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Licensed clinical psychologist and health care ethicist Jenny Shields discusses her article, “DSM-5 doesn’t name it, but moral distress is everywhere in medicine.” Jenny illuminates the pervasive issue of moral distress among clinicians, defining it as the psychological toll exacted when they know the ethically appropriate action but are systematically prevented from taking it by institutional constraints such as hospital policies or insurer mandates. She carefully distinguishes moral distress from burnout or trauma, characterizing it as a chronic erosion of professional identity that occurs when daily work consistently conflicts with the core values that drew clinicians to their profession. Examples cited include understaffing in the face of rising executive compensation and adherence to insurer-driven care plans over sound medical judgment. Jenny describes the accumulation of “moral residue”—a lasting emotional injury—and a form of institutional gaslighting where systemic issues are presented as improvements, causing clinicians to doubt their own perceptions. She argues that by not naming moral distress, diagnostic manuals like the DSM-5 contribute to medicalizing symptoms like burnout, thereby avoiding the underlying ethical fractures in a health care system primarily designed around revenue and efficiency, which consistently deprioritizes ethics. The article calls for a shift away from focusing on individual clinician resilience towards demanding fundamental systemic changes to address this profound ethical crisis.

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Transcript

Kevin Pho: Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Jenny Shields. She is a licensed clinical psychologist. Today’s KevinMD article is “DSM-5 doesn’t name it, but moral distress is everywhere in medicine.” Jenny, welcome to the show.

Jenny Shields: Thanks so much for having me.

Kevin Pho: All right, so tell us a little bit about your story and then the reasons why you shared this particular article to KevinMD.

Jenny Shields: Well, thank you. It’s May, so it’s Mental Health Awareness Month. I’m a clinical psychologist. I have a background in bioethics and health policy, and I think with it being the month of May, we’re hearing all kinds of buzz around mental health, mental health awareness, and what people frequently comment on your show about burnout in medicine and where we’re at as a whole right now. So I do a lot of work with folks that are facing just that.

Kevin Pho: All right. So for those who haven’t had a chance to read this particular article, what is it about?

Jenny Shields: I’m burned out on burnout talk. We are doing so much of it; in and of itself, it has almost become a buzzword. And while we’ve moved the conversation forward around burnout, in a lot of ways we’re still behind in the field of psychology, really thinking about what type of treatments help this type of problem and, really, is it a problem? This nuance of: are we pathologizing something that is just a natural response to stress?

What I talk about in the article is just that. We are forced to work in systems that continuously and persistently put us in a space that is not designed to support our well-being and, in fact, actually damages that on a regular basis by putting us in these compromising positions. We are seeing the natural progression of that. We as a whole are working to combat a problem that really exists right now in the field.

Kevin Pho: So you mentioned that you do a lot of work in this area. For some of the people who come to see you from the health care field, what are they describing? Why are they coming to see you?

Jenny Shields: They usually show up with a very similar presentation: They’re exhausted, and I think that’s the part we would label burnout and can identify pretty clearly. But one step beyond that is this moral distress, which is this: I’m going to work, I got into this to try to make things better for the people that I serve, and I’m finding that I can’t do that in the ways that are being prescribed for me. My caseload is this size, or my documentation is whatever, and we’re facing insurance companies and all of that.

So they’re really asking bigger questions around, is this something that’s sustainable? Can I continue to do this? And certainly, how do I then navigate my decision-making based upon the debt that I’m carrying, based upon the fact that my entire professional identity has become wrapped up in my career as a physician, as a nurse, or whatever it is. Unpacking that together is a lot of the work that I do.

Kevin Pho: Why is it so important to make that distinction between burnout and moral distress?

Jenny Shields: I think it starts with: whose impetus is it? Who is the impetus on to change what’s happening here? Resilience has almost become a dirty word in my vocabulary. The idea that a provider needs to become more resilient, that it’s something they need to fix within themselves in order to be able to continue to perform in a certain way.

When we talk about moral distress, though, what we’re looking at is a broken system, a system that needs to adapt and change. The consequence of responding to that broken system as a single individual is this moral residue, this harm that comes to the provider. Because medicine as a system is not something that any one individual can change. And so the fallout from that then, and labeling it as moral distress, is a values-based discussion about what is the work we want to do and are perhaps being prevented from being able to do successfully.

Kevin Pho: So you introduced that term moral residue; explain why that’s not alleviated by typical self-care strategies that are often recommended for burnout and sometimes requires system change.

Jenny Shields: Just thinking about how we approach this: psychologists, therapists… often you’ll come into the therapy room, and many of your listeners have probably heard of something like cognitive behavioral therapy. The idea is that we have thoughts that are negatively impacting our mental health and well-being.

Suppose you were to come see me in the therapy room and you tell me something very real, not anything that’s distorted, but is just the fact of the matter: that because of the length-of-stay initiative at your hospital, you’re being pressured to discharge patients before you believe that it’s time to do so. It would be so improper, and certainly not beneficial to you, for me to say, “Well, if that’s what you need to do, how is that distorted thinking about needing to move them out of the hospital more quickly? Let’s work to reframe that thought. There’s only so much you can do.” It invalidates the very real experience of this moral consequence of, “I’m being asked for, or pressured into doing something that I very much believe is not the right thing to do.”

Kevin Pho: One other term that you introduce is institutional gaslighting. So tell us exactly what that is, because when you wrote about it, I found that concept pretty compelling.

Jenny Shields: I think anyone who has spent any time in a large health care system or been to an administrative meeting has probably at one time or another experienced this, where you have people standing up on high or making decisions who have a perspective or a narrative they’ve been given around what needs to occur. Maybe that’s coming from a place that is well-intentioned but fails to really see what’s happening on the ground. There’s this experience of when you’re just struggling to keep up and maybe you hear somebody in administration say, “We just don’t have the money to do that. We just can’t make the decision to implement this or that, or we’re going to have cuts again.” And you were already at a place where you thought, “This is not sustainable,” and you hear one more thing, but you see actions that are counter to that. I remember once hearing somebody having to count the sheets of copy paper that they were using to print things on to meet expectations around budgeting. And yet they look at the break room in the executive suite and they go, “Why am I counting copy paper right now?”

And then from there, it’s the requirement to put your head down and act aligned with that narrative, to pretend as if, “Yep, I’m on board with this, and I’m aligned,” when you know very well that’s not the case. The emotional exhaustion that comes from showing up and pretending each day really starts to wear on people after a period of time.

Kevin Pho: We’ve talked about, of course, moral distress and the powerlessness that a lot of clinicians feel when experiencing moral distress. So talk to us about some initial steps that you counsel them on when they come and see you. For instance, what are some things that need to happen in order to address this issue?

Jenny Shields: I’ve thought a lot about what it is that we, my colleagues, what do we need in order to get support? Because quite frankly, in watching the suffering and repeated suicides of my physician colleagues and beginning to understand that this is something that people do not feel safe enough to get help with or do not have the hope anymore that something could actually make it better, I got really intentional about the things that are barriers to care.

From a starting place, physicians are very often fearful, and rightfully so, that any type of mental health information might be documented in an electronic health record. We all know it loops back into the system. Not to pick on Epic, for instance, but we know that Care Everywhere shares those records, and even though psychotherapy notes of some sort are supposed to have these extra protections, we know that people access this information. We know that institutional decision-makers and risk managers can access that information for all sorts of reasons. Because of that, first, find a provider that understands and really is intentional about that risk. I will go to the extent of maintaining paper records—they’re back in style—for my clients that are very much concerned about seeking support.

Then, I think also working with someone who is understanding of the fact that moral distress is perhaps a normative reaction to the environment that they’re within; that the need to pathologize or diagnose that condition is not necessary in order to receive help. By reaching out for help, there often is a way that we can balance the risk of putting a label on something like that. To be able to provide non-diagnostic—whether we want to call it therapy, coaching, or support—but mental health care to manage some of this distress in a way that is not going to tank their careers or invite fear of getting help, I think that is one very tangible way that we can encourage providers to seek help.

Kevin Pho: One of the other points that you made in your article is that moral distress disproportionately affects clinicians with less institutional power or from those with marginalized backgrounds. So talk about how those inequities intersect and exacerbate moral distress in these individuals.

Jenny Shields: So I think even the ability to speak about this issue comes from a place of privilege. It is risky anytime a person chooses to talk about something that is not going to fit the existing narrative and the narrative that protects the institution. And so, recognizing that those that are able to speak about it often do bear a certain type of privilege. When we’re counseling those, or perhaps trying to give advice on what someone should do, we are really acknowledging that not everybody has that privilege.

While it may be safe for one person to set boundaries, which is often a very well-intentioned piece of advice—”You just need to set some boundaries”—it may not be the case for everyone that they can just go to leadership and say, “I’m not going to do this anymore,” without serious consequences. Understanding that affecting them disproportionately can have a differential impact on their experience of distress.

Kevin Pho: How about those health care leaders who are listening to you on this podcast? What are some first steps that they can do from a health system standpoint to address the moral distress in the clinician staff?

Jenny Shields: I think honesty and authenticity are scarce resources in health care right now. And I would say for any leader that wants to really take a step towards meaningful change, it would start with a recognition that just talking about psychological safety does not make a place psychologically safe. In fact, if that’s an area that’s being actively discussed, it may be the case that it’s a very psychologically unsafe place.

And so, anytime that we approach these conversations, we must acknowledge the fact that it is, in fact, imperfect and understanding that the ability to have peer support is often the very best starting place. The natural power differential between administration and health care providers makes it so that both sides are never going to entirely understand the other’s experience.

Where we can build in safety and we can build in solidarity amongst the care team to be able to then raise and elevate issues as a whole rather than as a single individual, I think that brings a lot of power with it for people to make effective change. And for those that do speak up, for them to have the appropriate institutional protections for their jobs so that they are not retaliated against for bringing those concerns forward.

Kevin Pho: We’re talking to Jenny Shields. She’s a licensed clinical psychologist. Today’s KevinMD article is “DSM-5 doesn’t name it, but moral distress is everywhere in medicine.” Jenny, let’s end with some take-home messages that you would like to leave with the KevinMD audience.

Jenny Shields: I would say just for those that are in a position where they’re questioning, “Is this it? Is this how it is going to be forever? What do I even want to do anymore?” or, “This feels unsustainable,” and they’re wondering what’s next, I would just say that’s really normal.

I would say that most people that are coming to me—I work with people in 43 states now—are seeking support for just being in a place where they’re exhausted. They need to figure out what matters to them and what is next. And there are ways to get access to that support without tanking their career.

So I would just say, as stock an answer as it may sound, help is available. You’re not alone. We don’t want to lose a single other person to something like physician suicide. And if you’ve been too afraid to seek care, this is just your Mental Health Awareness Month reminder. There are providers out there who very much want to be able to support you and to do it in a way that protects your confidentiality and need for privacy protections.

Kevin Pho: Jenny, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Jenny Shields: Of course. Thank you so much.