burnout or moral injury
Dear reader,
Earlier this summer I was talking to a dear friend who, like me, is going through the process of unlearning the habits we've picked up during medical training. She made an analogy between being in residency and diabetes. Initially, diabetes can be an invisible illness, developing insidiously, easy to ignore as you go on living. But as it progresses untreated it can turn horrific, eventually leading to organ damage or limb amputation, something we witnessed together many times during our first clinical rotation as baby medical students.
Similarly in medical training, the damage is invisible at first. We sacrifice a little bit of sleep here, some social functions there, and all our colleagues are doing it around us too so we barely notice. Medical culture demands that we continue to push ourselves harder when we're tired, so we learn to ignore our body's signals to rest. We don't have time to process emotions around what's happening in the hospital, so we compartmentalize and repress them. It becomes normal to witness something heartbreaking and then turn around and see several more patients without pausing to feel anything. We learn how to get by, until we literally can't anymore. We reach a point where we are numb, exhausted, and detached.
Around this time, for many of those who make it through, training finally ends. We are then supposed to go into the world and start taking care of patients. But how are we supposed to care for others if we've never learned to take care of ourselves? In what reality do we want our healers to be fatigued and dissociating? What is this horrible system?!
Some people call these symptoms burnout, which leads to suggestions to rest, meditate, exercise, go to therapy - all important and sometimes very helpful interventions, but things that frame us as weak individuals unable to cope with stressors. I prefer the term moral injury, which describes knowing what our patients need but being unable to provide it due to systemic constraints. This can show up as being forced to focus on documentation rather than time with patients or as the pressure to do too much in too little time because of staffing cuts. Moral injury situates our profit-driven healthcare system as the problem, rather than the individual.
While my lived experience is in medicine, I know burnout and moral fatigue aren't unique to us - any situation where you're forced to continue to push yourself in a broken system can lead to the same outcome. I have heard public defenders, activists, and therapists describing the exact same frustrations. It can be so common to internalize the problem, to think that you are weak rather than that the system is broken.
Even when we're focusing on individual changes that we can make here-and-now like sleeping more, eating better, engaging in relaxation techniques, etc, I think that it's important to remember that we don't need to do these things because we are broken or weak. We take care of ourselves so that we can have the energy to change the systemic issues and make the world a better place for each other.
<3 Kalen Flynn, MD