Anne Louise Phelan, M.D., is a retired physician and a writer, currently working on a memoir titled “The Disrupted Physician.” The following article by her was published in the Richmond Times-Dispatch. The link to the article is connected to the title.  Please go on the website and leave a comment. Dr. Phelan also asks for letters to the editor in response to this article.

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And now for her article:

Moral injury, mortal wounds and the COVID pandemic

The COVID-19 pandemic is a slow-moving, mass-casualty event. The omicron wave has put extraordinary demands on front-line health care professionals whose physical and emotional resources, including compassion, already are depleted. As they struggle to function in a medically and ethically acceptable manner, a chasm develops between what they feel honor-bound to do and what their circumstances permit. The cognitive dissonance and psychological distress associated with this chasm is referred to as “moral injury.”

Moral injury is similar to, but not synonymous with, burnout. Burnout can be relieved with rest and a change in circumstances; moral injury is imbued with feelings of shame, regret and self-incrimination that haunt those who bear it. Unrelenting moral injury, over time, can contribute to physical illness, substance abuse and mental health disorders. Like a burn wound, the deeper the distress, the longer it lasts and the more pervasive its effects, the greater the injury.

While moral injury is well documented in veterans of war and can contribute to post-traumatic stress disorder, it also affects health care professionals as they contend with time constraints, bureaucratic demands, dysfunctional medical records systems, staff shortages and organizational chaos. Trained to put all available resources into saving individual lives, they are ill-equipped to pivot toward the crisis standards of care that could force them to choose who might live and who will surely die.

Even after this crisis has passed, its deleterious effects on our front-line health care workers, their colleagues and our health care system will linger for years. In his impassioned March 2021 guest column in The Washington Post, Dr. Thomas Kirsch wrote:

“I sometimes wake up at night, suddenly, sharply aware and deeply sad. Haiti comes back to me again. It’s been 10 years. After the earthquake, I worked there in a cramped, hot, ill-equipped tent on the grounds of a half-destroyed Haitian hospital, trying to care for the sick and injured as they poured in, overwhelming our capacity to help them all. Now I lay awake dreading what might be coming as the covid-19 pandemic sweeps the world.”

Some front-line health care workers will transition to less stressful specialties; others already have quit their jobs or retired early. Survivors of COVID-19 infection may have long-term health complications that impede their ability to practice. These are losses our health care system can ill afford.

Health care professionals who suffer severe moral injury face a substantially increased risk of PTSD, anxiety, depression, substance abuse and suicidal ideation in the years to come. Unfortunately, health care entities — hospitals, licensing boards and the medical profession itself — tend to believe mental health disorders, even with proper treatment, automatically impair a practitioner’s ability to provide optimal patient care.

The associated sense of shame of being labeled “impaired” worsens psychological problems and puts clinicians in a no-win situation. If they seek formal care, they must divulge their diagnoses, putting their privilege to practice at risk. If (to protect their privacy) they treat themselves, they’re committing an ethical violation that can have similar repercussions. If they eschew medical care altogether, they are stuck in a world of hurt, a place where I and many of my colleagues have lived at times over our years of practice.

Even a temporary suspension of hospital privileges or license to practice can have a career-long impact. All adverse professional actions against physicians must be reported to the National Practitioner Data Bank, an official physician records repository. Licensing boards and other entities check the NPDB when physicians apply for (or renew) their clinical privileges or medical licenses. Adverse NPDB reports can interfere with a physician’s ability to obtain or renew a medical license, find work elsewhere or move out of state. There is no mechanism for removing derogatory data, no matter how irrelevant or inaccurate it’s proven to be.

There need not be any actual evidence of professional impairment for licensing boards to take action against a licensee. In direct violation of the Americans with Disabilities Act, the mere existence of a mental health diagnosis can result in discipline. Physicians and nurses who are alleged to have a substance use disorder have no choice in their treatment. As a condition of keeping their license, they must comply with their board’s onerous regimen of invasive, prolonged and expensive treatment and monitoring.

Any slip-up, including an alleged relapse, can result in immediate license suspension or further discipline. So psychologically injurious can these contracts be that they have driven some physicians to suicide. A well-known case is that of Gregory Miday, a Missouri physician who, after a brief alcohol relapse, took his own life rather than face another five years in a mandated physician health program.

We must recognize there might be serious consequences of this pandemic to our front-line health care professionals long after the acute crisis is resolved. Lauding them as heroes now will not help them later as they struggle to cope with moral injury, and other physical and emotional wounds. We need to remove the stigma of mental and physical illness, and provide sanctuary rather than discipline to our wounded healers. Licensed health care professionals must be treated with the same compassionate, appropriate and confidential care that anyone with a service-related disability deserves.