Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
