Letters: Reframing Clinician Distress: Moral Injury Not Burnout

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To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2

As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.

Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7

Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.

Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.

Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.

In closing, this topic is too important not to discuss. Let the conversations continue!

Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD

Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine

Correspondence: Lynne Padgett ([email protected])

Disclosures: The authors report no conflict of interest with regard to this article.


1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.

2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.

3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-B.... Published May 28, 2019. Accessed October 10, 2019.

4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.

5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.

6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.

7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.


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