Interview with Dr. Jennie Byrne – 354
Today's episode features my interview with the author of Moral Injury: Healing the Healers.
We explore the concepts of burnout and moral injury within the healthcare profession through a detailed discussion with Dr. Jennie Byrne. Dr. Byrne shares her insights and experiences, highlighting the evolution of these issues, their impacts on healthcare professionals, and potential solutions.
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The Evolution from Burnout to Moral Injury
Burnout has long been recognized as a significant issue in healthcare, intensifying in discussions since the 70s and 80s. However, Dr. Jennie Byrne and others have shifted the focus to “moral injury” as a more accurate description of what healthcare professionals experience.
Moral injury involves:
- participating in or witnessing events that conflict with one's personal or professional values,
- under directives from superiors,
- in which high stakes are involved.
This concept, originating from military contexts, provides a deeper understanding of the profound, soul-wounding experiences of many in the healthcare field.
Personal Stories and Systemic Issues
Dr. Byrne shares her journey and experiences in healthcare, from her varied educational background to her work in psychiatry and healthcare consulting. She highlights the systemic issues that contribute to moral injury, including the intense pressures and emotional challenges faced by medical professionals.
Personal anecdotes, such as her experience with a medical board investigation, illustrate how non-workplace-related events can also inflict significant wounds. These stories underscore the complexity of moral injury, extending beyond workplace stress.
Healing Strategies and Systemic Changes
Addressing moral injury requires both personal and systemic approaches. Dr. Byrne emphasizes the importance of open conversations and peer support as initial steps toward healing. Creating safe spaces for healthcare professionals to share their experiences and feel seen and heard is crucial.
On a systemic level, having dedicated resources such as a Chief Wellness Officer and structured support systems can provide lasting solutions. Additionally, small acts of kindness and advocacy work play a significant role in the healing process, fostering a culture of empathy and support within the medical community.
Summary
Dr. Jennie Byrne can be contacted and found through her professional website DrJennieByrne.com, where you can learn more about her background, services, and resources. Additionally, she shares insights and updates on her LinkedIn profile, where you can connect with her professionally and stay updated on her latest activities and contributions. Dr. Byrne's blog, also accessible through her website, offers information on various topics related to her fields of expertise.
NOTE: Look below for a transcript of today's episode.
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Links for Today's Episode:
- Dr. Jennie Byrne's LinkedIn Profile
- Dr. Byrne's Website
- Dr. Byrne's Private Psychiatry Practice
- Moral Injury: Healing the Healers, by Dr. Jennie Byrne (This is an Amazon affiliate link).
- Dr. Warren Kinghorns's LinkedIn Profile
- Amy Story's LinkedIn Profile
- Humans in Healthcare
- Monica Bean, BSN's LinkedIn Page
- Dr. Tammie Chang's Website
- Dr. Paul Dechant's Website
- (This is an Amazon affiliate link.)
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Transcription PNC Podcast Episode 354
How to Recognize and Overcome Moral Injury in Healthcare
- Interview with Dr. Jennie Byrne
John: The concept of burnout's been around for a long time, I don't know, maybe decades if not centuries, but it seems like in the 70s and 80s, it started to be applied to healthcare just because of the intensity and the long periods of education and so forth. And I remember talking about it with colleagues, early in my career in the mid 80s. And then at some point, it started to evolve into this concept of moral injury as a better descriptor of what's actually happening. And so I thought it was about time that we just address that issue here on the podcast. So to that end, I'm very happy to have Dr. Jenny Byrne here on the show today. Welcome, Dr. Byrne.
Dr. Jennie Byrne: Hey, great to be here.
John: I'm really looking forward to picking your brain. You know, you've got the book and I was able to go through the book, but it definitely hits all the points that I'm interested in hearing about. So I'm glad to have you here and have you talk us through this. But I always wanna give my guests a chance to talk about themselves for a few minutes. I've had a very long and illustrious career, but talk about your medical training, what you do, what you do now for the most part, and then we'll get going into the topic of the day.
Dr. Jennie Byrne: Great, so I'm originally from Pennsylvania, and I don't know, I know you have a lot of physicians listening. I did not know I wanted to be a doctor when I grew up. I was a music performance major. Going into college, became a French major so I could live overseas. And it really wasn't until I came back, took a class in brain and behavior and fell in love with it. So pretty much my whole career circles around brain and behavior in some form or fashion. So I did an MD PhD. I don't know if you have any MD PhD listeners. Mudfud's out there, but I did an MD PhD in neurophysiology. Again, love the intersection of human brain and behavior. So I trained as a psychiatrist. I did my MD PhD at NYU, and then I did psychiatry at Mount Sinai. So I lived in New York City for a very long time, which was very exciting. And then I did a leap of faith down here at North Carolina, which is where I live now and I love it here. And I've done a whole bunch of different stuff. I'm always curious, I'm always learning, and I'm always saying yes to things and that's led me in a bunch of different directions. I've had a outpatient practice that I sold a couple of years ago. I grew that out over about nine year period. So I've practiced psychiatry for over 20 years. I got involved in Medicaid in North Carolina, helping design programs for integrated care, worked a lot with primary care docs, real fondness for primary care. Then I went to work as a national executive for a company called CareMore out of California. ran all of behavioral health and specialty for them nationally. So I saw what like a fully scaled healthcare organization looks like and kind of behind the curtain of what it's like to be an executive at some of these companies. But I love early stage. So that's what I do now. I advise early stage healthcare companies, a lot of which are mental health, but also value-based care and really just human behavior because that's pretty much everywhere in health, including physician behavior. You know, we're, human too, even though we don't like to admit it and we do dumb human stuff like everybody else. So that's what I focus on now. I do see patients a little bit and I have a practice that is not publicized, but for you all listening may be interesting, I take care of other physicians. So I have a really cool AI hybrid infused practice where I can care for other physicians as a psychiatrist, a therapist, or a coach.
John: That's all very interesting. And you talked about the healthcare advising that you do, I think, and there's probably at least five or 10 different things we could talk about on another podcast episode. But so I'm really glad you took the time to join us though to talk about this topic, moral injury. You know, I just, you know, like the book is what attracted me and because I had this question, a lot of bunch of questions about moral injury and what it means. And so let me, let's go to why did you write the book?
Dr. Jennie Byrne: While I was thinking about it, and I have to say, writing my second book in under a year wasn't really on the top of my list for this year. Um, but the reason I wrote it was because I, I feel passionate and I felt there was a real urgency to talk about this, now this year. And it really started where I was just having conversations with folks like your listeners or you, or, you know, colleagues, physicians, other clinicians. And maybe because I'm a shrink, people just tell me stuff, but What I heard really upset me and worried me. It's really bad. It's really bad out there Medical students are ready to leave the profession before they even get started Residents are ready to leave. People who are amazing clinicians are ready to leave people retiring early. I mean There's a reason for all of this and my kids Pediatrician left and it really threw me for a loop. I was like this was someone who was I don't know maybe late forties, early fifties, seemed to love her job and, and she just kind of disappeared and that really, you know, struck a chord with me. Like what is going on? And of course, in my private practice, I've taken care of physicians and I know that, you know, sometimes we look at our peers and they seem like they have everything together, but behind closed doors to their psychiatrist, you know, they'll tell me they're thinking about suicide or they're, they're paranoid or not to go off on a negative tangent, but you know, it's really bad. So I really wanted to figure this out and I wanted to know what was going on. So I started just doing some research, talking to people and came across the idea of moral injury from a colleague in North Carolina, whose name is Dr. Warren Kinghorn. He is a psychiatrist, but he also works with the veterans of the VA. And he also has a divinity degree. So he's got this really interesting intersection of faith, military and psychiatry. And he told me about moral injury. It's a concept that comes from the military.
John: You know, I have to admit too, that I've heard the same thing, because I'm talking to people looking about getting out of medicine. And what I've heard is that, you know, the med students will say, oh, I got to tough it out. You can't get any worse. And then they get in the residency and the burnout, whatever you want to call it, seems to be worse. And each year it gets worse, you know, depending on the residency. And it's just not very hopeful at this point, if that's kind of the way our system is built.
Dr. Jennie Byrne: So, so the definition of moral injury. So this is where kind of this topic about burnout versus moral injury. I think that words matter. I'm a psychiatrist. I think words matter. I think it's important for us as physicians and others to articulate what we feel inside. And that's particularly hard for us because our culture is one of, you know, repression and denial and all those coping skills we got to get through school. So we feel bad inside and we don't know why. So moral injury, the definition is threefold. The first is that you are part of something, do something, witness something that goes against your values, whether that's personal values or professional values. Second, that it is ordered or condoned by somebody superior to you. And third, that the stakes are high. So you can imagine all these military folks coming back from maybe combat zones where they weren't really in the line of fire, but they just really struggled to reintegrate into their lives and it wasn't PTSD and it wasn't depression. And it was really this like, I think about it as like a wound on your soul. And that's different than burnout. Burnout is more of this industrial energy concept that we're tired and fatigued and burned out and we just need to go recharge our batteries or take a vacation, do some yoga and come back and we'll be just fine. But I think it's like this wound, this metaphor of a wound really resonated with me. And so that's why I really liked this concept.
John: So that kind of gets to the root causes, I guess, is what's behind it. I mean, we have, like you said, what we're doing generally, depending on the circumstances, they're high stakes and yet we don't feel supported, we're being told what to do that may be against even what we think we should do. I know, did you get the sense during the pandemic that this was just like an overdrive?
Dr. Jennie Byrne: The problem predated, clearly the pandemic, right? Clearly, but the pandemic just put it into stark relief. And then post pandemic, there wasn't a period of healing. So the wound, if you think of, I talk in the book about staging it like a wound, the wounds were bigger, right? The pandemic really, really made those wounds gaping. And then we didn't have any opportunity to heal post-pandemic. So those wounds are still there and they're for most people still pretty gaping wounds.
John: Yeah, I think that was one of the notes to myself was to ask you to expound on that issue of like sort of using the pressure ulcer as, as you mentioned in the book, and I thought it was a pretty good analogy.
Dr. Jennie Byrne: I love the good visual, right? So I told a story in the book about one of my worst rotations in med school. I was at Bellevue training and I had to do vascular surgery because I couldn't get my top elective choice. For some reason, they put me in vascular surgery. I don't know why. And it was awful. And I got to know wounds really, really well during that rotation. And some of them were just horrific. And so this idea of what it really means to heal wounds. I think that's a great metaphor for a moral entry because you can look at a pressure, we stage pressure wounds in particular. So you kind of say, okay, stage one, there's redness, maybe a little tenderness. You can tell something's brewing in there, but if you just let it be, it'll probably be okay. To me, that's kind of the burnout, like take a vacation, change jobs. you know, something like that, that'll heal on its own. Then you break the surface, you know, the stage two, the surface is breached. Okay, well now the burnout's worse, and I don't think it's just gonna heal on its own. It needs something, maybe your own psychotherapy or coaching or adding consulting, doing something different, you know, maybe that will heal it, maybe that gives you enough to heal. And then you get to stage three where it's pretty messy. It's a pretty messy wound and there's really, you need systemic healing to be in place. You need the system, the environment around the wound to be properly maintained. It has to be clean, it has to be dry. Maybe it needs antibiotics. You know, you gotta do some stuff for that to heal. And then you get to stage four where you're, you know, you're in there looking at the bone. And that's what I remember from my vascular surgery days. You know, there were days where I was packing things where I could see the bone. And that is a whole other ball game. And some folks are at that place. And that's where, unfortunately, physicians in particular can internalize and go to really dark places. Or they can externalize and get really angry and hostile, which can lead to other problems. So I like this idea of a wound, because we can all kind of imagine that and understand healing, not fixing. I don't like the fix. I don't like burnout that we're gonna fix it. I think these are wounds, and wounds require healing, not fixing.
John: Now, the other thing that has occurred to me thinking about this topic is, and you mentioned the military, and we're talking about medicine. It's basically a workplace-related situation, is it not? I mean, I guess there might be other circumstances, but in most cases, the things that you've described are happening in a workplace of some sort. So it would seem to be something that OSHA or some other organization besides just the maybe the physician or the others affected by this, the military and so forth would have to address. What do you think about that?
Dr. Jennie Byrne: I think yes and no. I think sometimes that wound is the workplace. You know, the death by a thousand cuts, the EMR clicking and the, you know, 10 patients an hour and the blah, like, yes, yes. But there's more to it than that. And I think this is where the conversation gets interesting for me. So in addition to the workplace kind of injurious things, you know, I opened the book with a very personal, vulnerable story about an incident that somebody reported me to the medical board. That had nothing to do with the workplace. That was purely about me having to deal with someone questioning my values and my skills as a clinician, even though I was not in the wrong. And at the end of the day, it didn't really matter. But I had to go through this huge process where other physicians on the medical board had a process which wounded me. And I had to go take a class on controlled, on opioid prescribing, which was ironic because I wasn't even prescribing opioids. And when I went to that class, they flashed slides of jails where they send doctors who prescribe opioids. That was what I sat through, you know, and that wounded me at such a deep level. I can't tell you, even writing about it for the book really was painful. And my hope is that by writing and sharing the story, it heals me as well as maybe healing others who have had similar things. So Sometimes the injuries don't come from the workplace. Sometimes they come from a lack of respect in the community, the way we're treated. Sometimes it comes from our peers who injure us, whether intentionally or not. Sometimes it comes from just the difficulty of managing chronic illness with so much information that we can't possibly keep up. Our human brains can't possibly keep up. Sometimes it comes from trying to manage this increasing intersection of things like gender and politics and sexuality and like culture and like, you know, and it's really hard. It's not like it used to be. I have a grandfather that was a doc in the 40s, you know, and I have his little black bag sitting over here. You can't see it. Things were a lot different back then and it's just not that way anymore. So I guess the answer is yes to the workplace but also other things which we don't talk about as much.
John: Well, that in my mind also kind of points to, let's say being sued, a lawsuit, I would think. That adds like a whole another layer of pressure.
Dr. Jennie Byrne: And I'm sure you have people listening who probably have had these things happen and they've never told anyone. I didn't tell anyone about my medical, I was so embarrassed, ashamed, you know, pained by it. I didn't even tell anybody. So I'm sure there are folks listening who've had, like you said, a malpractice suit, a patient complaint, a medical board issue. You know, people don't talk about these things. I'm sure that people out there have had this happen and I'm sure that it was wounding to them the same way that it was wounding to me.
John: This is a little bit of a left turn just for a moment, but one of the things that you just mentioned is I did an interview some time back about sham peer review, where the peer review process was actually being sort of misused to get someone off staff, destroying their career and so forth. I don't know if you've experienced, if you've coached, if you've treated people under that, that could be almost unbearable kind of pressure.
Dr. Jennie Byrne: I have. And it's something that unfortunately that's kind of part of our culture, you know, the old school medical culture, right, of being a resident and being shamed, publicly shamed in front of others as the way to learn. That's just kind of part of our culture and it doesn't make it right. But we still do that to each other. And it's not, I don't blame, I don't blame the other physician doing it because when you're in a negative, stressed burned out, time crunched, injured mindset, is very easy to injure somebody else, whether intentionally or not. So I don't blame them. I have deep empathy for them as well, because I know that under other circumstances, they probably wouldn't do that to their colleague.
John: Well, I think we should shift gears and talk about what are the solutions or what can we do to at least ameliorate, if not eliminate this problem eventually. What thoughts do you have on that?
Dr. Jennie Byrne: Well, one of the best news is, I know this is kind of a serious topic, but one of the best news is that just talking about it is part of the solution. So we know this from the military. Just talking about it, being able to identify that feeling that's inside of you, being able to share your story in a safe place, not that the other person can change what happened to you, but feeling seen and heard by a peer is incredibly healing. So, talking about it, having the words to describe what's going on, and having others in our ecosystem listen to us and giving them the language to talk to us about what's going on. Because I can tell you, I work with a lot of administrators, executives, tech people. They're not greedy, evil people. I know that's the narrative that's convenient. No, it's a convenient narrative. And sometimes it's true, but mostly they're trying to do the right thing and they could make money more money doing something else too. So they lack the understanding of what it's like and we don't help them. We don't give them the language to talk to us and we act like we're perfect. So I think just talking about it and giving others the tools to have real conversations is something which actually doesn't cost any money and is incredibly healing. So that's the first thing. Yes to the system change. Yes to the like designing clinical products for clinicians, understanding the psychology of clinicians. Yes to all of those things too. And then I think, you know, I write about in the book, I do believe in butterfly effects, especially from one clinician to another. Or as a patient, like I'm a patient, we're all patients too, right? It's not just us as clinicians, we're all patients too. And I always tell someone, you know, when you see your clinician, tell them thank you for all you do. Just do that. Like small acts of kindness, they don't fix the wound, but they can really help. So the more small acts of kindness and empathy that you can show others or call your peer. I had a psychiatrist that was a mentor of mine send me an email today. He said, I read your story in the book and I can't believe I was so upset by what you wrote. And he said, I had something happen to me like that. And I never told anyone. And I was like, I can't believe, you know, and just so that sharing and that kindness, especially from one peer to the other. So taking that five minutes to write that email to your peer, like, you know, I was in a really tough spot the other day and you came and you told me this, that really helped me. Or if you see your colleague who's struggling, say, I don't know what's going on. It seems like something's gone on and I'm here if you want to chat with me or what, you know, like these small things I believe really matter. So in addition to the bigger systemic change, I do think there are things that we can do right now that actually don't cost any money.
John: You know, as you were talking, it occurred to me something else that I've experienced for times in my life where there were issues. One was a support group for divorced men and I for a reason that I won't disclose now, but I mean, I attended Al-Anon and you know, those are supposed to be private and not anonymous per se, but they're not discussed outside and it's supposed to be supportive and all that. Have you ever seen that ever used with physicians?
Dr. Jennie Byrne: Yeah, so for example, some resources to check out for your audience, so Amy's story, She is a PA by training. She has a company called Humans in Healthcare, and that's exactly what they do. It's clinician groups where they share stories. Sometimes they grieve together for patients that have died or their own losses. She's doing amazing work. There are a ton of coaches out there. So if you're a nurse, probably don't have nurses listening, but. There's a woman, a nurse, Monica Bean, who does this for nurses. She's a nurse by training. Trying to think of some others. I could, you know, have people reach out to me. I can share some of these resources, but there are lots of groups of physicians coming together. There's one woman that focuses on moms, physician moms. And I did forget to mention one thing that's important for your audience to know that. One of the ways you can heal that I've heard from my interviewer interviewees is through advocacy and through feeling like you're part of the solution. So if folks are thinking about advising other companies, taking a leadership mentorship roles or being an advocate for even if it's just a single patient or another physician or that really can help you heal too. So If you find a way to have an impact that's not just your day-to-day with patients, often that's quite healing.
John: Well, I just took a quick peek back at the index of the book, Moral Injury, and I think a lot of these things are really addressed there in much more detail, so I would encourage everyone to get the book. So let's talk about that. How do we get the book, and where do we find it, and so forth? And how do we find you?
Dr. Jennie Byrne: So if anyone else has written a book, you'll know that Amazon is where all the books are. So the book is on Amazon as well as my first book which is called Work Smart. And if anybody is interested in a book club or sometimes we'll go do a talk where we get a whole bunch of books, just reach out to me if you're interested in anything like that. In terms of getting a hold of me for questions about advisory work, again, LinkedIn is a great place to just send me a message. I do have a website, drjennieburn.com, which is kind of a list of some of the stuff I've done. And then I'm gonna share with this group. I don't share this with all the people I do podcasts with. I have a small private practice that is not advertised where I care for other physicians, whether that be coaching, psychotherapy, or I think 12 states I can do medications as well. And that is called constellationpllc.com So you can also just reach out if you need help. If I can't help you, I'll do my best to find somebody else in your state or wherever you need help.
John: I'm gonna put a dig in here against the industry right now just for a second, only because I think I read in the book that the number one cure for moral injury is not resilience training. Is that my off base there? But because I get offended when they tell me that, that's the solution.
Dr. Jennie Byrne: I think that's happily falling out of favor this year. My statement in the book is I believe clinicians are inherently resilient. I don't know how on earth anyone gets through all that training without being resilient. I mean, seriously. So that doesn't mean we're not human and we need help. But I think if my point is if a clinician of peers, they're not resilient, you should be asking what's going on.
John: Hmm, because they've reached -they've gone way beyond the point where it's not dangerous, you know. Have you seen any big organizations? This is what I keep looking for because I know of physicians who have addressed burnout, moral injury, you know as a coach or something and they'll spend a lot of time with an organization But have you seen any put into place something that is lasting and is effective over time?
Dr. Jennie Byrne: So I think the most effective long-term solutions come from leadership when they put, when they basically put money into it. So when a leader, a CEO or something, you know, creates a wellness group, like a chief wellness officer, and really devotes significant resources to it, that's probably the best long-term solution is to actually have people internal to the organization who are driving it forward. So I, one of the people I talked to was Dr. Tammy Chang. So she's been doing this for a long time. She's a great resource to reach out to. She's at a health system as their chief wellness officer and she's just a wealth of information. And then there's some others who do like private interventions, but company solutions. So Dr. Paul Duchant does that. So he's a good resource. He and Diane Shannon wrote a really good book on physician burnout, which I recommend as well. So there are folks who do it. Now, he leans a little heavy on the operational end of things, and I'm more the shrink. I really think that the healing has a lot to do with our hearts, not just operations. So we, I don't wanna say we disagree. We don't disagree. I just, I think we undervalue the emotional component of change. And I think it's, it's actually easier than we think it is sometimes to connect with someone at that like heartfelt level, and make a real difference in their life. I don't think it always has to be fixed the EMR fixed. I mean, yes, do those things, but and have that human connection that heart part because I think that's how we heal. It's not just our bodies, right? Like our hearts have to heal.
John: Very good. But I appreciate you taking the time and sharing all this with us, giving me a little more clarity on exactly what it is. And like you said, the metaphor, the pressure ulcer, trying to explain it to people. And you gave me a little hope there at the end that there are people that are making a difference in this area. So I'm going to have to let you go soon. We're pretty much out of time. But I guess, do you have any last words of advice for, let's say, the listeners who might feel... I mean, one of the reasons they're looking sometimes to change their career or their life is because they're having this particular problem. Any other advice for them individually to how to find a solution for themselves?
Dr. Jennie Byrne: Yeah, the main thing is really you're not alone. There are a lot of us out there, we're feeling the same way, we may not be talking about it, and you're not helpless. A lot of us, we get in that negative mindset, we feel very helpless, you're not helpless. You have tremendous skills, you're in tremendous demand, you've come a long way, right? Like you have more control than you think you do, and there are people out there who will help you. So I guess my only precautionary thing would be, leaving the practice of clinical medicine altogether may not heal all those wounds. So I still see patients, it's important to me and I do advising for a living. So just a little like, you know, it may not heal everything just to leave. So if you are interested in doing clinical practice and doing something else, you can do both. You don't have to give up one for the other. It may not fix all your wounds just to leave clinical medicine because it's probably, there was a reason you went through medicine in the first place. And that part of you is important.
John: I used to focus almost entirely on like, what are the options for just getting out? But I'm convinced now that there's so many options for staying in. If you can kind of carve out the things that are making your life miserable or that you're just reacting to in whatever way you're reacting to, get rid of the bad parts, keep the good parts. And there are more and more ways of doing that, even though the employment has been going up, I think we're reaching a point where you can do DPC and whatever, other forms of practice and just set boundaries and write your list of your must haves and really start to take control. But what you said earlier, people don't even realize that they're in the midst of burnout or moral injury. So they don't really look at it that way and take a step.
Dr. Jennie Byrne: And one final thing would be too for those who are a little later in their career, a little older like me, sometimes being a mentor, being a support for younger early stage folks, that's really rewarding too. So if you decide I just can't go back to clinical practice and maybe you wanna do advisor or other work, but you can still find ways to support those who are coming up who maybe have a little more energy. And maybe you can prevent them from feeling so wounded so they can go and do that good work. That can be a really wonderful way to stay connected with clinical medicine in a way that maybe supports you in whatever stage of your career that you're in.
John: Awesome. Thanks for that. Thanks for taking the time to talk to us today. I really appreciate it. I advise everyone get the book, go to Amazon, Moral Injury. Let's see, what's the byline? Moral injury?
Dr. Jennie Byrne: Healing the healers.
John: Healing the healers, okay. I had that written down here somewhere, but it's really good and it's pretty comprehensive. I mean, there's a lot in there starting from recognizing it to even potential solutions. So it's a great resource. Okay, thanks Jenny, I really appreciate it. And hopefully maybe we can have you come back and talk about some of the other things you're up to at some point.
Dr. Jennie Byrne: Thank you for having me and to everyone out there listening, be well, please take care of yourselves, please. Please get help if you need it.
John: All right, bye now.
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Transcription PNC Podcast Episode 354
How to Recognize and Overcome Moral Injury in Healthcare
- Interview with Dr. Jennie Byrne
John: The concept of burnout's been around for a long time, I don't know, maybe decades if not centuries, but it seems like in the 70s and 80s, it started to be applied to healthcare just because of the intensity and the long periods of education and so forth. And I remember talking about it with colleagues, early in my career in the mid 80s. And then at some point, it started to evolve into this concept of moral injury as a better descriptor of what's actually happening. And so I thought it was about time that we just address that issue here on the podcast. So to that end, I'm very happy to have Dr. Jenny Byrne here on the show today. Welcome, Dr. Byrne.
Dr. Jennie Byrne: Hey, great to be here.
John: I'm really looking forward to picking your brain. You know, you've got the book and I was able to go through the book, but it definitely hits all the points that I'm interested in hearing about. So I'm glad to have you here and have you talk us through this. But I always wanna give my guests a chance to talk about themselves for a few minutes. I've had a very long and illustrious career, but talk about your medical training, what you do, what you do now for the most part, and then we'll get going into the topic of the day.
Dr. Jennie Byrne: Great, so I'm originally from Pennsylvania, and I don't know, I know you have a lot of physicians listening. I did not know I wanted to be a doctor when I grew up. I was a music performance major. Going into college, became a French major so I could live overseas. And it really wasn't until I came back, took a class in brain and behavior and fell in love with it. So pretty much my whole career circles around brain and behavior in some form or fashion. So I did an MD PhD. I don't know if you have any MD PhD listeners. Mudfud's out there, but I did an MD PhD in neurophysiology. Again, love the intersection of human brain and behavior. So I trained as a psychiatrist. I did my MD PhD at NYU, and then I did psychiatry at Mount Sinai. So I lived in New York City for a very long time, which was very exciting. And then I did a leap of faith down here at North Carolina, which is where I live now and I love it here. And I've done a whole bunch of different stuff. I'm always curious, I'm always learning, and I'm always saying yes to things and that's led me in a bunch of different directions. I've had a outpatient practice that I sold a couple of years ago. I grew that out over about nine year period. So I've practiced psychiatry for over 20 years. I got involved in Medicaid in North Carolina, helping design programs for integrated care, worked a lot with primary care docs, real fondness for primary care. Then I went to work as a national executive for a company called CareMore out of California. ran all of behavioral health and specialty for them nationally. So I saw what like a fully scaled healthcare organization looks like and kind of behind the curtain of what it's like to be an executive at some of these companies. But I love early stage. So that's what I do now. I advise early stage healthcare companies, a lot of which are mental health, but also value-based care and really just human behavior because that's pretty much everywhere in health, including physician behavior. You know, we're, human too, even though we don't like to admit it and we do dumb human stuff like everybody else. So that's what I focus on now. I do see patients a little bit and I have a practice that is not publicized, but for you all listening may be interesting, I take care of other physicians. So I have a really cool AI hybrid infused practice where I can care for other physicians as a psychiatrist, a therapist, or a coach.
John: That's all very interesting. And you talked about the healthcare advising that you do, I think, and there's probably at least five or 10 different things we could talk about on another podcast episode. But so I'm really glad you took the time to join us though to talk about this topic, moral injury. You know, I just, you know, like the book is what attracted me and because I had this question, a lot of bunch of questions about moral injury and what it means. And so let me, let's go to why did you write the book?
Dr. Jennie Byrne: While I was thinking about it, and I have to say, writing my second book in under a year wasn't really on the top of my list for this year. Um, but the reason I wrote it was because I, I feel passionate and I felt there was a real urgency to talk about this, now this year. And it really started where I was just having conversations with folks like your listeners or you, or, you know, colleagues, physicians, other clinicians. And maybe because I'm a shrink, people just tell me stuff, but What I heard really upset me and worried me. It's really bad. It's really bad out there Medical students are ready to leave the profession before they even get started Residents are ready to leave. People who are amazing clinicians are ready to leave people retiring early. I mean There's a reason for all of this and my kids Pediatrician left and it really threw me for a loop. I was like this was someone who was I don't know maybe late forties, early fifties, seemed to love her job and, and she just kind of disappeared and that really, you know, struck a chord with me. Like what is going on? And of course, in my private practice, I've taken care of physicians and I know that, you know, sometimes we look at our peers and they seem like they have everything together, but behind closed doors to their psychiatrist, you know, they'll tell me they're thinking about suicide or they're, they're paranoid or not to go off on a negative tangent, but you know, it's really bad. So I really wanted to figure this out and I wanted to know what was going on. So I started just doing some research, talking to people and came across the idea of moral injury from a colleague in North Carolina, whose name is Dr. Warren Kinghorn. He is a psychiatrist, but he also works with the veterans of the VA. And he also has a divinity degree. So he's got this really interesting intersection of faith, military and psychiatry. And he told me about moral injury. It's a concept that comes from the military.
John: You know, I have to admit too, that I've heard the same thing, because I'm talking to people looking about getting out of medicine. And what I've heard is that, you know, the med students will say, oh, I got to tough it out. You can't get any worse. And then they get in the residency and the burnout, whatever you want to call it, seems to be worse. And each year it gets worse, you know, depending on the residency. And it's just not very hopeful at this point, if that's kind of the way our system is built.
Dr. Jennie Byrne: So, so the definition of moral injury. So this is where kind of this topic about burnout versus moral injury. I think that words matter. I'm a psychiatrist. I think words matter. I think it's important for us as physicians and others to articulate what we feel inside. And that's particularly hard for us because our culture is one of, you know, repression and denial and all those coping skills we got to get through school. So we feel bad inside and we don't know why. So moral injury, the definition is threefold. The first is that you are part of something, do something, witness something that goes against your values, whether that's personal values or professional values. Second, that it is ordered or condoned by somebody superior to you. And third, that the stakes are high. So you can imagine all these military folks coming back from maybe combat zones where they weren't really in the line of fire, but they just really struggled to reintegrate into their lives and it wasn't PTSD and it wasn't depression. And it was really this like, I think about it as like a wound on your soul. And that's different than burnout. Burnout is more of this industrial energy concept that we're tired and fatigued and burned out and we just need to go recharge our batteries or take a vacation, do some yoga and come back and we'll be just fine. But I think it's like this wound, this metaphor of a wound really resonated with me. And so that's why I really liked this concept.
John: So that kind of gets to the root causes, I guess, is what's behind it. I mean, we have, like you said, what we're doing generally, depending on the circumstances, they're high stakes and yet we don't feel supported, we're being told what to do that may be against even what we think we should do. I know, did you get the sense during the pandemic that this was just like an overdrive?
Dr. Jennie Byrne: The problem predated, clearly the pandemic, right? Clearly, but the pandemic just put it into stark relief. And then post pandemic, there wasn't a period of healing. So the wound, if you think of, I talk in the book about staging it like a wound, the wounds were bigger, right? The pandemic really, really made those wounds gaping. And then we didn't have any opportunity to heal post-pandemic. So those wounds are still there and they're for most people still pretty gaping wounds.
John: Yeah, I think that was one of the notes to myself was to ask you to expound on that issue of like sort of using the pressure ulcer as, as you mentioned in the book, and I thought it was a pretty good analogy.
Dr. Jennie Byrne: I love the good visual, right? So I told a story in the book about one of my worst rotations in med school. I was at Bellevue training and I had to do vascular surgery because I couldn't get my top elective choice. For some reason, they put me in vascular surgery. I don't know why. And it was awful. And I got to know wounds really, really well during that rotation. And some of them were just horrific. And so this idea of what it really means to heal wounds. I think that's a great metaphor for a moral entry because you can look at a pressure, we stage pressure wounds in particular. So you kind of say, okay, stage one, there's redness, maybe a little tenderness. You can tell something's brewing in there, but if you just let it be, it'll probably be okay. To me, that's kind of the burnout, like take a vacation, change jobs. you know, something like that, that'll heal on its own. Then you break the surface, you know, the stage two, the surface is breached. Okay, well now the burnout's worse, and I don't think it's just gonna heal on its own. It needs something, maybe your own psychotherapy or coaching or adding consulting, doing something different, you know, maybe that will heal it, maybe that gives you enough to heal. And then you get to stage three where it's pretty messy. It's a pretty messy wound and there's really, you need systemic healing to be in place. You need the system, the environment around the wound to be properly maintained. It has to be clean, it has to be dry. Maybe it needs antibiotics. You know, you gotta do some stuff for that to heal. And then you get to stage four where you're, you know, you're in there looking at the bone. And that's what I remember from my vascular surgery days. You know, there were days where I was packing things where I could see the bone. And that is a whole other ball game. And some folks are at that place. And that's where, unfortunately, physicians in particular can internalize and go to really dark places. Or they can externalize and get really angry and hostile, which can lead to other problems. So I like this idea of a wound, because we can all kind of imagine that and understand healing, not fixing. I don't like the fix. I don't like burnout that we're gonna fix it. I think these are wounds, and wounds require healing, not fixing.
John: Now, the other thing that has occurred to me thinking about this topic is, and you mentioned the military, and we're talking about medicine. It's basically a workplace-related situation, is it not? I mean, I guess there might be other circumstances, but in most cases, the things that you've described are happening in a workplace of some sort. So it would seem to be something that OSHA or some other organization besides just the maybe the physician or the others affected by this, the military and so forth would have to address. What do you think about that?
Dr. Jennie Byrne: I think yes and no. I think sometimes that wound is the workplace. You know, the death by a thousand cuts, the EMR clicking and the, you know, 10 patients an hour and the blah, like, yes, yes. But there's more to it than that. And I think this is where the conversation gets interesting for me. So in addition to the workplace kind of injurious things, you know, I opened the book with a very personal, vulnerable story about an incident that somebody reported me to the medical board. That had nothing to do with the workplace. That was purely about me having to deal with someone questioning my values and my skills as a clinician, even though I was not in the wrong. And at the end of the day, it didn't really matter. But I had to go through this huge process where other physicians on the medical board had a process which wounded me. And I had to go take a class on controlled, on opioid prescribing, which was ironic because I wasn't even prescribing opioids. And when I went to that class, they flashed slides of jails where they send doctors who prescribe opioids. That was what I sat through, you know, and that wounded me at such a deep level. I can't tell you, even writing about it for the book really was painful. And my hope is that by writing and sharing the story, it heals me as well as maybe healing others who have had similar things. So Sometimes the injuries don't come from the workplace. Sometimes they come from a lack of respect in the community, the way we're treated. Sometimes it comes from our peers who injure us, whether intentionally or not. Sometimes it comes from just the difficulty of managing chronic illness with so much information that we can't possibly keep up. Our human brains can't possibly keep up. Sometimes it comes from trying to manage this increasing intersection of things like gender and politics and sexuality and like culture and like, you know, and it's really hard. It's not like it used to be. I have a grandfather that was a doc in the 40s, you know, and I have his little black bag sitting over here. You can't see it. Things were a lot different back then and it's just not that way anymore. So I guess the answer is yes to the workplace but also other things which we don't talk about as much.
John: Well, that in my mind also kind of points to, let's say being sued, a lawsuit, I would think. That adds like a whole another layer of pressure.
Dr. Jennie Byrne: And I'm sure you have people listening who probably have had these things happen and they've never told anyone. I didn't tell anyone about my medical, I was so embarrassed, ashamed, you know, pained by it. I didn't even tell anybody. So I'm sure there are folks listening who've had, like you said, a malpractice suit, a patient complaint, a medical board issue. You know, people don't talk about these things. I'm sure that people out there have had this happen and I'm sure that it was wounding to them the same way that it was wounding to me.
John: This is a little bit of a left turn just for a moment, but one of the things that you just mentioned is I did an interview some time back about sham peer review, where the peer review process was actually being sort of misused to get someone off staff, destroying their career and so forth. I don't know if you've experienced, if you've coached, if you've treated people under that, that could be almost unbearable kind of pressure.
Dr. Jennie Byrne: I have. And it's something that unfortunately that's kind of part of our culture, you know, the old school medical culture, right, of being a resident and being shamed, publicly shamed in front of others as the way to learn. That's just kind of part of our culture and it doesn't make it right. But we still do that to each other. And it's not, I don't blame, I don't blame the other physician doing it because when you're in a negative, stressed burned out, time crunched, injured mindset, is very easy to injure somebody else, whether intentionally or not. So I don't blame them. I have deep empathy for them as well, because I know that under other circumstances, they probably wouldn't do that to their colleague.
John: Well, I think we should shift gears and talk about what are the solutions or what can we do to at least ameliorate, if not eliminate this problem eventually. What thoughts do you have on that?
Dr. Jennie Byrne: Well, one of the best news is, I know this is kind of a serious topic, but one of the best news is that just talking about it is part of the solution. So we know this from the military. Just talking about it, being able to identify that feeling that's inside of you, being able to share your story in a safe place, not that the other person can change what happened to you, but feeling seen and heard by a peer is incredibly healing. So, talking about it, having the words to describe what's going on, and having others in our ecosystem listen to us and giving them the language to talk to us about what's going on. Because I can tell you, I work with a lot of administrators, executives, tech people. They're not greedy, evil people. I know that's the narrative that's convenient. No, it's a convenient narrative. And sometimes it's true, but mostly they're trying to do the right thing and they could make money more money doing something else too. So they lack the understanding of what it's like and we don't help them. We don't give them the language to talk to us and we act like we're perfect. So I think just talking about it and giving others the tools to have real conversations is something which actually doesn't cost any money and is incredibly healing. So that's the first thing. Yes to the system change. Yes to the like designing clinical products for clinicians, understanding the psychology of clinicians. Yes to all of those things too. And then I think, you know, I write about in the book, I do believe in butterfly effects, especially from one clinician to another. Or as a patient, like I'm a patient, we're all patients too, right? It's not just us as clinicians, we're all patients too. And I always tell someone, you know, when you see your clinician, tell them thank you for all you do. Just do that. Like small acts of kindness, they don't fix the wound, but they can really help. So the more small acts of kindness and empathy that you can show others or call your peer. I had a psychiatrist that was a mentor of mine send me an email today. He said, I read your story in the book and I can't believe I was so upset by what you wrote. And he said, I had something happen to me like that. And I never told anyone. And I was like, I can't believe, you know, and just so that sharing and that kindness, especially from one peer to the other. So taking that five minutes to write that email to your peer, like, you know, I was in a really tough spot the other day and you came and you told me this, that really helped me. Or if you see your colleague who's struggling, say, I don't know what's going on. It seems like something's gone on and I'm here if you want to chat with me or what, you know, like these small things I believe really matter. So in addition to the bigger systemic change, I do think there are things that we can do right now that actually don't cost any money.
John: You know, as you were talking, it occurred to me something else that I've experienced for times in my life where there were issues. One was a support group for divorced men and I for a reason that I won't disclose now, but I mean, I attended Al-Anon and you know, those are supposed to be private and not anonymous per se, but they're not discussed outside and it's supposed to be supportive and all that. Have you ever seen that ever used with physicians?
Dr. Jennie Byrne: Yeah, so for example, some resources to check out for your audience, so Amy's story, She is a PA by training. She has a company called Humans in Healthcare, and that's exactly what they do. It's clinician groups where they share stories. Sometimes they grieve together for patients that have died or their own losses. She's doing amazing work. There are a ton of coaches out there. So if you're a nurse, probably don't have nurses listening, but. There's a woman, a nurse, Monica Bean, who does this for nurses. She's a nurse by training. Trying to think of some others. I could, you know, have people reach out to me. I can share some of these resources, but there are lots of groups of physicians coming together. There's one woman that focuses on moms, physician moms. And I did forget to mention one thing that's important for your audience to know that. One of the ways you can heal that I've heard from my interviewer interviewees is through advocacy and through feeling like you're part of the solution. So if folks are thinking about advising other companies, taking a leadership mentorship roles or being an advocate for even if it's just a single patient or another physician or that really can help you heal too. So If you find a way to have an impact that's not just your day-to-day with patients, often that's quite healing.
John: Well, I just took a quick peek back at the index of the book, Moral Injury, and I think a lot of these things are really addressed there in much more detail, so I would encourage everyone to get the book. So let's talk about that. How do we get the book, and where do we find it, and so forth? And how do we find you?
Dr. Jennie Byrne: So if anyone else has written a book, you'll know that Amazon is where all the books are. So the book is on Amazon as well as my first book which is called Work Smart. And if anybody is interested in a book club or sometimes we'll go do a talk where we get a whole bunch of books, just reach out to me if you're interested in anything like that. In terms of getting a hold of me for questions about advisory work, again, LinkedIn is a great place to just send me a message. I do have a website, drjennieburn.com, which is kind of a list of some of the stuff I've done. And then I'm gonna share with this group. I don't share this with all the people I do podcasts with. I have a small private practice that is not advertised where I care for other physicians, whether that be coaching, psychotherapy, or I think 12 states I can do medications as well. And that is called constellationpllc.com So you can also just reach out if you need help. If I can't help you, I'll do my best to find somebody else in your state or wherever you need help.
John: I'm gonna put a dig in here against the industry right now just for a second, only because I think I read in the book that the number one cure for moral injury is not resilience training. Is that my off base there? But because I get offended when they tell me that, that's the solution.
Dr. Jennie Byrne: I think that's happily falling out of favor this year. My statement in the book is I believe clinicians are inherently resilient. I don't know how on earth anyone gets through all that training without being resilient. I mean, seriously. So that doesn't mean we're not human and we need help. But I think if my point is if a clinician of peers, they're not resilient, you should be asking what's going on.
John: Hmm, because they've reached -they've gone way beyond the point where it's not dangerous, you know. Have you seen any big organizations? This is what I keep looking for because I know of physicians who have addressed burnout, moral injury, you know as a coach or something and they'll spend a lot of time with an organization But have you seen any put into place something that is lasting and is effective over time?
Dr. Jennie Byrne: So I think the most effective long-term solutions come from leadership when they put, when they basically put money into it. So when a leader, a CEO or something, you know, creates a wellness group, like a chief wellness officer, and really devotes significant resources to it, that's probably the best long-term solution is to actually have people internal to the organization who are driving it forward. So I, one of the people I talked to was Dr. Tammy Chang. So she's been doing this for a long time. She's a great resource to reach out to. She's at a health system as their chief wellness officer and she's just a wealth of information. And then there's some others who do like private interventions, but company solutions. So Dr. Paul Duchant does that. So he's a good resource. He and Diane Shannon wrote a really good book on physician burnout, which I recommend as well. So there are folks who do it. Now, he leans a little heavy on the operational end of things, and I'm more the shrink. I really think that the healing has a lot to do with our hearts, not just operations. So we, I don't wanna say we disagree. We don't disagree. I just, I think we undervalue the emotional component of change. And I think it's, it's actually easier than we think it is sometimes to connect with someone at that like heartfelt level, and make a real difference in their life. I don't think it always has to be fixed the EMR fixed. I mean, yes, do those things, but and have that human connection that heart part because I think that's how we heal. It's not just our bodies, right? Like our hearts have to heal.
John: Very good. But I appreciate you taking the time and sharing all this with us, giving me a little more clarity on exactly what it is. And like you said, the metaphor, the pressure ulcer, trying to explain it to people. And you gave me a little hope there at the end that there are people that are making a difference in this area. So I'm going to have to let you go soon. We're pretty much out of time. But I guess, do you have any last words of advice for, let's say, the listeners who might feel... I mean, one of the reasons they're looking sometimes to change their career or their life is because they're having this particular problem. Any other advice for them individually to how to find a solution for themselves?
Dr. Jennie Byrne: Yeah, the main thing is really you're not alone. There are a lot of us out there, we're feeling the same way, we may not be talking about it, and you're not helpless. A lot of us, we get in that negative mindset, we feel very helpless, you're not helpless. You have tremendous skills, you're in tremendous demand, you've come a long way, right? Like you have more control than you think you do, and there are people out there who will help you. So I guess my only precautionary thing would be, leaving the practice of clinical medicine altogether may not heal all those wounds. So I still see patients, it's important to me and I do advising for a living. So just a little like, you know, it may not heal everything just to leave. So if you are interested in doing clinical practice and doing something else, you can do both. You don't have to give up one for the other. It may not fix all your wounds just to leave clinical medicine because it's probably, there was a reason you went through medicine in the first place. And that part of you is important.
John: I used to focus almost entirely on like, what are the options for just getting out? But I'm convinced now that there's so many options for staying in. If you can kind of carve out the things that are making your life miserable or that you're just reacting to in whatever way you're reacting to, get rid of the bad parts, keep the good parts. And there are more and more ways of doing that, even though the employment has been going up, I think we're reaching a point where you can do DPC and whatever, other forms of practice and just set boundaries and write your list of your must haves and really start to take control. But what you said earlier, people don't even realize that they're in the midst of burnout or moral injury. So they don't really look at it that way and take a step.
Dr. Jennie Byrne: And one final thing would be too for those who are a little later in their career, a little older like me, sometimes being a mentor, being a support for younger early stage folks, that's really rewarding too. So if you decide I just can't go back to clinical practice and maybe you wanna do advisor or other work, but you can still find ways to support those who are coming up who maybe have a little more energy. And maybe you can prevent them from feeling so wounded so they can go and do that good work. That can be a really wonderful way to stay connected with clinical medicine in a way that maybe supports you in whatever stage of your career that you're in.
John: Awesome. Thanks for that. Thanks for taking the time to talk to us today. I really appreciate it. I advise everyone get the book, go to Amazon, Moral Injury. Let's see, what's the byline? Moral injury?
Dr. Jennie Byrne: Healing the healers.
John: Healing the healers, okay. I had that written down here somewhere, but it's really good and it's pretty comprehensive. I mean, there's a lot in there starting from recognizing it to even potential solutions. So it's a great resource. Okay, thanks Jenny, I really appreciate it. And hopefully maybe we can have you come back and talk about some of the other things you're up to at some point.
Dr. Jennie Byrne: Thank you for having me and to everyone out there listening, be well, please take care of yourselves, please. Please get help if you need it.
John: All right, bye now.
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