The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States

Figures & data

Table 1. Demographic characteristics of resident and hospitalist participants in a study of moral distress (N-40).

	Residents (N = 18)	Attendings (N = 22)
Hospital
Site One	5 (27.8%)	6 (27.3%)
Site Two	5 (27.8%)	6 (27.3%)
Site Three	5 (27.8%)	5 (22.7%)
Site Four	3 (16.7%)	5 (22.7%)
Gender
Male	2 (11.1%)	6 (27.3%)
Female	16 (88.9%)	16 (72.7%)
Age in years (SD)	29.4 (2.9)	41.3 (7.0)
Race/Ethnicity
White, Non-Hispanic	11 (61.1%)	14 (63.6%)
Black, Non-Hispanic	0 (0.0%)	2 (9.1%)
Asian, Non-Hispanic	2 (11.1%)	5 (22.7%)
Hispanic	4 (22.2%)	0 (0.0%)
Other/More than 1	1 (5.6%)	1 (4.6%)
Level of Training
Post-graduate year 1	6 (33.3%)	–
Post-graduate year 2	5 (27.8%)	–
Post-graduate year 3	7 (38.9%)	–
Years of Practice
0-5 years	–	8 (36.4%)
6-10 years	–	8 (36.4%)
11-15 years	–	3 (13.6%)
>16 years	–	3 (13.6%)
Academic Appointment
Instructor	–	2 (9.1%)
Assistant or clinical assistant professor	–	12 (54.6%)
Associate or clinical associate professor	–	4 (18.2%)
Professor or clinical professor	–	3 (13.6%)
No faculty appointment	–	1 (4.6%)

Table 2. Theme and sub-themes illustrating how features of the U.S. healthcare system contribute to individual physicians’ experience of moral distress.

Themes	Sub-themes
1. Norms of medical education and the practice of medicine	1. Hierarchy defines trainee expectations of learning and professionalism
	2. Hierarchy can drive overuse
	3. Favoring action over restraint
2. Corporatization of the U.S. Heathcare System	1. Incentivizing wasteful spending
	2. Prioritizing hospital growth over physician capacity
	3. RVU-based reimbursement models lead to inferior care
	4. Implementation of protocols and policies
	5. Resource constraints and allocation decisions

Table 3. Four examples of limited resources that led to moral distress with accompanying exemplary quotations.

	Limited resource	Resulting in	Culminating in	Quotation
1.	Understaffing and decreased ancillary services on weekends	Radiologic services and access to subspecialists frequently not physically present on the weekend	Lack of appropriate, and even safe, patient care on a Saturday or Sunday vs. a weekday	Children can be incredibly sick or in a tenuous situation, regardless of the day. And so, I think that it’s very hard when diagnostic scans are delayed or procedures can’t be scheduled. It definitely is an issue that my co-residents, and the attendings find incredibly distressing. R13
2.	Qualified certified medical interpreters for non-English-speaking patients and their families	Delayed patient history taking, delayed patient status updates, and reduced emotional support	Lower quality care for non-English speakers	This family was Spanish speaking only, and while we were trying to get interpreters, in-person interpreters is often impossible. I still really didn’t feel like the family had a good grasp on the severity of the situation and what had happened to their child. R14
3.	Shortages in home nursing care	Inability to safely discharge medically stable patients with case management or home care needs	Extended hospitalization of patients at high risk of harm from hospital-induced complications	… kids stuck in the hospital for months because there is not adequate home nursing, and the family feels that they can’t take care of their kid alone at home. R15
4.	Nearby inpatient psychiatric facilities	Long-distance transfers, long waiting lists	Remaining in the emergency department admitted or untreated for extended period	… kids who come into our emergency room who don’t meet requirements for medically being hospitalized, but aren’t safe for discharge because they’re a harm to themselves or someone else. They’ll sit in our ED for weeks and not get appropriate care. That is something that really bothers me. I think it bothers a lot of the providers. R16