Letters: Reframing Clinician Distress: Moral Injury Not Burnout

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To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.

Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.

Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3

While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.

I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?

On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.

The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.

Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.

Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.

Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.

COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA

Author Affiliation: Uniformed Services University of the Health Sciences

Correspondence: Elspeth Cameron Ritchie ([email protected])

Disclosures: The author reports no conflict of interest with regard to this article.


1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.

2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.

3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alien....

4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.

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