Physician burnout is a major issue in the US, receiving attention in medical education, medical specialties and at various government levels. Moral injury, in my professional and teaching experience, is a significant and growing challenge to physician wellness. Moral injury happens when one’s personal convictions are unwelcomed and one is pressured to think, be silent, speak, act or not act in a way that compromises one’s conscience.
I graduated from the VCU School of Medicine (formerly Medical College of Virginia) in 1991, trained in family medicine and served in a mission hospital in Asia for 16 years. In 2015, I transitioned to a Virginia university practice and became heavily involved in the lives of medical students.
In the time that had passed since I was a medical student, I found the environment of medicine and medical education had significantly changed. One area of change was the emergence of the “provider of services model.” “Provider,” a relatively new term at the time, is now commonplace.
In my training, we were formed as “professionals.” Though we provided a service — as does one providing a latte — there was a broader vision in our professional formation than I see now. Implicit in professionalism was that we professed something. Philosophically, we professed the goal of health as an objective good, not a subjective one. There was an inherent objective goodness, even excellence, of the embodied human. Our calling was to maintain and restore health as much as was within our power and expertise. The Hippocratic Oath offered a moral framework to live out the profession of medicine.
In current medical education, I see an increasing lack of clarity, even confusion, about what we profess. I observe a redefining of health into a subjective, not objective, category. Perceptions of health increasingly reflect a dualistic or divided view of humans, disintegrating them into categories of mind vs. body.
Traditionally, we spoke of an integrated “whole-person medicine.” Now we predominantly speak of patient autonomy, with the center of the autonomous patient in the mind and will, not the body and often disconnected from the body. In this disintegrated anthropology (understanding of what a human being is), the body suffers a grave reduction in status, reduced to a degree that interventions are done in US medicine to normal human bodies that were unthinkable two decades ago.
This “provider of services model,” wedded with the ascendance of patient autonomy and a subjective view of health, can result in the physician providing whatever patients desire based on their subjective views of health.
As the body’s status has suffered, so has the physician’s status as a human moral agent. In any ethical relationship (physician-patient included), there are two persons, two autonomies, both deserving of respect. The present hegemony of patient autonomy is accompanied by an increasingly anemic view of professional autonomy. Physicians’ convictions and principles, what they “profess,” are to be abandoned in this imbalanced view of the relationship. The physician simply “provides” services.
Medical students tell me that they will be expected, if not obliged, to provide legal and broadly accepted services requested, regardless of their convictions. Students who hold to moral traditions that profess an integrated anthropology, view the body as intrinsic to the whole person, and profess an objective view of health feel increasingly unwelcome in the present medical education system. They can be coerced into silence or acquiescence. I have walked with such students through the stressful journey of an educational culture that pressures them to be formed in a way that conflicts with their deepest convictions.
Moral injury is increasingly a significant factor among our physician wellness challenges. Our institutions must assess reigning models, clarify confused definitions, decide what the profession of medicine actually professes, protect the autonomy of both patient and physician, and welcome the rich, diverse moral traditions we have inherited from the past. Only then will we see a flourishing of the next generations of medical professionals.
Dr. Scott Armistead is a board certified Family Medicine physician. He grew up in Hanover County, Virginia and attended William and Mary for college and the Medical College of Virginia for medical school. After completing his residency in Kansas City, he and his wife and three boys served for 16 years at a mission hospital in Pakistan. He is fluent in Urdu. He returned to the US in 2015 and has been working both in primary care and in student ministry through the Christian Medical and Dental Association’s VCU chapter. He is interested in comprehensive family medicine for all ages, refugee and immigrant health, teaching, and international missions. He has led medical students on short-term medical missions trips to Africa and Asia and to work among the underserved in Richmond. Dr. Armistead is a family physician at Garden of Eden Health Center in North Chesterfield.