Moral distress

As a 3^rd year medical student, I am a junior member (also known as a clinical clerk) of a large health care team. Throughout my rotations, situations arise where – if I was in charge – I would do things differently.  Most of the time, these differences in style or approach are minor in nature and not worth talking about.  Every so often, however, an incident occurs where things are done so contrary to my own values that it can be quite upsetting.  In health care, we call this feeling “moral distress.”

Moral distress is the stress that “occurs when one [believes one] knows the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action.”  This concept was first established in nursing literature in the 1980s and has been established as a leading cause of nursing burnout and attrition.  Nurses have been found to be particularly vulnerable due to the fact that they are simultaneously equipped with knowledge that may impact patient care, but have very little decision-making power.  According to a 2007 study in the journal Nursing Economics, nurses reported feeling “below” physicians.  They felt that their opinions and concerns were not heard by doctors.  Moreover, they experienced the burden of living with the results of decisions made by others.

Moral Distress in Delivering End of Life Care – Palliative Care from Canadian Virtual Hospice on Vimeo.

More recently, several studies have found that health professionals from various other disciplines also experience significant moral distress. Included in these newly identified groups are medical students, who face a quandary similar to that of nurses.  While medical students feel a sense of responsibility for their patients, they are often constrained from action by their position in the hierarchy, their desire for good evaluations (i.e. fear of reprisal), and a lack of confidence in the knowledge they have acquired so far.

A 2009 study in The American Journal of Surgery found that students face choices between intervening in morally hazardous situations or else going along with the decisions of their superiors. The resultant moral distress has been linked with cynicism and burnout.  Improper communication was identified as the biggest issue that caused distress amongst third year medical students, with both physician-patient and physician-physician interactions cited as having communication problems.  This would include, for example, a physician failing to demonstrate empathy when delivering bad news to a patient.  Another common problem is “badmouthing,” wherein physicians or others speak in a derogatory manner about patients when they are thought to be out of earshot.

Medical students have been found to feel uncomfortable with challenging medical team members regarding unethical behaviour because they felt that they were either ignorant of clinical circumstances or that they lacked the experience to make relevant decisions.  A 1994 study of medical students found that 80% of respondents reported having done something that they believed to be unethical. Over 60% of participants reported having witnessed unethical behaviour by other members of the medical team, and of these respondents, more than half felt like accomplices. Disturbingly, nearly all students surveyed had heard physicians refer to patients in a derogatory manner.  Medical students perceived that their own unethical behaviour occurred in the context of wide acceptance of such behaviour, which they felt was influenced by specific social pressures:

• The pressure and desire to be a team player.  Medical students felt a need to function proficiently and adhere to the status quo.  Furthermore, unethical behaviour was sometimes rationalized as a display of loyalty to other team members.
• The desire for a good evaluation from team members.  Forty percent of respondents reported having done something unethical for fear of a poor evaluation.

As evidenced by these examples, a large contribution to the moral distress felt by medical students is due to the culture of medicine, or, as it is sometimes referred to in the literature, as the hidden curriculum of medical school.  This is the “commonly held ‘understandings,’ customs, rituals and taken-for-granted aspects of what goes on in the life-space we call medical education.”

After medical school, graduates move on to additional training in residency programs.  As highlighted in a study in the journal Medical Education, many of these programs are currently focused on “competencies,” implying that the subject and practice of medicine are “master-able”. This approach fails to take into account the challenge and complexity of true professionalism.  Paradoxically, so-called “practical wisdom” is identified in curricula as being important to future doctors, yet the tools necessary to make complex decisions are not given sufficient attention in the competency based model.  It is therefore essential that the elements of a physician’s practice that lay beneath observable performance are both valued and nurtured appropriately.  Unfortunately, the word “professionalism” is often scattered throughout curricula, with little to no indication of what it actually means or how it is going to be taught.

Although medical curriculum reform has increasingly stressed the importance of ethics, some investigators have found that the moral reasoning of medical students does not compare favourably to that of students of similar age and education from other disciplines.  “There is concern that medical students and residents display regression of moral development during training, rather than moral growth.” While eliminating moral distress from the medical student experience may not be possible, it can certainly be reduced through discussion and reflection when students are given an open forum to discuss their concerns.  Some American medical schools have tentatively begun to introduce such forums into their teaching.  The idea behind these initiatives is that open and confidential discussion of these issues acts as an effective form of “group therapy.”  This may lead to solutions to some of these problems as well as prevention of “moral residue,” that bad taste in one’s mouth that can linger long after a distressing incident.  Similar approaches have been adopted by paramedics and other first responders following a disturbing call.  They refer to these sessions as “critical incident stress debriefings.”  However, this idea is still fairly novel and far from being universally applied in hospital settings.

On a personal note, I can confirm that nothing distresses me more that hearing other health care workers speak ill of patients, especially my patients.  Sometimes it is almost as if others feel the need to counteract the air of empathy they display in front of patients with a rectifying display of cynicism in front of their peers.  I don’t want to create the wrong impression: those who behave this way are in the minority.  But there are enough of them that sometimes they can transform a great day into a terrible one.  As I understand it, this is largely a symptom of professional burnout, which, as a system, we need to do a much better job of preventing, identifying, and addressing.