Physicians routinely face challenging situations and difficult decisions. This can be morally distressing, especially during times of crisis, such as the COVID-19 pandemic. In this podcast, Dr. Yolanda Madarnas, CMPA Physician Advisor, and Dr. Steven Bellemare, CMPA Director of Practice Improvement, are joined by Dr. Caroline Gérin-Lajoie, psychiatrist at The Ottawa Hospital, and Executive Vice-President of Physician Health and Wellness at the Canadian Medical Association. Listen to them discuss why it is important to recognize and manage moral distress and explore various coping strategies that physicians can adopt to stay well.
CMPA Perspective article:
Moral distress: The cost of uncertainty during a pandemic
www.cmpa-acpm.ca/en/advice-publications/cmpa-perspective/2020/message-from-the-cmpa-president
Dr. Yolanda Madarnas: Hello everyone. Welcome to the second podcast in the series of the COVID-19 pandemic. I’m Dr. Yolanda Madarnas.
Dr. Steven Bellemare: And I’m Dr. Steven Bellemare.
Yolanda: So Steven, physicians routinely face challenging situations and difficult decision-making processes.
Steven: No, absolutely. And those can, at times, cause moral distress for us and that can occur even more frequently in times of crisis like COVID-19.
Yolanda: We hear from you every day on the phones. I hear you telling me that you’re worried about having to make difficult decisions that you may not have had to make but for the pandemic. So it’s important to learn how to recognize when we may be experiencing that moral distress.
Steven: We hear from you as well that you’re worried about your safety and that of your loved ones.
Yolanda: And how difficult it is to shift from a patient first ethical framework to a public first one.
Steven: So with this podcast, we thought we’d take the focus a little bit off the medical legal issues and more on physician wellness. We hope to discuss these very normal and common concerns that you have and provide you perhaps, a little bit of a framework to make sure that you help yourself be as well as you can be.
Yolanda: We hope to identify some of the coping strategies that you might tap into to prevent the negative impact on your wellbeing.
Steven: Today, Yolanda, we have a very special guest. We have Dr. Caroline Gérin-Lajoie, who is the Executive Vice-President of Physician Health and Wellness at the Canadian Medical Association.
Yolanda: Dr. Gérin-Lajoie is also a psychiatrist at the Ottawa Hospital. Welcome Caroline.
Dr. Caroline Gérin-Lajoie: Thank you. I’m happy to be here.
Steven: In Canada, you know we pride ourselves on a system that strives to provide everyone with an equal opportunity to access and receive medical treatment.
Yolanda: So this is possible when there is sufficient resources. Our last podcast dealt with that.
Steven: Indeed.
Yolanda: That the pandemic might force us to triage patients and make difficult decisions about who receives which level of care and under what circumstances.
Steven: And making these resource allocation decisions can be so stressful for people on the front lines.
Yolanda: Particularly when we sometimes feel that we have to make clinical decisions that are influenced by circumstances that are beyond our control.
Steven: Especially so, right? Caroline, can you tell us a little bit what you know about this difficult issue?
Caroline: Having to triage or to go through that process of setting priorities for resource allocation to manage a surge of patients, it can become even more ethically complex in these times of catastrophe, a little bit like what we’re living now with COVID-19.
Steven: Right.
Caroline: And these are the kinds of situations that can lead to moral distress. And when you think about that concept of moral distress, it can be when we feel unable to fulfill what we believe to believe, to be an ethically appropriate or a right course of action, and we can think about it as a psychological response or psychological distress, but that’s specifically related to an experience of moral conflict or of moral constraint. So this is especially likely to occur these days during the COVID-19 period, as well as in other situations where there may be extreme resource limitations that can affect patient care, or even the safety of our health care providers.
Steven: In moral distress, if I understand it correctly, someone feels morally compromised by the impossibility to pursue what they believe is the right course of action. Is that right?
Caroline: Yeah, exactly. So this kind of creates a moral conflict or a situation where you believe that an action, or the lack of action, can contradict their ethical obligations or commitments, or they fail to live up to their own expectation of ethical practice.
Steven: Right.
Yolanda: Caroline, are there common elements to moral distress?
Caroline: Yes, so for example, a feeling of complicity and wrongdoing. So that would be when you believe that you’re doing the wrong thing or that you have very little power to change a situation.
Steven: You know when we speak to physicians about this very issue they often describe the feeling of not being heard, or not feeling that they have a voice. Is that part of that?
Caroline: Absolutely. And speaking of that lack of voice, that’s when you believe that you have insights and you have knowledge relevant to a situation, but where you feel it’s not heard or it’s not taken seriously.
Steven: So if we experience moral distress at different times or in different scenarios, are those all separate individual experiences or are they somehow cumulative?
Caroline: Actually, Steven, they can be. These repeated situations of moral distress, they leave what we call moral residue and that heightens someone’s level of moral distress in the subsequent experiences that they may have.
Yolanda: So if I understand correctly, moral residue is the distress that remains when the situation that triggered the moral distress initially, has actually ended.
Caroline: That’s correct. So moral residue is what each one of us carries with us from all of those times in our lives when we feel we are morally compromising ourselves or allowed ourselves to be compromised in the face of a distressing situation. And so if the individuals level of moral distress doesn’t resolve but rather, remains high, it may increase even more the next time that they’re encountering a morally distressing situation and that’s really why it’s so important that we deal with it.
Yolanda: Caroline that sounds a lot like the genesis of burnout and compassion fatigue.
Caroline: That’s a good observation. Actually, we know that moral distress can be related to compassion fatigue, to burnout, and even to depression. So these are things that affect the individual physicians or caregivers, but we also know that moral distress can have an impact on the organizational level and we could see that through patient safety incidents, distancing from patients, and even decreased job satisfaction.
Yolanda: Caroline, could you give us an idea of how a physician might recognize when they’re experiencing moral distress. Is it more than just a feeling?
Caroline: Yeah. And I think it’s important to start by clarifying that moral distress really is not a mental health disorder in itself, but it’s important to manage it well so that it doesn’t lead to complications and those could include mental health issues. It’s also important to know that people experience moral distress in different ways. For some people, it may be very easily manageable, but for other people it can be completely impairing. And you may wonder what some of the symptoms are and these could include things like physical symptoms. So these could be fatigue or headaches, difficulty sleeping. They can also include some emotional symptoms. There could be anger, fear, anxiety, but also behavioural symptoms and these could lead to addictive behaviours, maybe drinking or taking drugs are also influencing our behaviours in relationships with our loved ones.
Steven: You know Caroline, as I hear you list these signs and symptoms, I can’t help but think that some of our listeners, if not a number of our listeners, might actually be recognizing themselves in those descriptions.
Yolanda: For sure.
Caroline: They absolutely could and really the key message here is to be aware of the concept of moral distress and to have a better sense of how to recognize it within themselves but hopefully within other colleagues.
Yolanda: So what could physicians do to minimize the impact of moral distress?
Caroline: You know unfortunately, it is not possible to eliminate the situations that cause moral distress or to eliminate many other challenging situations that we may come across in health care. But there are ways where we can try to mitigate its impact, so remembering that moral distress can involve at least three different levels: the individual physician; the unit, team or department; and also the organization or a system. And what that means is it opens the door to potential ways to ease that experience of moral distress at each one of these different levels.
Steven: That’s very interesting. I’m sure that we couldn’t possibly give advice, deep advice on all of the strategies that we could implement in such a short podcast. But Caroline, I wonder if there’s perhaps, one or two things that we could discuss, perhaps for each level?
Yolanda: So could we start at the individual level, a couple of things that a physician or a health care provider could do.
Caroline: So as an individual, and I would say beyond the basics of health and that would include proper sleep, nutrition and exercise, but within the limit of what’s realistic right now. What I would encourage physicians and health care providers to do is share their emotions and their experiences with people they trust. Whether that’s their team at a team meeting, for example, and these could include sharing emotions like distress, it could be guilt. It could be that sense of unfairness. And the idea is to open up communication and to share the stories about what they went through. I would also encourage people to reach out if they need to, the ethicist working in their environment and that can help you to kind of work through some of these really challenging situations when you encounter them and when they may lead to moral distress.
Steven: It’s really about realizing that we are not alone in this, that you’re not the only person—likely not the only person feeling this.
Caroline: And it’s leveraging the people in your direct environment to help you cope optimally in these situations.
Steven: People who can understand you.
Yolanda: Your peers, your colleagues. This may be a little bit more difficult in the days, today. You know a generation ago there was a doctor’s lounge, we could shoot the breeze and chat with our colleagues at the end of a difficult day. That’s no longer as easily or readily available. In fact, absent in some places, so that much more important to dedicate some quality time at some point during the day to exchange these meaningful feelings with our colleagues.
Caroline: And so what that means is the onus is now on us even more so, to do a check-in with ourselves and that if a person recognizes that they are in a high level of distress or having increasing difficulty functioning, they absolutely need to reach out to their family physician, or an employee assistance program if they have one, or even to the provincial physician health program. But at the end of the day, what’s important here is that we learn to treat ourselves with empathy, with self-compassion, and also with self-forgiveness.
Steven: Very good advice there. I mean, we don’t have the time to get into a whole lot of details about managing emotions and cognitive behavioural therapy, but very good point. Caroline, what about team level issues? What are some ways that we can address moral distress there?
Caroline: There’s actually a great opportunity here for leaders to help recognize the impact of moral distress and to try to build in processes to directly address it with their staff. So for example, they may want to hold more regular meetings, and that can be within your department or with other departments and that can help to build this feeling of team cohesion and to help have very clear and timely communication, shared decision-making and this way everyone feels included and part of the experience. Another option could be to hold debrief meetings on a more regular basis, particularly when these morally charged situation occur. So as an example, that could be when there’s a clinical triage decision that needs to be made.
Steven: Or maybe when a patient has died or is about to die and doesn’t have a family member with them. I mean, I know how distressing that it. We hear that a lot and having the opportunity to debrief around that, I think might be helpful.
Caroline: And finally at the team level, it’s important to encourage members to support each other and make sure that no one isolates themselves, and so actively trying to find those people and reach out to offer them support and that can be done by creating a buddy system. And a buddy system is where you just pick someone you trust and you try to do regular check-ins with. And interestingly during COVID, this has been a really popular phenomenon within physician groups.
Yolanda: Interesting.
Steven: You know I brought up the whole idea of debriefs whenever a patient, for instance, is dying and alone and that causes distress. Yolanda, I think we’ll have more podcasts.
Yolanda: Yeah.
Steven: Later on, we’ll have an opportunity to talk about debriefs. But today’s discussion really does highlight the important role that they play.
Yolanda: Recognizing that it may be difficult to find the time for a debrief because they may not be part of the everyday in many groups, the buddy support system takes on that much more importance and might actually be the easiest one to implement, at least at first. Caroline, what are some of the things that can be done at the organizational level?
Caroline: So we tend to forget this, but the organizations can actually play a really big role in these types of situations, particularly in recognizing and validating that experience of moral distress, but more importantly, I think conveying to health care providers that feeling that we’re in this together and that we have your back. It is so crucial.
Steven: Caroline, thank you so much for raising that point. You know, we may have a lot of listeners who are physician leaders, who are in a position to actually put in place processes to implement some of these recommendations. Is there anything more that you can provide, other little tips, pearls for them?
Caroline: Yeah. Other strategies could include things like being very honest and transparent about the situation at hand. For example, if there was a situation with resource constraints, or to provide really clear guidance on changing policies and procedures and we know that can happen at an extremely rapid pace. They can be very clear with triage criteria, for example, and if ever there was to be a triage process activated, it really should be accompanied by some kind of plan to mitigate the physician or health care provider, moral distress. And just to give a little bit of an example there, hospitals and organizations could create triage teams and what that would do is allow for the separation of the clinical and resource allocation decisions. And what that does is it helps to reduce that moral burden created by the decisions for a specific physician so they don’t have to feel so alone in making these really difficult and emotional decisions. And finally, I would recommend that organizations create guides so that their leaders can provide support for their teams even more easily and make efforts to advertise wellness supports, to encourage peer support as we mentioned, and more importantly, it’s to create the opportunity for people to access those supports and to practice a lot of self-care.
Steven: Sounds like we just can’t take for granted that people will instinctively know how to help themselves and each other, that we have a role as institutions in helping promote that wellness.
Yolanda: One advantage of implementing some of these strategies now in our current circumstances is that when the time comes and this health crisis has abated, some of these processes may become part of the new normal, part of the new structure in which we continue to practice medicine and can only continue to help health care providers and their patients.
Steven: In fact, you know what I suspect, Yolanda that when all of this is over, it won’t necessarily mean that all will be back to normal, right Caroline?
Caroline: I agree completely. And that’s why I think we should even be using the term “new normal” because we really cannot go back to how we were living medicine prior to two months ago, for example. But what you raise is the importance of the post-COVID period and what we absolutely need to do is ensure that there are supports and resources available to all staff so that we minimize the moral residue and we really try to enhance wellbeing. And in fact, I would say we have an ethical imperative to prepare for that period because we can probably expect a rise in mental health issues and in needs. So we have a duty to make sure that that’s available. And as human beings, one of the ways that we can cope better through these difficult times is to look back and try to learn from what happened and take those learning’s to then move forward and improve the health care system.
Yolanda: Thank you, Caroline. We have covered a lot of territory in a very short podcast, and the intention wasn’t to go in-depth into too many of these aspects. But before we go, are there two distill takeaway points that we can leave our listeners with?
Caroline: Absolutely. So remember, it’s normal to experience moral distress in the context of a pandemic, such as what we’re going through with COVID-19, and just recognizing moral distress is an important first step to then being able to mitigate its impact. And the second thing would be to always remember the multi-level approach to ease our experience of moral distress.
Steven: Well thank you very much, again, Caroline. This was fantastic advice. For our listeners, if you’re looking for more information, you can certainly visit our CMPA COVID hub on our webpage. And Caroline, are there any resources available at the CMA?
Caroline: Absolutely. And this can be accessed through CMA.ca. And on that webpage you will find a section specifically for COVID-19 with a lot of information and resources.
Steven: Well we hope this was helpful to you, our listeners.
Yolanda: And as I said, while it’s a complex topic, we do hope to have provided you with some practical tools that can help you approach this really challenging issue.
Steven: Good-bye, everybody. Stay well.
Yolanda: Good-bye, everyone. Thank you. Stay well.
Caroline: Thank you.
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian health care providers.