Beyond Burnout: Why Moral Injury Is Costing Female Physicians Years of Life
When I posted about female physicians losing years off their lives simply by being female physicians, it got a lot of attention. There were many comments by female physicians and other healthcare workers about how such a grave statistic is felt so deeply by many of us.
Many asked why the years of life are lost.
Many cited “moral injury” as the cause.
I thought it was called burnout.
In my medical career, the term “burnout” is constantly discussed. It references the overworked, over-burdened, and under-rested physician.
According to one article, many physicians “aren’t overworked and frustrated”. Well, I am overworked and frustrated. I understand the burnout concept.
But I have multiple criticisms of the burnout discussion.
It places heavy focus on administrative burden, which is certainly a large factor, but gives only lip service to fundamental human needs: natural light, rest, and nutrition.
Residency programs often sponsor unhealthy habits by offering a stipend for use at hospital food vendors. Where I trained this was a cafeteria, snack closet and Starbucks. Many hospitals have other fast food or chain restaurant type offerings. Attendings (supervising physicians) sometimes paid for takeout during a 24 hour shift. That felt like a treat. Actually it’s a physiologic insult.
There’s a rule, both spoken and unspoken in medicine: eat when you can, sleep when you can. Historically, quantity of both food and sleep are hard to come by in medical training. In today's world of processed food and handheld artificial light, we have the additional concern of quality.
I often tried to make healthy choices with salad or fruit but I also was constantly caffeinated with sugary beverages. It's part of healthcare culture to be over-caffeinated and underhydrated and it’s program-sponsored to stay that way.
There was a small gym that I would occasionally frequent. By the end of my residency, my husband and I started purchasing at-home exercise equipment. This was conveniently before the Covid pandemic when gyms were closed, so we transitioned easily to at-home workouts and haven't stopped since.
Even if I went to the gym, I had no idea what I was doing. In medical training, we are not trained to understand exercise physiology. I’m just now doing intentional training after a decade of chronic stress and physical deterioration from medicine. My body is entirely different now, changed for the better. I don’t know what I was doing back then.
There are work hour restrictions in residency. Here's the problem: that disappears after residency. I work more now than I did as a resident. There are certainly differences in life as an attending physician, namely the increased income. But there is no restriction, priority, or consideration for rest.
“Wellness” results in more administrative burden. The “wellness” or “physician well-being” sessions are just more burden. It’s another meeting, more on the calendar. It’s literally more things to complete when part of the problem is the number of things to complete.
The ACGME, the non-profit governing body of residency programs, has a vague requirement to support the well-being of physicians. This includes being able to spend time with family and go to medical appointments, even if during scheduled working hours.
This led programs to add “wellness sessions”. This adds another task. It doesn’t change medical culture.
I met resistance when I took a day off to go to a wedding during my first year of residency.
We were actually conditioned to do our medical, dental, and other personal tasks during a rotation of nights, specifically to avoid missing work. This is true of many night-shift workers. If you work at night, you can do your tasks during the day without missing any work. Again, the support may be in words from the ACGME but the culture doesn't change.
Beyond burnout, it seems everyone is talking about moral injury, particularly of physicians, female physicians, and healthcare workers in general. I knew this term intimately before I ever heard it.
What is moral injury?
Moral injury is a term originally used in the military. It describes the internal distress arising from seeing or participating in events that conflict with one's own morals.
There’s certainly an accumulated emotional toll from working in healthcare.
At first I thought by discussing moral injury, maybe we were getting closer to hitting the nail on the head: we are not interested in being martyrs for a healthcare system.
Nope. It turns out this is actually just a rebrand of burnout.
To enlist in the military, one is agreeing to die on behalf of the job and the country.
Female physicians lose years off their lives simply by doing the job. I didn’t enlist to be a martyr for a hospital.
How does the moral injury discussion in healthcare fall short?
The term moral injury can certainly apply to healthcare workers.
The problem is that any solutions I’ve found are missing one important thing: morals.
They focus on the business and systems of healthcare and these are undoubtedly problematic. There is no discussion of morals or even religion.
I even read the word “covenant” used to describe the relationship between organizations and its employees.
The covenant is actually between me and God, followed by me and my family.
In a system that increasingly asks us to be robotic machines, the conversation of moral injury must include our humanity.
What is moral injury, really?
True moral injury arises from the following discrepancies:
The expectation of having a fulfilling job while realizing that it cannot be completely fulfilling.(“But first seek the kingdom of God and his righteousness” Matthew 6:33)
It’s not possible. It falls short.
Because everything on earth will fall short.
There may be fulfilling moments. It may be a helpful, purposeful, even noble profession.
But it is not in itself completely fulfilling, though we’re conditioned to think that it will be.
Being solely measured by productivity while simultaneously holding no value. Moral injury is being treated like Martha, knowing God wants me to sit like Mary (“few things are needed, or indeed only one” Luke 10:41-42).
The system regards us as dispensable employees. That's demoralizing.
The healthcare system expects us to be robotic and secular while simultaneously exuding empathy and humanity. That’s dehumanizing.
The moment I truly understood moral injury, I was released in a way.
I was released from guilt.
Guilt for thinking that I was ungrateful when I was grateful. I still am. I’m grateful for my health, my physical ability to do this job, to offer something to my community. I thank God for that every single night.
I was also released from some administrative burden. Much like other employees who leave work and respond to e-mails later (or not at all), I stopped considering all incoming messages to be emergencies. My nervous system thanks me for that.
I was released from turning to the healthcare system, the hospital, and the job to complete me or even to help me. I turned to God to help me.
True healing from moral injury
In a flipped script, I started regarding the healthcare system as what it actually is: earthly false idolatry. I no longer expected soul-deep fulfillment. I certainly had no plan to be a martyr for it.
It’s possible to do good work without idolizing the organization. It’s possible gain clarity about life's priorities. It’s possible to have gainful employment while maintaining priorities.
I realized I’d been playing into the demoralization and dehumanization. It's easy to do in a healthcare system that demands secularism, particularly in women's health.
I turned around.
I didn’t run away from religion anymore.
I leaned into it.
It wasn’t just part of my background anymore.
It was my path to preservation, now and eternally.
It saved me physically and emotionally, likely saved me from quitting my job, and saved me spiritually (better late than never).
I’m glad the term moral injury was brought to my attention. It's of particular importance in the context of female physicians, all physicians, and healthcare workers. Given the en masse exit from traditional healthcare or the profession entirely, a true solution is needed.
We need healthcare, medicine, and physicians. I agree with some formation of collective action for physicians. To this point, there has not been consistency, transparency, or flexibility from hospitals in the largely employed physician population.
More meetings, more tasks, more mediation between business and worker may change systems but it will not heal.
To the healthcare workers, here's what will heal:
Regard yourself as an employee just as the corporation does.
Regard the corporation as earthly, just as God does.
It will set you free.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
The author can earn commissions through affiliate links.
Disclaimer: This is not medical advice. This is for educational purposes only. Discuss with your doctor.
https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformattedrequirements/cprresidency_2025_reformatted.pdf