard medical system which is focused on RVU's, documentation, EMR's, physician grades from happy or sad patients IN ADDITION to the weight of what the military system brings to the table. You can try to change the military system all you want, or embrace it like @haujun mentions.

I recommend embrace it whether or not you want to stay in or get out. You'll be happier. Embrace doesn't mean settle though. You can find ways to adapt it to make your life better. If you can influence real change, try...but don't be frustrated if your common sense ideas are shot down. Don't fight bad leadership, adapt to it. Eventually it becomes too much to handle and people leave. Some at 4 years post-residency, some at 20+ after retirement.

This goes hand in hand with what @John1513 and @Cooperd0g says about expectations. If you expect this to be the civilian world you will be let down. If you expect not to have to do a GMO tour, then get sent out, you will be crushed. Just like with going to the movies, keep your expectations low, or at least realistic, embrace the parts of the system which can't be changed at our level and work hard to adapt your world to keep you happy while trying to influence real change which will help everyone.

 

[Cooperd0g]

But ZDogg isn’t even talking about the military, he is talking about medicine in general. More and more physicians are employees and not self-employed now. You lose autonomy and authority when you become and employee and are subject to their RVU expectations and support limitations. Insurance companies want to cut reimbursement, Medicare cuts your reimbursement if you don’t switch your decades old practice to EMRs, etc. If you don’t know and understand these things, if you are wide eyed and naive about the actual work environment, then your expectations do not match reality and you are set up for disillusionment and “burnout.”

 

[pgg]

I recommend embrace it whether or not you want to stay in or get out.

The line calls it embracing the suck. I sometimes think it's akin to Arthur Dent and Ford Prefect being tortured with Vogon Poetry.

The Vogon began to read --- a fetid little passage of his own devising.

``Oh frettled gruntbuggly ...'' he began. Spasms wracked Ford's body --- this was worse than ever he'd been prepared for.

``... thy micturations are to me | As plurdled gabbleblotchits on a lurgid bee.''

``Aaaaaaarggggghhhhhh!'' went Ford Prefect, wrenching his head back as lumps of pain thumped through it. He could dimly see beside him Arthur lolling and rolling in his seat. He clenched his teeth.

``Groop I implore thee,'' continued the merciless Vogon, ``my foonting turlingdromes.''

His voice was rising to a horrible pitch of impassioned stridency. ``And hooptiously drangle me with crinkly bindlewurdles,| Or I will rend thee in the gobberwarts with my blurglecruncheon, see if I don't!''

``Nnnnnnnnnnyyyyyyyuuuuuuurrrrrrrggggggghhhhh!'' cried Ford Prefect and threw one final spasm as the electronic enhancement of the last line caught him full blast across the temples. He went limp.

Arthur lolled.

``Now Earthlings ...'' whirred the Vogon (he didn't know that Ford Prefect was in fact from a small planet in the vicinity of Betelgeuse, and wouldn't have cared if he had) ``I present you with a simple choice! Either die in the vacuum of space, or ...'' he paused for melodramatic effect, ``tell me how good you thought my poem was!''

He threw himself backwards into a huge leathery bat-shaped seat and watched them. He did the smile again.

Ford was rasping for breath. He rolled his dusty tongue round his parched mouth and moaned.

Arthur said brightly: ``Actually I quite liked it.''

Ford turned and gaped. Here was an approach that had quite simply not occurred to him.

 

[notdeadyet]

I saw the ZDogg video. I get the point but it bristled a bit.

I think it’s a little irritating to anyone who does a fair bit of trauma work and helps folks with actual moral injury.

Physicians talking about “moral injury” for working in a broken system is kind of like hearing Kylie Kardashian as self-made billionaire.

If you’re a physician whose only employment is performing abortions when it’s against your religion or religious principles, let’s talk. If you’re a physician who works too many hours and doesn’t like the hours and restrictions to clinical judgment placed on you by your employer, DEA, state licensing board, and/or guild, it’s called “burn-out” not moral injury.

For anyone suffering from ZDogg’s “moral injury,” switch to part-time practice and an employee-driven environment and watch the palliation kick in.