Burnout and Moral Injury

“I’m done” were the words that seemed to resonate. I have been hearing that more and more frequently from my colleagues, both nurses and physicians. The ER nurse I spoke with was ready for a new job, a greener pasture. I listened and agreed. I offered my help: a phone call, a letter of recommendation, anything to help them escape the madness of another understaffed shift in the ER. This was done with hesitancy, knowing that if another experienced nurse leaves, our ER may not be functional. Problems are brewing across ER’s in America. Solutions are slow. The burnout of ER life takes it toll.

The Brewing Storm

The last few months in the ER haven’t been pleasant. Daily patient volumes in the ER have doubled and some days tripled from what we were seeing during the COVID era. We are seeing volumes that surpass pre-COVID volumes and are doing so with a small portion of the nursing staff that we used to have. A recent article out of Oregon has made the rounds on social media. It highlighted struggles that many ER’s and hospitals across the nation are facing.

The ER was the designated COVID zone for most of the country as primary care locations refused to see any people who had the hint of a cough or a sneeze. Interestingly when COVID first hit the volumes of patients coming to the ER precipitously dropped. Patients were afraid.

Nursing and physician hours were cut drastically in 2020 as hospital CEOs saw their bottom line falling through the floor. Hiring freezes hit hospitals across the nation. Nurses scraped for hours. Many moved on, deciding to pursue further education or a new life with predictable hours and non-violent patients.

The penny pinching mentality of the administrative erudite proved to be nearsighted. The brewing storm has seem to hit with full force. Come 2021 patients hit the ER doors running. After a year of not seeking medical attention the not so proverbial bus is unloading every day at emergency room entrances all over the country. What should not have been emergencies have now become so. A year of neglecting high blood pressure, diabetes, and heart disease has led to a new batch of problems. A nation shut down to COVID has reopened to a world of worsening health. The cure for Covid has become the cause.

Feeling the Squeeze

At times I feel like a dry orange in the Sahara Desert. My job squeezing every last ounce of sanity I have. People ask if I like my job. I usually say yes. After working almost every day of the last two weeks a different slew of emotions come to mind. “Yesterday i hated my job. Today it’s tolerable. Give me few days off and I may enjoy it again.” I don’t think that is unique to my profession, but the day to day whirlwind seems to be a lot more noticeable.

We are constantly reminded in medicine to “Be aware of burnout”. We are taught the warning signs. A few that I occasionally recognize in myself:

1. Insensitivity towards patients
2. Helplessness
3. Impatience
4. Depression
5. Callousness

I once tried to only work night shifts for 6 months. I was a shell of a human. While driving in the car I told Kelsey that I was “depressed”, a word I never thought I would say about myself. The truth is I was suffering burnout. I’m a fairly happy go lucky type of guy. When gloom and doom hits me I find that it’s time to take a few steps back.

The truth is over the last 6 months all of us in medicine have felt some burnout. Myself and other coworkers ask for help covering a shift. The ER doesn’t close and a physician has to be there. The birth of a child, a friends wedding, a parents funeral, or simply a need to get some fresh air; all legitimate needs for a day off. The responses to cover the open shifts come in slowly. Unfortunately everyone needs the day to recover.

In the Madness

In the daily madness a patient comes to the ER. Their eyes and skin a giveaway at their diagnosis…jaundice. “Any pain”, I ask. “Not really” the patient replies. Just like the textbooks say, a pancreatic mass. The prognosis grim and options few, I take time I didn’t have. I sit down and take 15 minutes with the patient and their spouse. I explain the best I can what is going on, what to expect in the short term, and explain their grim prognosis for the future. In the process of caring I suddenly feel human again. The burnout from the chaos outside of the room seems to fade away. I’d spend all of my night in that room…if only I didn’t have a waiting room full of patients to see.

Solutions to Burnout

The reality of modern medicine is that it will not get easier. Increasing rules, regulations, and bureaucracy are tightening the grip on our profession. Some have suggested we stop calling what’s happening as “Burnout” but rather refer to it as “Moral Injury”. For too long the blame of burnout has been placed on the provider. It happens because you haven’t taken enough vacation time, you’re not exercising, you’re not eating healthy, you’re weak. The solutions to burnout have long focused on reforming the clinician rather than improving the system.

I am no stranger to vacations. Besides golfing one of the things I am best at in life is planning vacations. Inevitably they help me cool off, relax, and reflect. I come back from vacation a better clinician and better human. The vacation solution to burnout unfortunately is a bandaid which inevitably gets ripped off.

More practical solutions at resolving “moral injury” revolve around transforming the workplace, not transforming the practitioner‘s personal life. Solutions like:

1. Hiring sufficient personnel to manage the load
2. Rewarding outstanding performance instead of focusing on negative feedback
3. Providing incentives for continued excellent performance

What’s Next?

Unfortunately solutions like this are increasingly hard to come by. After all, health care is a business. Productivity and the bottom line reign supreme.

I don’t pretend to be unaware of the challenges that health care administrators face. A hospital that is not fiscally solvent is also not a great place to work. The government places new restrictions daily and insurance is constantly cutting reimbursement. Difficult decisions need to be made on a daily basis. Right now it seems that those difficult decisions are disproportionately hurting the people that hospitals need the most….Janitors, Techs, Nurses, APCs, Doctors.

To my nursing friends and all other hospital staff who are working hard and have doubled your load…Thank You! To those of you who have decided to move on from the ER, you will be missed. To those daring to stick around, we need you! Our patients need you!

About the Author

I’m a husband, dad, golfer, and ER doctor. I believe in the two great commandments: “Love the Lord thy God with all they heart, and with all thy soul, and with all they mind…The second is like unto it, Thou shalt love thy neighbor as thyself.”