Dr Seema Haider explores the collective ‘moral injury’ that doctors are facing, and confronts the institutional failings contributing to it
We are all too aware of the systemic problems within the NHS: chronic underfunding; recruitment and retention issues; growing public expectation coupled with increasing medical complexity; not to mention navigating the aftermath of an unprecedented global pandemic. It’s easy to see why the profession is feeling demoralised and dejected.
Words like ‘resilience’ and ‘wellbeing’ are bandied about as if they are the panacea for all that is wrong with our NHS. Doctors are having mental wellbeing courses thrown at us from every angle in reactive, almost panicked attempts to prevent a mass exodus. Yet ironically, there were threats to remove the Practitioner Health Programme for secondary care, which fortunately NHS England has now backpedalled on after vehement uproar from the profession. The rhetoric from the top is confusing and insulting. There appears to be a lack of compassionate leadership at the highest level and we are left feeling undervalued and unprotected as doctors.
As a GP, I have been trying to unpick why my vocation is leaving me with a feeling of perpetual discontent; what specifically is it that I am struggling with? I have distilled it down to a painful truth: I cannot be the doctor I want to be to my patients due to the current climate of the NHS. I feel completely disempowered.
It turns out I’m not alone. The BMA has long highlighted that doctors are experiencing high rates of moral distress. Moral distress is the psychological discomfort that healthcare professionals experience when they are forced to make decisions or behave in a way that is not aligned with their moral framework. It is the perception that, as a doctor, you do not feel able to provide the care that your patients deserve. It is often triggered by institutional deficiencies such as a shortage of resources and understaffing. It is compounded by the lack of agency doctors may feel about not being able to positively influence or see meaningful change in a failing system.
Sustained moral distress can lead to moral injury which can engender feelings of profound shame, guilt and anger. Moral injury is associated with impaired function and psychological harm. The 2021 BMA survey identified that a staggering 78% of respondents felt that the term ‘moral distress’ resonated with their workplace experiences. 51% said the same about moral injury. Within the survey results, intersectionality was also relevant with ethnic minority doctors and doctors with disability being the subgroups who were more likely to experience moral distress. Although the pandemic has undoubtedly increased moral distress in doctors, the data was irrefutable: this distress existed prior to the pandemic.
The recent report from the GMC on Workplace Experiences has provided a bleak insight into NHS workloads. It found that over 55% of GPs were categorised as struggling with their workload compared to 38% of all doctors. 45% of GPs reported experiencing compromised patient care and 62% found it difficult to provide sufficient care each week. Yet another damning indictment of our NHS.
For me personally, the construct of moral distress explains why the psychological burden of a clinical day carries a huge weight for me; and on bad days it can leave me in a state of emotional dysregulation. I would describe myself as an empath with perfectionist traits (probably a common profile in medicine) and I have always felt these to be my strengths as a doctor. But the NHS is a very punishing place for me right now. I find each 10-minute consultation is a painful reminder of what I fail to achieve for my patient; a microtrauma on repeat up to 35 times per day. Compassion fatigue can set in and ultimately shutting off your empathy becomes a survival technique – but this level of disconnect feels jarring and is a fast road to burnout.
NHS leadership will tell me that this needs a mindset shift, to surrender to the things beyond my control or to sharpen my resilience and optimise my wellbeing. We are effectively being asked to find workarounds so we can get comfortable with providing substandard care. It’s a painful paradox and I can’t contain my resentment at having to contort myself to fit into such a dysfunctional system. A system that seems to prey on the characteristics that can often be found in medics: the empaths, the perfectionists, the imposters and the people pleasers. This is how the NHS survives, running on the good will of others but unfortunately this good will has almost evaporated.
The senior NHS leadership and those in Government need to be careful: when you start to erode the very core of a doctor’s identity, you will obliterate the entire foundation of our health system, one which was once celebrated as one of the greatest healthcare systems in the world.
Dr Seema Haider is a GP partner & GP trainer in Havering. You can find her on X (formerly Twitter) @SeemaHaider1
well written, but will the powers that be understand it? and will the electorate still prioritise the persuit of private wealth and privatisation of NHS care?
So well articulated. This paragraph resonates..
‘ NHS leadership will tell me that this needs a mindset shift, to surrender to the things beyond my control or to sharpen my resilience and optimise my wellbeing. We are effectively being asked to find workarounds so we can get comfortable with providing substandard care.’
Courses and reflection won’t change the system for patients or GPs. We need whatever government is left after 4th July to listen and invest
Thank you Dr Haider for this powerful article
In relation to this: I find each 10-minute consultation is a painful reminder of what I fail to achieve for my patient; a microtrauma on repeat up to 35 times per day
May I encourage you to adopt the BMAs Safe Working Guidance, for all GPs in your practice, with a flexible average of 15 minutes per appointment depending on the clinical scenario. You should aim to see no more than 25 appointments per day on your routine surgery. That will reduce your daily appointment offer to your patients but it will, to use a strapline, be SAFE for you, SAFE for your patients, and SAFE for your profession. Without an increased share of NHS funding, General Practice is not funded to do more — an outcome of political and NHSE decision-making which you should not accept at the cost of your well-being
This is exactly why I am leaving the NHS; moral injury has had a massive negative impact on my personal life, my compassion reserve is almost gone, and to top it all, it is a very toxic environment that does not value the people who are really committed to this vocation. I am a very experienced GP with a lot of skills and a portfolio, but I am taking all that elsewhere where it is more appreciated!
Yes it’s this that exhausts me most. I return home tearful and depleted, it really does feel like some sort of essential chemical has been drained from my mind, maybe it’s serotonin. It’s 36-48hrs before I’m recovered after two days of this, which is why I’m now 1/2 time. I would say I feel bullied and abused, but in reality it’s our patients who suffer more.
Reading Julius Parker’s comments, I don’t know whether it’s deadpan humour, or he’s actually being serious. I’m sure Dr Haider, as a clearly caring GP, has already considered all angles but if every Working GP followed his advice, the GP waiting times would double…and also why didn’t the BMA advise this 10 years ago instead of now when it’s too late?
If the jaunty triple SAFE strapline is the best the BMA’s gonna come up with, then primary care is doomed. Can the BMA leadership engage with the public so they understand what’s happening in primary care, or organise highly visible demos.
And it wasn’t just Govt and NHSE political decision making that led to this, but BMA mismanagement in the poor advice they gave to practices. Any BMA IA will amount to nothing.
1000% yes. This job is slowly destroying us all and it makes me so angry. Currently off with depression and the strain of working in this system for the last 20+ years is in no small way responsible.
instead of “resilience courses” they should be offering us courses on how to provide substandard care in third world health system. But what adds insult to the injury is how both public and leadership accept crap from secondary care and emergency services but hold us to account if we deviate from “gold standard”. patients are genuinelly surprised and upset that I am not able to find solutions to their problems- problems like waiting list is 18 months long, specialist not asnwering, ambulance takes too long.
interestingly… none of that nonsence in private sector. people get what they pay for and everyone is content
Absolutely, Seema.
“NHS leadership will tell me that this needs a mindset shift, to surrender to the things beyond my control or to sharpen my resilience and optimise my wellbeing”.
Apologies for the glib analogy, but the NHSE approach is like teling the victim who got assaulted that it was because they were wearing the wrong clothes.
Without wanting to deny credit to the doctors who have worked hard to develop tools to manage stress, at its core “resilience training” puts the responsibility on the doctor to manage the injury being inflicted upon them. At worse, its gas-lighting.
Wow! Put so beautifully and resonates so well with how I feel after each day. Especially “But the NHS is a very punishing place for me right now. I find each 10-minute consultation is a painful reminder of what I fail to achieve for my patient; a microtrauma on repeat up to 35 times per day. Compassion fatigue can set in and ultimately shutting off your empathy becomes a survival technique “. The empathy is gone and you have nil to give back at home. You feel there is something wrong with you as other some colleagues seem to breeze through the day and blame yourself as a failure. While after a particularly tough day you feel muddled, confused and fatigued. 10 minutes is not enough for anything and the conveyor belt continues. The biggest tragedy of uk general practice is our own stupidity, putting up with these ridiculous notions of speed and bravado and failing to make changes in a ever changing environment.
There are countless signs of our broken system but alongside access, the one-problem consultation is a prime example of our meek acquiescence. All our training, all hard-learned consultation skills, all our empathy, thrown out the window. One problem consults are crap and dangerous, Some patients (bless-em) have swallowed the bullshit too and won’t mention red-flag symptoms if it’s a second issue. I cannot and will not do one-prob consults and do not train my registrars to do so either. We have sold our clinical souls.