RP201 – Session 3: Moral Injury & Response (11 March 2020)

Session Readings



“Burnout” is a popular but controversial term in medicine.  Medicine has always been a lot of work, but is it really becoming too much for us?  Is there something about we physicians that makes us unable to handle what previous generations could?  Or is there something different about medicine?  

Two years ago, two physicians proposed that “moral injury” may be a better term for much of what we call burnout.  They noted that the rise in burnout is correlated with the corporatization of medicine. Physicians are most often employees of hospitals, and have to navigate insurance companies and pharmacies to care for their patients.

The essays that prospective medical students write for acceptance have not changed.  None talk about maximizing relative value units or performing highly remunerative procedures.  Instead, they talk about patients, connection and understanding.

Moral injury is a term initially coined for war, when soldiers suffered greatly after violating their own moral beliefs.  In medicine, moral injury is theorized to stem from a similar betrayal of long-held beliefs, from large or cumulative smaller episodes of failing to treat, to advocate, to care due to systemic constraints.

  • What is a moral dilemma and moral injury?
  • How does moral injury affect physicians?
  • How can health systems lead to moral injury in physicians?
  • How can we address moral dilemmas?

This session is devoted to looking at moral injury in medicine to see if this theory can explain and more importantly, provide means of combating one of the most important issues of your new career.


  1. Read/watch the following 3 resources prior to the session.  Review other sources as time allows.
    • Article: Physicians aren’t ‘burning out.’ They’re suffering from moral injury (link above)
    • JAMA article: Clarifying the Language of Clinician Distress  (see Sakai)
    • ZdoggMD video (link above)
  2. Reflect on personal experiences either during medical school (or prior if applicable) when you recognized a moral dilemma that made you question the way medicine was delivered.  Although these situations can overlap with conflict, focus on a separate incident than the one you reviewed in that session.
  3. Using any artistic modality (painting/sketch/drawing, poetry, prose, short story, photography, sculpture, music, dance, etc. — be creative and do what you love!), create a reflective work that relates to your personal experience of moral dilemmas in clinical medicine.  Ideally, this should be something that was particularly relevant to you during the clerkship year.  This work can be a symbol of the issue, the effect it had on you, or something that brought you relief or encouraged resilience.
  4. Bring your creation to the small group; be prepared to discuss what your reflective piece means to you.


  • Dr. Wendy Dean is a psychiatrist and the former Vice President of the Henry Jackson Foundation for the Advancement of Military Medicine.  She formed and operates the nonprofit foundation Moral Injury in Healthcare, LLC.
  • Dr. Gwen Hunt is a third year resident in Internal Medicine at Walter Reed National Military Medical Center.  Dr. Hunt has been selected as Chief of Residents for the Internal Medicine program at Walter Reed following graduation.


By the end of the small group session on “Moral Injury in Health Care”, students will demonstrate the ability to:

  1. Understand the definition of “moral injury” as it pertains to healthcare professionals.
  2. Reflect on experiences involving moral dilemmas and how the experience affected them.
  3. Explore avenues for identifying and addressing the systemic issues behind moral dilemmas.
  4. Reflect on the issue of “burnout” amongst physicians, residents and medical students and the applicability of the theory of moral injury.
Physicians aren’t ‘burning out.’ They’re suffering from moral injury "The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience."
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YouTubeZDoggMD: It's Not Burnout, It's Moral Injury
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Reframing Clinician Distress: Moral Injury Not Burnout Drs. Dean and Talbot define moral injury as it pertains to healthcare, and distinguish it from what has long been labeled as "physician burnout".
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mscp-logoHow Doctors and Nurses Can Team Up to Fight Moral Injury in Healthcare Physicians are not the only members of the healthcare team who sense and suffer "moral injury". This commentary presents a shared problem and proposes collaborative ways of addressing it.
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When Art Talks: Expressions of Clinician Well-Being This exhibition, organized by the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience, showcases art created by clinicians, students, patients and loved ones, and represents their views clinician burnout and well-being.
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Session originally created by: Francesca Cimino | Uniformed Services University | Curriculum Director, Reflective Practice | Family Medicine