REVIEW COORDINATOR: Courtney Miller

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September 3rd, 2019 1:20:31 pm

Medicine’s Moral Injury

A differential diagnosis and healing narratives

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Abstract

“Physicians aren’t burning out; they are experiencing moral injury.” That claim has struck a nerve among physicians. Moral injury is “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” The conversation in medicine juxtaposes metaphorically the ethical and emotional damage of physicians with the experiences of combat veterans. Primary and secondary trauma occur in both medicine and war. This paper uses evidence from medical student writing to describe the symptoms of the trauma and the consequent dis-ease--moral injury. Moral injury is sometimes called "burnout" or "moral distress," and remedies are proposed including meditation, mindfulness, and resiliency skill training. All of those are helpful techniques, but they do not address the deeper pain physicians and medical students are experiencing, nor do they honor the contexts, meaning, and stories of the traditions from which meditation and mindfulness come. Marx’s theory of alienation will deepen the diagnosis of the dis-ease. Creative medical educators and students, practicing narrative medicine, will point toward healing responses for living in creative tension with the dis-ease.

“Physicians aren’t burning out; they are experiencing moral injury.”(1) That claim has struck a nerve among physicians. Moral injury is perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”(2) The conversation in medicine juxtaposes the ethical and emotional damage of physicians with the experiences of combat veterans. This paper uses evidence from medical student writing to describe the symptoms of the dis-ease.  Marx’s theory of alienation will deepen the diagnosis. Creative medical educators and students, practicing narrative medicine, will point toward healing responses for living in creative tension with the dis-ease.

Symptoms: the Dis-ease and its Naming(3)

Here is a story from an Iraq war veteran-turned medical student:

Don’t think about dying when joining the Army. Kneeling over thirteen men as they made their journey to the other side. Removing Jack’s sensitive items from his bloated body that had been wedged under the Helmand River for three days. Putting tourniquets on all four missing limbs. Guard duty in the middle of the night, listening to Tyrone cry over the radio … that Wayne and Mac were gone…. Watching blood spurt out of a child’s head and then stop. Looking into a two-inch hole in his chest. Chuck’s pale face in the open casket after he put a bullet through it. Can’t forget the dead after leaving the Army….(4)

Here is a story from another student after a night in the Emergency Department:

Context:  a small, terrified child from a car accident with head trauma and crushed leg whose parents are in hospitals miles away; a young woman the same age as the medical student screaming in pain as broken glass is removed from her body, and exposed bone protrudes where there should be skin; two attempts at resuscitation on other patients, neither of which is successful; conversations with spouses and loved ones; return to the non-acute patients.

“They see I’m flushed and dripping with sweat. After I ask one how he is he reflects … back [to] me. “How are you?” “I’m okay,” I say calmly with a smile. I was okay. I wouldn’t be later. But later is later, now is now. And now demands all of me so I give it.

“There’s finally a pause in all the traumas. I …leave since I’ll be getting up for clinic in a few hours. I pack my bag. The last thing I see as I’m walking out the door is the little boy, still lying in the bed, still totally alone.

“He stays with me even though I couldn’t stay with him.”(5)

Consider these narratives as initial evidence that combat soldiers and medical students both undergo trauma. The stories are visceral, haunting, and echo the certainty of unresolved and unrelenting memory. It is important not to reduce the experience of either veteran—of war—or of medicine – to the other; rather the soldiers’ stories are metaphors for the stories of medical students. Metaphors are not analogies; they are concepts that illuminate some aspects of a thing and shadow others. A metaphor invites us to see one thing in terms of another as it “places in proximity two different things whose surprising contrasts suggest dimensions of both not previously appreciated.”(6) Naming the medical students’ experiences trauma—juxtaposed to that of veterans—allows us to see dimensions of each not previously perceived.

Rita Nakashima Brock makes an important distinction: this is not Post-Traumatic Stress Disorder (PTSD). “Clinicians have treatments for PTSD, and such therapies are crucial for those diagnosed with it. The moral questions emerge after the traumatizing symptoms of PTSD are relieved enough for a person to construct a coherent memory of his or her experience.”(7) Trauma is a catalyst for moral injury, as defined by Jonathan Shay: a betrayal of ‘what’s right’; either by a person in legitimate authority or by one’s self; in a high-stakes situation.(8) Brock argues that moral injury can be the result of what is often called secondary trauma—witnessing, failing to prevent, even participating in another’s trauma: “Experiences of another’s trauma can invade the inner states and inhabit the imaginations of others…as something like emotional contagion.”(9) Primary and secondary trauma cause moral injury, which challenges a person’s identity and integrity: What have you destroyed in me? You have destroyed, simply --with all my past life—the idea that I have always had of myself.(10)

Differential Diagnosis of the Dis-ease:

In medicine, the process of imagining all the alternatives that a collection of symptoms could influence is called the differential diagnosis (Ddx).  The Ddx of medicine’s dis-ease includes: moral injury, moral distress, burnout, and at a more superficial level: work-life balance.(11) Burnout and moral distress are commonly used diagnoses for the dis-ease experienced by physicians and medical students.(12) 

Moral Distress

Consider the phenomenon of moral distress as a possible symptom of moral injury. Moral distress describes the situation when people lower in the hierarchy are in a situation where they may have an idea of what to do, or they may have an intuition that what is happening is not ethical, but they lack the power and authority to act in accordance with their ethical intuitions. Moral distress can be an indicator of two different things: on the one hand, it can be an indicator that the distressed person’s moral intuitions and ethical compass are alive and well. On the other hand, moral distress that is unrelenting can lead to moral injury.(13),(14) 

Moral distress can be an indicator of health. Daniel Chambliss, echoing Socrates, says: "The greatest ethical danger . . . is not that when faced with an important decision one makes the wrong choice, but rather that one never realizes that one is facing a decision at all.”(15) Some analysts, however, discuss moral uncertainty—where there may be more than one morally reasonable resolution—as if that situation is problematic.(16) On the contrary, this kind of moral wrestling is important: it is a sign of moral intuitions and ethical sensibilities alive, awake, and engaged. Not even seeing ethical issues or thinking that there is only one right answer is a much bigger problem. How those moments are named, acknowledged, and treated can influence whether it becomes moral injury or a catalyst empowering courageous change.(17),(18)

Burnout

Burnout—defined as emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment—has been studied extensively in nurses, physicians, and students, and a common proposed remedy includes mindfulness practice and resiliency skill training. (19),, (20) If the dis-ease is burnout, then there is evidence that such practices can help reduce stress, renew focus, and provide resources for resiliency.(21) If the dis-ease is moral injury, those interventions are inadequate to address its seriousness; furthermore to use such practices as mere techniques—interventions that can be ordered like scans or labs—is to trivialize the both the seriousness of the dis-ease of moral injury and the depth of teaching and wisdom traditions from which meditation and mindfulness emerge. While these interventions have proven helpful with burnout, they do not “fix” moral injury, which is more like a chronic disease than a broken arm to be set at Urgent Care.(22) 

Alienated Labor

Karl Marx argued that the experiences that workers in 19th century factories—called “hands”—were dehumanizing. Workers were valuable primarily for their hands, and one job on a production line removed them from the products of their labor, the process of creating it, the reasons for doing it, and even from themselves. Consider alienated labor another metaphor to examine the moral injury suffered by medical students. Below are examples of Marx’s four types.

1) Alienation can occur from the “product”—the healthy patient—to the student’s dismay:  

I am … afraid that I have lost pieces of myself. I have seen people flayed apart and been exposed to various forms of physical and emotional trauma. ... I strive to be as empathetic as I can, but I … put up barriers for my own sanity. I remember screams of a patient’s daughter and wife [in the ED my first time]. I remember not sleeping that night and feeling deeply troubled…. A year later I have been on numerous codes many of which resulted in bad outcomes.  During these I practiced intubations and interpreting [tests and labs]. I’m afraid that I’m forgetting that these are real people. They are not manikins or paid actors. They are people with a story and loved ones. I am protecting myself but I don’t want to. I don’t want to become accustomed to other’s suffering.(23)

Here is another story of a student as witness to a physician alienated from the patient:

Our next patient is a 92 year old man with dementia who is brought in for a routine ear cleaning. As we walk into the room, I see him sitting in a wheelchair, chin tucked against his chest. He's wearing gray sweatpants, a [stained] ragged red shirt, and a pair of dirty, old sandals. His gray hair is matted…. As we enter, he slowly raises his gaze to meet ours. The attending doesn't introduce himself [or me] to the patient…. Instead, he immediately picks up his instruments from the side table and starts … picking out dried earwax from the patient's ear canal, oblivious to the wincing of the patient as he is poked and prodded. I introduce myself and melt into the wall, once again the invisible medical student in the uncomfortable silence. We leave the room after about three or four minutes.

Never once does the attending shake the patient's hand, speak to him, or even meet his eye.(24) 

This student experiences a betrayal of what’s right by a legitimate authority. It is indicative of what this patient might face with this physician in a much more high-stakes situation. The student passively participates.  It models a practice of removing oneself from the patient, so that the first form of alienation – from the ‘product’ – is accomplished.(25) 

2) The second form of alienation—from the process –can occur through increased specialization and through increased separation of the physician from the patient by technology. There were no specialists in medicine in the US until the 1930s. By 2015, 67% of US physicians were specialists and sub-specialists.(26)The electronic medical record (EMR) was designed to promote communication among a team of people caring for a patient, to support the health of the patient, to provide access for the patient to her physician-team. It becomes a billing machine.(27) The EMR “has burrowed its tentacles into every aspect of the health care system.”(28) Alienation from the process of the physician caring for the patient is accomplished.

3) The third form of alienation is from the calling into medicine: to help, to heal, and when possible, to cure:

I wonder if medicine is really any different [from other professions], or if we just tell ourselves it is to try to justify everything that we put ourselves through. … Caring about patients may motivate you to work harder at certain aspects of your job … but … won’t even get you the basic respect of your peers in many circles. What will get you [respect] … is charting promptly, getting patients discharged, … feigning impossible levels of enthusiasm for every task you are assigned, and … making things easier for your superiors… I want sincerity in all my interactions. I want to direct my energy toward meaningful purposes.  I want to be in an environment where wanting those things isn’t interpreted as a sign of weakness or lack of dedication….(29)

When organizational and social structures prevent living out that calling, it can result in moral injury separating the practitioner from the calling into medicine.

4) The final form of alienated labor Marx identifies results in alienation from what it means to be human – from the patient, from one’s community, family, and self. Physicians and students witness to and wrestle with tragedy on a daily or weekly basis. Tragedy cannot be “fixed,” and education in responding to those moments are found elsewhere—philosophy, literature, religion, art. Physician and medical trainee suicide rates are particularly poignant: between 300-400 physicians every year kill themselves.(30) 

A new documentary, entitled Do No Harm, focuses on physician suicide; it begins:  

Jumping off hospital rooftops, hanging themselves in janitorial closets, overdosing on drugs—they’re A students and their suicides are often like well-planned school projects. Doctors are our healers, yet they have the highest rate of suicide among any profession. Medical students and families of physicians touched by suicide come out of the shadows to expose this silent epidemic and the truth about a sick healthcare system that not only drives our brilliant young doctors to take their own lives but puts patients lives at risk too.(31)

The tragedy presented by this phenomenon echoes Dr. Rieux, the narrator in Camus’ The Plague: “What filled his breast was the passionate indignation we feel when confronted by the anguish all men share.”(32)At heart, the physician’s ultimate challenge is to be to be human in the face of tragedy. That cannot happen alone.(33)

Just as a problem exists in not even seeing ethical issues, so it is a problem that some medical researchers and teachers do not see the moral injury caused by the medical system.  For example, one of the most widely cited articles on physician burnout uses the following metaphor: “Students must be taught the concept that physicians are themselves therapeutic instruments and as such require calibration.”(34) The metaphor of the physician as a therapeutic instrument sadly reinforces medicine as a mechanical, dehumanized practice. It further exacerbates the dis-ease, because it does not address the foundational issues.(35) If the practice of medicine requires being human and confronting the tragic, pretending this is not the case deepens the alienation.

I have argued that calling moral injury “burnout” and recommending remedies that include techniques of “stress management”– trivializes both the seriousness of the alienation, the moral injury, as well as the depth of the wisdom traditions that have produced yoga and meditation. How can students and physicians experiencing moral injury live in creative tension with this reality, engage moral imagination, and work with moral courage? There are hints of hope in the narratives created by medical students who are in a creative model of medical education.

Healing Narratives: Naming the trauma, exploring the moral injury, and engaging moral imagination

Creative approaches to medical education are acknowledging the depth of the need to address moral injury.  Educational models such as longitudinal clerkship programs (LIC) create a relational model of education: students stay all year in the same place—with a panel of patients they care for, under preceptors who get to know them, and with a group of peers.(36) Students have safe spaces to write, listen, share their stories of trauma-primary and secondary, alienation, name their moral injury, as well as experience moments of hope.(37) They observe individual and social ethical issues in medicine. Together, they inspire each other to re-imagine stories other than the dominant narratives. It is a way to engage and ignite moral imagination— “the ability to envision a wide range of possibilities for understanding and resolving a particular ethical challenge.”(38) This mutual listening and storytelling is an incubator for healing medicine.  

Jonathan Shay’s work with combat veterans emphasizes that narrative heals moral injury—if and only if there is a “trustworthy community of listeners.”(39) This mutual storytelling occurs in a LIC Ethics and Humanism program on one campus.(40)  For example:

Witness(41)

A man struck by an aberrant car.

Brain swelling beyond return to his previous life.

100 people in support waiting outside the ICU doors.

I sob after I leave.

Months later,

I meet

The woman who hit him

Alone, crushed, traumatized

Her mind broken.

Both lives destroyed by an inattentive moment.

I am a witness.

As this 55-word story indicates, medical students have at least cameo performances in tragic plays, vignettes, and epics in which their patients are main characters. Tragedy – experienced alone – alienates. Tragedy – shared through theater, music, art, literature, poetry, shared story – remind people that we are not alone – and that we are human beings living in a world with aching tragedy and with love.

Student writing like this can address the moral injury of witnessing tragedy. It uses the two features of Aristotle’s definition literary tragedy: peripeteia (sudden reversal) and catharsis (recognition). In this particular 55-word story, the perspectives of each of the three characters named—the patient, the driver, and the medical student—are crafted so that the sudden reversal of fortune—the peripetia—is three-way. The limitations of human life, the limitations of medicine: naming these bring a catharsis/ recognition for the narrator, who is left with one role—that of a witness.(42) When shared with empathic listeners—other medical students in the same program—the catharsis is shared, and the power of art to provide community is made real. Camus’ narrator, Dr. Rieux, captures this tragedy and moral imperative:  “To be an honest witness, …In a world where sorrow is so often lonely, …it was up to him to speak for all.”(43) 

Here is a revisionist medical presentation of a “patient” (the student’s grandmother), written by a student in a LIC, shared with a group of her peers:

Ida is a 90-year-old female with history of (cooking for family and friends) diabetes, (growing up smoking, later quitting) NSTEMI, (multiple bridge trophies) osteoporosis, (loss of her husband, friends and home country; continued strong will to survive) depression, and (violent loss of friends before their time and her home to religious persecution in Baghdad) anxiety.

The student’s 55-word story gives the patient a voice, and thus contrasts the richness of the patient’s life with the depersonalized presentation the student had been taught. It contrasts the life of both the diseased person (e.g., the grandmother) and of the dis-eased practitioner (e.g., the medical student) with the deeper realities of the two characters. When shared with a “trustworthy community of listeners,” there are healing possibilities.(44)

Another student imagines systemic change, instead of being locked into fifteen-minute timeslots, fee-for-service, EMR-guided billing, fragmented treatment for partial parts of a person, instead of centers for the health of communities and individuals who live in them: “Is it too much to ask to create trauma-informed health care within a system that does not create additional secondary trauma -- and treat individual patients as people not just problems to be fixed – and at the same time – address structural causes of dis-ease?  I have this dream of an alternate reality where we practice in clinics embedded in community centers with old people and tiny people keeping each other company and a grocery store that accepts food stamps and an open door policy and therapists of all kinds and needle exchange programs and rehab and afterschool tutoring and a library and vocational coursework.…  I want to create environments where medical care is not necessarily the focus, but just one of many available resources on the journey to health.”(45) 

Rather than seeing this as utopian, this student is taking time to learn business on her way to completing her MD, so that she can, with a trustworthy community of colleagues, live out this dream.

One student learns from the elders who teach her and she sees these opportunities:

The life giving moments…. Reminding a 32 year old mother of 3 who had never had a vaginally penetrative experience that was not painful that she was not, her body was not, an object for the sexual gratification of others.

To hand a patient something tangible; To help mothers hold the world together; To remind women and femmes that our existence is vital: our pain matters, our fears matter, our trauma matters, our hopes matter, our health matters.

Medicine is an incredible opportunity to join with another person in their life journey. It offers the chance to support someone as they do their own healing work– to make an offering of love.(46)

This student’s education allows her to practice the wisdom of looking seven generations back and forward to reimagining medicine that could honor and not appropriate the wisdom of native elders, while connecting with patients caught between worlds.

Medical education that re-connects the mystery and the meaning of what it means to be alive provides hope for the next generation of physicians.  It faces the abyss of trauma—secondary and primary, names moral injury, and encourages moral imagination.  Dr. Rieux captures the creative tension required for this calling: ”He knew that the tale he had to tell … could be only the record of what had to be done, and … would have to be done again in the never ending fight against terror and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers.”(47), 

Bibliography

Adair, Camille. “Burnout vs. Moral Injury: Does It Matter What We Call It?” Kevin MD (blog), May 14, 2019. https://www.kevinmd.com/blog/2019/05/burnout-vs-moral-injury-does-it-matter-what-we-call-it.html.

Camus, Albert. The Plague. Vintage International Edition, 1991.

Chambliss, Daniel. Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics. Chicago: Chicago University Press, 1996.

Charon, Rita. “At the Membranes of Care: Stories in Narrative Medicine.” Academic Medicine 87 (2012): 342–47.

Di Nicola, Vincenzo. “Two Trauma Communities: A Philosophical Archaeology of Cultural and Clinical Trauma Theories.” In Trauma and Transcendence: Suffering and the Limits of Theory, edited by Eric Boynton and Peter Capretto, 17–52. New York: Fordham University Press, 2018.

Dyrbye, Liselotte N., Matthew R. Thomas, Jefrey L. Huntington, Karen L. Lawson, Paul J. Novotny, Jeff A. Sloan, and Tait D. Shanafelt. “Personal Life Events and Medical Student Burnout: A Multicenter Study.” Academic Medicine 81, no. 4 (April 2006).

Fogarty, Colleen T. “Fifty Five Word Stories: Small Jewels for Personal Reflection and Teaching.” Family Medicine 42, no. 6 (n.d.): 400–402.

Fourie, Carina. “Who Is Experiencing What Kind of Moral Distress? Distinctions for Moving from a Narrow to a Broad Definition of Moral Distress.” AMA Journal of Ethics 19, no. 6 (June 1, 2017): 578–84. https://doi.org/10.1001/journalofethics.2017.19.6.nlit1-1706.

Hoffman, Matt, and Kevin Kunzmann. “Suffering in Silence: The Scourge of Physician Suicide | MD Magazine.” National Public Radio, February 5, 2018. https://www.mdmag.com/medical-news/suffering-in-silence-the-scourge-of-physician-suicide.

Johnson, Mark. Moral Imagination: Implications of Cognitive Science for Ethics. Chicago: The University of Chicago Press, 1993.

Lantos, JD. “Moral Distress and Ethical Confrontation: Problem or Progress?” Journal of Perinatology 27 (2007): 201–2.

Latessa, Robyn A., Robert A. Swendiman, Anna Beth Parlier, Shelley L. Galvin, and David Hirsh. “Graduates’ Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study.” Academic Medicine 92, no. 9 (2017): 1313–1319. https://doi.org/doi: 10.1097/ACM.0000000000001621.

Montello, Martha. “Narrative Ethics in Clinical Practice,” n.d., 10.

Neumann, Melanie, Friedrich Edelhauser, Diethard Tauschel, Martin Fischer, Markus Wirtz, Christiane Woopen, Aviad Haramati, and Christian Scheffer. “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents.” Academic Medicine 86, no. 8 (August 2011): 996–1009.

Ofri, Danielle. “The Business of Health Depends on Exploiting Doctors.” New York Times, June 8, 2019.

Rita Nakashima Brock. Soul Repair: Recovering from Moral Injury after War. Boston: Beacon, 2012.

Shay, Jonathan. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner, 1994.

———. “Moral Injury.” Psychoanalytic Psychology 31, no. 2 (2014): 182.

Symon, Robyn. Do No Harm: Exposing the Hippocratic Hoax. Accessed August 30, 2019. http://www.donoharmfilm.com/.

Talbot, Simon, and Wendy Dean. “Physicians Aren’t ‘Burning out.’ They Are Experiencing Moral Injury.” STAT, 2018.

Talbot, Simon G., and Wendy Dean. “Beyond Burnout: The Real Problem Facing Doctors Is Moral Injury.” Medical Economics, 2019.

Treadway, Katharine, and Neal Chatterjee. “Into the Water—the Clinical Clerkships.” New England Journal of Medicine 364, no. 13 (March 31, 2011): 1190–93.

West, Colin P., Liselotte N. Dyrbye, Patricia J. Erwin, and Tait D. Shanafelt. “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis.” The Lancet 388 (2016): 2272–81.

ZDOGG, MD. “Stop Saying Burnout!” Slightly Funnier Than Placebo. Accessed August 29, 2019. https://www.youtube.com/watch?v=L_1PNZdHq6Q&list=RDL_1PNZdHq6Q&start_radio=1&t=0.

Footnotes

  1.  Talbot and Dean, “Physicians Aren’t ‘Burning out.’ They Are Experiencing Moral Injury.”
  2.   Talbot and Dean.
  3.  Alternative medicine practitioners have used the term “dis-ease” to highlight the experiences of people who may have diagnosed ‘diseases.’ Ira H. Sloan, MD, uses it with our medical students and we find it a very useful distinction.
  4.  Medical student. Used with permission.
  5.  Julia Draper, unpublished. Used with permission.
  6.  Charon, “At the Membranes of Care: Stories in Narrative Medicine.”
  7.  Rita Nakashima Brock, Soul Repair: Recovering from Moral Injury after War, xiii.
  8.  Shay, “Moral Injury.”
  9.   Brock, Soul Repair.
  10.  Di Nicola, “Two Trauma Communities: A Philosophical Archaeology of Cultural and Clinical Trauma Theories.” Di Nicola is quoting a line from the poet Pier Paolo Pasolini,
  11.  If the diagnosis were simply work-life balance, then there is a quantitative prescription to fix it: assess priorities; make/ negotiate changes at work and at home, and test it.  Given the evidence of the experience and the research, this is completely inadequate to respond to the seriousness of the symptoms of the dis-ease physicians have.
  12.  Dyrbye et al., “Personal Life Events and Medical Student Burnout: A Multicenter Study”; West et al., “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis.”
  13.  Fourie, “Who Is Experiencing What Kind of Moral Distress?”
  14.  Conversations with Mary L. Caldwell, M.A., M.Div., Clinical Ethicist at Mission Hospitals, Asheville, NC, have helped me understand moral distress much more deeply, as many of her consults involve addressing moral distress among nurses, physicians, and medical staff.
  15.  Chambliss, Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics. 59.
  16.  Fourie, “Who Is Experiencing What Kind of Moral Distress?” Dr. Fourie has made an important distinction: that moral distress in a broader sense, occurs from moral uncertainty—a feature of an ethically challenging situation. What is unclear from her article as well as from the vast number of articles on promoting resiliency skills for physicians, students, nurses, is whether the resiliency training is aimed at reducing this broader kind of moral distress or whether it is aimed at enabling morally distressed physicians, students, and nurses engage their moral imagination and moral courage to address the morally distressing situation.
  17.  The author did a study in 2012-13, (poster at the American Society for Bioethics and Humanities and at a conference for the Consortium of Longitudinal Integrated Clerkships) comparing a group of third year medical students in a longitudinal integrated clerkship (LIC) with a group in a traditional third-year rotation program.  The LIC students had an integrated “ethics and humanism” program, whereas the control group had more optional and less regularly scheduled opportunities for ethical reflection.  At the end of the year, the LIC students were both more aware of ethical issues than the traditional students, and they also revealed more moral distress. This could indicate that awareness of ethical issues, nurtured by a curriculum, can lead to moral distress that allows students to see the ethical issues – the point this paragraph argues.
  18.  Lantos, “Moral Distress and Ethical Confrontation: Problem or Progress?” Dr. Lantos argues for the importance of moral distress as a stimulant for noticing and addressing moral issues in this 2007 article.
  19.  West et al., “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis.”
  20.  Adair, “Burnout vs. Moral Injury: Does It Matter What We Call It?” The same point is made in a podcast entitled “Stop Saying Burnout!” by a physician who calls himself ZDOGG: Slightly Funnier Than Placebo.
  21.  West et al., “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis.” The recurring theme in the conversation among physicians and nurses about “burnout” and “resiliency” vs. “moral injury” is that the burnout/ resiliency conversations tend to blame the victims—the nurses and physicians who “need to strengthen their resiliency” rather than the systemic ethical issues that result in moral injury.
  22.  I am indebted to the work of Stephanie Citron, Ph.D., who founded and consults with Resources for Resilience and Reconnect for Resilience—an Asheville, NC-based training group that has extensive experience working with first-responders—police, people in the criminal justice system, teachers and students, for an understanding of the excellent skills-training that resiliency work can provide. This program is very clear that they are not providing therapy or in-depth psychological healing. Nevertheless, they have evidence that resiliency skills training give people more tools for responding to moral distress other stressful situations.
  23.  Ellery, Blaise. Unpublished essay. Used with permission.
  24.  Hamilton, Molly. Unpublished essay. Used with permission.
  25.  Treadway and Chatterjee, “Into the Water—the Clinical Clerkships”; Neumann et al., “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents”; Latessa et al., “Graduates’ Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study.” Of course, even using Marx’s term – “product” – is problematic: because it is a mechanistic, de-humanized view of a patient. Using Marx’s categories underscores the factory-like atmosphere that many physicians and trainees are finding themselves fighting against.
  26.  Dalen, James  E, et al. “Where Have the Generalists Gone? They Became Specialists, Then Subspecialists.” Commentary, American journal of Medicine. 2017 Elsevier Inc. http://dx.doi.org/10.1016/j.amjmed.2017.01.026
  27.  Talbot and Dean, “Beyond Burnout: The Real Problem Facing Doctors Is Moral Injury.”
  28.  Ofri, “The Business of Health Depends on Exploiting Doctors.”
  29.  Martin, Zach. Unpublished essay. Used with permission.
  30.  Hoffman and Kunzmann, “Suffering in Silence: The Scourge of Physician Suicide | MD Magazine.”
  31.  Symon, Do No Harm: Exposing the Hippocratic Hoax.
  32.  Camus, The Plague.
  33.  Conversations with Arlene Davis, JD, RN, Clinical Ethicist at Memorial Hospital in Chapel Hill, NC, and faculty in the Department of Social Medicine, UNC School of Medicine Chapel Hill, have helped me think about this category.
  34.  Dyrbye et al., “Personal Life Events and Medical Student Burnout: A Multicenter Study”; West et al., “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis.”
  35.  ZDOGG, “Stop Saying Burnout!” https://www.youtube.com/playlist?list=PL95A5CA3Co5869807
  36.  Latessa et al., “Graduates’ Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study.”
  37.  Montello, “Narrative Ethics in Clinical Practice.” Montello’s narrative ethics provides theoretical grounding for the Ethics and Humanism program at the UNC School of Medicine Asheville Campus.  Moral imagination is practiced with the students, along with narrative competence and listening for/ creating “mattering maps.”
  38.  Johnson, Moral Imagination: Implications of Cognitive Science for Ethics, 209.
  39.  Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character, 188–93. Those traits include: “listeners strong enough to hear the story without injury,” not denying the narrator’s experience, willingness to experience the emotions the narrator conveys (188-189).
  40.  UNC School of Medicine Asheville Campus Ethics and Humanism Program
  41.  Jordan, Katie., MD. Unpublished writing. Used with permission.
  42.  Fogarty, “Fifty Five Word Stories: Small Jewels for Personal Reflection and Teaching.”
  43.  Camus, The Plague, 302.
  44.  Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character. Shay argues that the most important way that healing from moral injury happens is in a community of peers. This is precisely the setting in which the longitudinal integrated clerkship’s Ethics and Humanism curriculum happens over the course of a full year.
  45.  Unpublished Manuscrupt, Greeshma Somashekar. Used with permission.
  46.  Leeallie Pearl Carter, used with permission. Some medical schools with longitudinal integrated clerkships are listening to the healers in First Nations and Native American tribal groups as well as among aboriginal peoples in Australia and New Zealand. Patients in those places do not need to choose between the traditions and stories of their people and the ways that western medicine can diagnose, predict, and prescribe.  Physicians who come from those communities do not have to reject their tribal wisdom and stories. This student spent much of the year in the Cherokee community in western North Carolina.
  47.  Camus, The Plague. 308.  This paper would not be possible without the significant dedication, creativity, moral imagination, and passion for justice and for healing-- of the third year medical students at the UNC School of Medicine Asheville Campus, the Ethics and Humanism Course Co-Director, Ira H. Sloan, MD, and the Associate Campus Dean of the UNC SOM Asheville Campus, Robyn A. Latessa, MD. I am deeply grateful.

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