Burnout, Moral Injury, and the Healthcare System: Clinical Reflections on July 4th

Steven Moffic, MD, discussed the intersection of physician burnout and moral injury in psychiatry and medicine, framing the July 4th holiday as an occasion for professional self-reflection and structural examination of the systemic forces that sustain clinician distress.

Moffic opened by observing that burnout among psychiatrists and physicians has remained at near-epidemic levels for approximately 25 years—fluctuating modestly but without meaningful sustained reduction—a pattern he argued reflects failures of the healthcare systems in which clinicians practice rather than individual deficits. He emphasized that while wellness programs and self-care initiatives carry personal and mental health value, the evidence indicates they do not produce significant reductions in burnout, which instead requires meaningful systemic change.

Moffic then turned to the related but conceptually distinct construct of moral injury, which he traced to the work of Jonathan Shay, MD, PhD, a clinical psychiatrist whose landmark 1994 book Achilles in Vietnam first elaborated the concept from his work with Vietnam War veterans.¹ Moffic noted that recognition of moral injury in healthcare settings followed a considerable lag, and that the construct has since been incorporated into both the DSM and ICD-11 as a recognized concern in healthcare. He defined moral injury as arising when clinicians' core moral values are compromised, whether through their own actions or more commonly through the decisions of institutional leadership that affect day-to-day clinical work. He distinguished moral injury from burnout on the grounds that moral injury carries an additional burden of self-reproach and shame that makes it harder to recognize and address, and argued that when moral injury co-occurs with burnout, the combined effect is particularly resistant to intervention.² Moffic acknowledged that evidence-based treatments for moral injury in healthcare contexts remain a work in progress, with peer discussion and trusted relationships—including colleagues and pastoral resources—among the most supported approaches.

Moffic concluded by encouraging psychiatrists to use holiday periods of reflection to examine whether workplace experiences of diminished competence or ethical compromise may be systemic rather than personal in origin, and to consider whether moral distress may be contributing to their occupational suffering.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

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

2. Hines SE, Chin KH, Glick DR, et al. Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic. Int J Environ Res Public Health. 2021;18(2):488.