Rachel Smith joined the U.S. Army in 2000 as a way to help finance her education. Then came the Sept. 11 attacks and the Iraq war, and she was deployed as a nurse in a field hospital. When she returned, she was plagued with doubts. "Why were we over there?" she said. "Why did we see these things? There was no meaning to it."These days, Smith is a physician assistant at Harvard's Ariadne Labs and is helping in an emergency room in Albany, New York, as the state's coronavirus crisis intensifies. She said that treating patients in a pandemic without the proper protective gear and, in some cases, working for hospitals that threaten to fire people who complain about it, has set up medical workers to feel that they're failing their patients.Those workers are now facing conditions that are almost unheard of in recent history. Across the country, hospital systems are nearing the breaking point as coronavirus patients arrive by the thousands, while stories of severe equipment shortages and unsafe conditions have become commonplace. In Michigan alone, more than 2,200 health care workers have so far come down with symptoms of covid-19. The national total could prove staggering.
Although these workers are being hailed as heroes, too little attention has been paid to how the pandemic will eventually affect them. And without significant intervention by policymakers, the consequences for the U.S. health care system could last for years. Smith said she feels a familiar sense of foreboding. "We are at war again, with a pandemic as the enemy," she wrote recently. "Moral injury will undoubtedly occur."
Long before the present crisis, researchers were struggling to come to terms with the psychological harms that health care workers can suffer under extreme conditions. Following the SARS outbreak in 2003, which spread primarily within hospitals and killed dozens of medical professionals, one study found that veterans of the crisis reported high rates of post-traumatic stress and psychological distress, low productivity, increased smoking and drinking, and elevated levels of a condition that was then known as burnout. In the intervening years, researchers have come to a new understanding of burnout — as something more akin to what soldiers suffer when they come back from war. In 2018, two doctors, Simon Talbot and Wendy Dean, wrote an opinion piece for STAT, arguing that both soldiers and health care workers can suffer from what's called moral injury, an often-debilitating burden of shame, sadness, anxiety and remorse. It's brought on when a comrade or patient gets hurt or dies, and sufferers often feel that had they acted differently or done more, the harm could've been prevented. Many cases of so-called burnout, the writers argued, were really moral injury.This idea resonated with medical workers well before the virus causing covid-19 came on the scene. Many were finding that rising workloads, increased paperwork, bureaucratic demands, financial considerations and other complications were preventing them from spending enough time with patients or otherwise doing their best work. Talbot told me in an interview that he usually works 80 to 100 hours a week. "The crazy thing," he said, "is if you look at the time I spent talking to patients, touching patients, operating on patients, that's probably only 15 to 20 hours."
One study found that more than half of U.S. physicians surveyed reported symptoms of burnout, while another concluded that those doctors were much more likely to quit. At a time when the U.S. is already facing a major shortage of physicians, and a shockingly high suicide rate among them, this is a serious concern for the entire profession, and for the health care system more broadly. The covid-19 pandemic could damage that system beyond repair.
Medical workers are scared of the novel coronavirus — not so much for themselves, though that's part of it, but for the people they're treating. Without adequate masks and other protective gear, they worry about spreading the virus to others, including their families. And without enough ventilators, trained staff and intensive-care unit beds, they're afraid they won't be able to give patients the kind of treatment that would save their lives.Talbot, a surgeon at Boston's Brigham and Women's Hospital, told me that the doctors he knows are particularly worried about spreading the disease or failing patients. Since he plans to join the front lines, he said, his hospital has had to discuss the traumatizing possibility of rationing life-saving health care if the crisis proves overwhelming. Doctors also worry that most rationing systems give them first priority — meaning that they may be more likely to get a ventilator if they need one, but would live with the guilt that someone else may have died as a result.
David Wood, a war correspondent and author of "What Have We Done: The Moral Injury of Our Longest Wars," said he began studying moral injury while working on a series about soldiers with extreme physical wounds. He started encountering psychological injuries, too — he met one soldier who had to pick up the pieces of her dead best friend, another who accidentally shot a child.Those who are most sensitive to moral injury, he told me, are the ones with a powerful sense of duty to others. In some situations, "You can't live up to that standard — people get injured or killed or things happen that are nobody's fault," he said. That can leave behind an unbearable load of anger, sadness and self-recrimination. "Moral injuries happen when people feel betrayed by leaders who sent them into dangerous situations," Rachel Smith said. "It's almost like being sacrificed."
As cities from New York to London gather in the evenings to cheer for their doctors and nurses, policymakers should not only seek to get those workers what they need to be effective now, they should also bear in mind that there will be a long road of recovery ahead.
On the frontlines, Smith said she hopes the medical community will adopt some of the methods the military uses to deal with moral injury. Healing is based on forgiveness and atonement, she said. You have to take the blame off the health care workers and place it on the crisis at hand. She recommends end-of-shift debriefings where these workers can share their anxieties with peers, even if time seems short, as well as a system of "battle buddies" that can assure them that someone always has their back. Once the immediate crisis subsides, though, more ambitious reforms should be on the table. Talbot and Dean advocate a coordinated federal effort to confront the human costs of moral injury among medical workers, ease the burden on health care providers, and reduce the perverse incentives that cause medical professionals to spend so much time doing paperwork rather than saving lives.
After the coronavirus, the medical profession, much like the rest of the world, will have to reckon with the scars, many of which date to well before covid-19 and point to larger weaknesses in the U.S. health care system. As Talbot told me, doctors don't need to be told to do yoga or meditate to fight burnout; they need a system that values their devotion, offers proper training for disasters, and provides the protection and support they need to do what they do best: take care of patients.
Flam is a Bloomberg Opinion columnist. She has written for the Economist, the New York Times, the Washington Post, Psychology Today, Science and other publications.
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