Moral distress plagued doctors during the COVID-19 pandemic. Here’s help

By Kristen Fuller, MD | Fact-checked by Barbara Bekiesz
Published November 29, 2022

Key Takeaways

  • The COVID-19 pandemic forced thousands of physicians to leave their jobs for the sake of their own mental health.

  • COVID-19 caused moral distress among practicing physicians as they had to choose between their safety and providing care to patients. Consequences of this distress include physician burnout, subpar patient care, job dissatisfaction, and a decline in mental health.

  • Healthcare institutions can help address this challenge by facilitating a supportive environment with open communication and consideration for staff to protect their mental health and encourage their input in operational decisions.

The US Bureau of Labor Statistics revealed data in mid-2022 which found that healthcare is among the top three industries that have been increasing in monthly “quit rate.”

Coined the “Great Resignation” in the spring of 2021, this period saw 3,272 practicing US physicians leave the healthcare workforce between the start of 2019 and the fall of 2021, according to the AMA.[]

Research has identified the moral distress that came with having to choose between patient care and one’s own personal safety as a major contributing factor to this mass exodus. How can the medical industry stanch this trend?

Leaving for their own health

The US healthcare system was already under severe pressure, showing cracks in the dam, and the COVID-19 pandemic broke the floodgates wide open.

The pandemic changed the world. Many people lost their lives, loved ones, and jobs, and struggled with their mental health—especially frontline workers, including physicians.

The physician shortage was already a problem before the start of COVID-19, but the “pandemic of mistrust” forced thousands of physicians to leave their careers for the sake of their own mental and physical health, according to AMA president Gerald Harmon, MD.[]

At the height of the pandemic, images of physicians with faces buried in their hands, exhausted and emotionally wrecked from the tragedies experienced in patient care, became a common sight in the media. Doctors worked around the clock, risking their lives, mental health, and personal relationships.

“We were already struggling with workforce issues in health care and physicians.”

AMA president Gerald Harmon, MD

Then, the COVID-19 pandemic made things worse.

“We lost opportunities to take care of chronic diseases,” Dr. Harmon continued. “Patients could not get to us. We had isolation, quarantine imposed upon us. We had concerns about PPE. Patients were concerned about being in a waiting room where they might be contagious or be exposed to chronic diseases. All those economic pressures were really thrust upon us.”

Moral distress among physicians

A study published by BMJ Open surveyed 2,073 clinicians about the moral distress they faced during the COVID-19 pandemic.[] Researchers found that 44.8% reported “mild” or “uncomfortable” levels of this distress, and 26.8% characterized their moral issues as “distressing,” “intense,” or the “worst possible.”

The most common situations leading to moral distress were those where patients could not receive the best care or the care they needed and those in which patients and staff risked COVID-19 infection. Other factors included abuse of clinic staff, patient and staff suffering, and inequities and injustices within the community.

The BMJ Open study also found that COVID-19 highlighted the wealth gap, as many underserved patients were at risk of COVID-19–related illnesses and had higher mortality than insured, high-earning patients. This disparity caused emotional distress among physicians who could not treat these individuals.

Moral distress was defined by the BMJ Open authors as “the psychological unease or distress that occurs when one witnesses, does things, or fails to do things that contradict deeply held moral and ethical beliefs and expectations.”

Related: Breaking point: COVID-19-era substance abuse by physicians

Consequences of distress

For many months at the height of the COVID-19 pandemic, the shortage of PPE put physicians in a stressful predicament, according to an account published by KevinMD.[]

The doctors felt they were compromising the safety of patients, loved ones, and themselves by continuing to see patients and risking infection. As a result, many physicians chose not to go home and spent nights in hotels or hospitals out of fear of spreading COVID-19.

“I faced a decision: Return to work with the vague PPE offer, continue to expose myself to other potentially COVID-exposed coworkers while doing the work I could have done from home, submit my resignation, or be considered AWOL (absent without leave),” recalled the author of the KevinMD article, Nesrin Abu Ata, MD.

“As a physician, I felt like a failure to my patients and myself in the face of my employer's expectations to put my health at risk.”

Nesrin Abu Ata, MD, KevinMD

“They felt I was making a big deal out of two physicians' letters recommending that I not return to work in person,” Dr. Abu Ata wrote. “Underneath, I felt shame.”

Moral distress among physicians contributes to burnout and disengagement from patients, resulting in subpar patient care, according to the BMJ Open research. Other consequences include compassion fatigue, a decline in mental health, job dissatisfaction, and job turnover.

Related: From the front lines: 3 physicians share vital COVID lessons

What can be done?

The BMJ Open researchers wrote about strategies healthcare institutions could employ to help reduce moral distress among their clinicians. For outpatient practices, management should:

  • Take steps to create supportive work environments.

  • Identify ways staff and physicians can discuss and learn about moral distress, with opportunities to safely bring up related issues, and to identify and address sources of the distress.

  • Provide clinicians with mental health support and time off, if possible.

  • Involve clinicians in operational decisions, especially during challenging times.

What this means for you

The subject of moral distress among physicians raises an important question: How do they take care of themselves so they can compassionately care for patients? Institutional leadership can play a vital role in addressing this issue by creating a supportive environment in which staff and patients can discuss concerns openly, and clinicians can get the care and time off they need, as well as provide input in operational decisions.

Read Next: COVID-19 burnout: Why physicians feel hopeless

Caring During COVID speaks directly to clinicians who are still facing the realities of the pandemic. Each week we feature perspectives, lessons, research, guidance, and more. Submit any question or topic you'd like to see covered, and let us know if you’d like to be a guest author.

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