An immune-compromised teenager was booed by parents at an August school board meeting in Minnesota when she spoke up about the benefits of masking to protect her own health and the health of others in the school. At a recent school board meeting in Tennessee, a 14-year-old talked about his grandmother, “Last year, my grandmother, who was a former teacher at the Rutherford County School System, died of COVID because someone wasn’t wearing a mask” and his comments were met with laughter and heckling by nearby adults.
Do these stories make you angry, depressed, sad, irritated? You may also be saying to yourself, “this is happening to me every day in my exam room.”
Physicians are facing angry, hostile patients in clinics and at the bedside. Patients and family members are rejecting our advice about COVID-19 vaccinations, rejecting the same expertise that may have carried them or their family member through a stroke, heart attack, or difficult pregnancy in the not-too-distant past. Primary care physicians are seeing patients with whom they have had decades-long relationships now becoming angry and rejecting the medical counsel they have trusted for years. Adults are threatening physical violence, not only in restaurants and grocery stores, but in clinic and hospital settings when asked to wear a mask.
The emergence of the Delta variant has led to a different kind of pandemic – a largely preventable one. People who remain unvaccinated are filling hospital beds and ICUs and dying in far greater numbers than their vaccinated peers. Many adults are putting their sense of personal rights ahead of community benefit in clear contradiction of the best available science. In doing so, they are putting vulnerable individuals and children at serious risk. Children too young to be vaccinated or living in unvaccinated families make up over one-quarter of new COVID cases at this point in the pandemic, filling pediatric beds and PICUs in ways not seen in the first waves.
To physicians who are schooled in the scientific method and evidence-based medicine, this makes no sense. It feels like madness. The rejection of science and of physician expertise in these matters of life and death feels very personal. It feels personal amid the emotional exhaustion of working to counsel around vaccine refusal. It feels personal amid the ongoing risk to vulnerable friends, community members, and family. It feels personal amid the risk of breakthrough infections. And for many of us it feels, frankly and frustratingly, new. It is an unprecedented, unwelcome, and sometimes demoralizing reaction to our beloved and trusted profession of medicine.
As physicians, we are bound by the oath we took when we became doctors. The ethical “contract” of the physician is the Hippocratic oath, which demands a moral standard of professional behavior. We are bound to treat the sick without regard for life circumstances or life choices. The physician feels a moral obligation to do the right thing, to save lives and preserve health. To be sure, there are other motivations, but most medical students are attracted to the profession by a desire to help people, put simply.
Mona Masood, MD, a psychiatrist from the Philadelphia area and creator of the peer-to-peer support program, Physician Support Line, has counseled many fellow physicians throughout the pandemic. She, among others, talks about moral injury. The term, first used to describe the mental and emotional trauma of returning Vietnam veterans, also applies to medical professionals, especially in these pandemic times. Consider the metaphors of war so often deployed over the past 18 months, such as “health care heroes” and “working on the front lines” and “the battle against COVID.”
Moral injury occurs when we perpetuate, bear witness to, or fail to prevent an act that transgresses our moral beliefs. Masood describes the moral injury physicians suffer when they experience feelings of failure and inadequacy when faced with impossible situations for modern medicine and, in particular, the pandemic. The pandemic has exposed pre-existing inequities in medical care, revealed limitations of our health system capacity, exaggerated anti-science sentiment, and highlighted differing attitudes toward the common good and public health. Physicians are caught in the middle of these towering societal woes. Our inability to fulfill our own expectations for job success can lead to anger and frustration, through no fault of our own, due to problems we are powerless to solve in the exam room.
Wendy Dean, MD, et al, in “Reframing Clinician Distress: Moral Injury Not Burnout,” an article published before the pandemic, uses the term moral injury in health care to describe the challenge of simultaneously knowing what care patients need, but being unable to provide it due to constraints that are beyond our control. This moral injury can apply to many of the systemic imperfections we deal with daily, as well as the challenges of trying to stop a contagious virus with an uncooperative and sometimes hostile minority of the population.
If the construct of moral injury resonates with you, the next step, again taking counsel from Masood, can be accepting that this is a normal, healthy reaction to being stuck in a helpless situation. Feeling frustration and anger indicates that your moral compass is indeed intact. You can forgive yourself for not achieving your self-imposed, impossible expectations and move on. The expression, “you are not required to set yourself on fire to keep other people warm,” certainly applies in this situation. To remain stuck in this state increases the risk of bad outcomes, depression, suicide. It also paralyzes us from taking action to change a broken system.
Be assured, you are not alone. The MMA exists, in large part, to provide support and community to Minnesota physicians, and to uphold and champion science and the medical profession. The MMA also exists to harness the individual frustrations and determination of physicians to make change. There is much to be done to move past this pandemic, to bolster our health care and public health infrastructures, and to reassert science.
We are all frustrated and tired of this pandemic. The naysayers, the skeptics, and the peddlers of misinformation will not succeed. Medicine and science are the keys to emerging from this pandemic – the times are uncivil, but your work is vital.
For additional information:
• Addressing COVID-19 Vaccine Misconceptions & Misinformation
• MMA Practice Well Collaboratory
• MMA Membership