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

Abstract

PhenomenonMoral distress, which occurs when someone’s moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians’ distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.

ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children’s hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.

FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents’ strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.

InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Keywords:

• Moral distress
• culture of medicine
• physician well-being
• hierarchy
• corporatization of medicine

Introduction

Around the world, healthcare professionals across disciplines and settings experience moral distress.^1–4 This phenomenon occurs when someone’s “moral integrity is seriously compromised, either because [they] feel unable to act in accordance with core values and obligations, or attempted actions fail to achieve the desired outcome.”^{5(p. 457)} Moral distress differs from the negative emotions experienced following traumatic events or professional burdens in that moral distress challenges deeply held values or beliefs. It is also distinct from burnout, which according to the most widely endorsed definition is a work-related syndrome involving “emotional exhaustion, depersonalization, and reduced personal accomplishment.”^{6(p. 192)} The term “burnout” suggests that “the problem resides within the individual, who is in some way deficient.”^{7 (p. 401)} Conversely, moral distress is experienced when healthcare professionals cannot carry out what they believe to be ethically appropriate actions, which—though distinct from burnout—can then result in burnout and other negative outcomes.

The vast majority of literature describes the experience of moral distress among nurses, who often are responsible for implementing treatment plans over which they have little authority.⁸ However, all healthcare professionals in various countries, including physicians, experience moral distress that is emotionally upsetting and can lead to job dissatisfaction and intent to leave one’s job.^9–11 Despite the known emotional toll, negative consequences for patient care,¹² and an increasing focus on physician wellness,^13,14 few effective interventions have been identified,^2,15 likely due in part to a lack of agreed upon vocabulary and an incomplete understanding of systemic sources of distress.¹⁶ Epstein et al., categorized sources of moral distress into 3 levels: (1) “Individual/Patient” (2) “Unit/Team” and (3) “Organization/System.”¹⁷ Though this theoretical framework includes some system-level factors such as having excessive documentation requirements, it does not explicitly identify sources of moral distress that arise from the approach to healthcare delivery and payment in the United States (U.S.).

Dzeng et al., recently asserted that “the phenomenon of individual moral distress can be mapped onto a larger and systemic ethical malaise within the medical profession.”^{18 (p410)}

Shanafelt et al., also connected physician distress to issues within the cultures of the profession, healthcare organizations, and the healthcare system that all make up the culture of medicine.¹⁹ Recognition that the culture of medicine comprises individual and systemic relations is missing in the interventions addressing moral distress. Such interventions often focus on cultivating individual resilience, while failing to address systemic factors and the potentially modifiable upstream causes.²⁰ Consequently, these interventions lack maximum effectiveness.

In medicine, pediatrics offers a unique opportunity to understand moral distress because of the physician-caregiver-patient triadic relationship, wherein the caregiver acts as surrogate decision-maker and the patients are inherently vulnerable. Thus, the objective of this study is to identify systemic factors of the U.S. healthcare system¹ that lead to moral distress among pediatric residents (hereafter referred to as “residents”) and pediatric hospitalist attendings (hereafter referred to as “hospitalists”) in an environment where the potential benefits to reducing moral distress are both great and multi-faceted.

Methods

Study design

We used a constructivist paradigm to conduct this research. This work was part of a larger research project addressing how residents and hospitalists experience and navigate moral distress. Distinct from our prior work, in which we explored ways hospitalists can support residents, our focus here was to identify systemic factors that contribute to moral distress. From August 2019 to February 2020, we conducted semi-structured qualitative interviews with residents and hospitalists working at four university-affiliated, not-for-profit, freestanding children’s hospitals located in the Western, Mountain, and Southern regions of the U.S. For this study, we analyzed responses to a subset of questions focusing on sources of moral distress.

Study personnel

We assembled a multidisciplinary collaboration with the aim of developing a more comprehensive understanding of sources of moral distress that may have eluded more restricted disciplinary representations. The research team included 4 hospitalists, a psychiatrist, 2 medical anthropologists, a clinical psychologist, and an education researcher. From the outset, the team worked collaboratively in study design and the analysis, interpretation, and reporting of the qualitative data to ensure all processes explicitly incorporated a wide range of distinctive perspectives.²¹ During research team discussions, the varied disciplinary perspectives often contributed to team members’ awareness of assumptions they brought to the analysis and interpretation, enhancing reflexivity and helping team members interpret the data thoughtfully and carefully.

Instruments

Informed by a literature review, one researcher (JB) developed a semi-structured interview guide.^22–27 Once it was reviewed and refined by the entire research team, we pilot tested the interview guide with residents and hospitalists and revised it to optimize comprehension and to elicit rich descriptions relevant to our study aims (supplemental Appendix – interview guide).

Sample

We recruited a purposeful sample of residents and hospitalists from sites chosen for diversity in geography and hospital size. All residents (n = 541) and hospitalists (n = 168) at participating hospitals were invited by email from their respective site leads (4 hospitalists); there were no exclusion criteria. We selected participants from a pool of interested individuals based on residents’ year of residency and hospitalists’ academic rank. We confirmed our target sample of 40 was sufficient when the final 5 interviews yielded no new insights; our sample had sufficiently achieved thematic saturation and the team agreed on robust description of the meaning of the themes.

Data collection

Data were collected via individual semi-structured telephone interviews conducted by three research team members (JB, CR, or JW), all of whom had previous experience facilitating qualitative interviews. The lead author (JB) had previously interacted with many of the residents and most attending physicians at his site. To avoid any potential bias or discomfort, the other interviewers (CR, JW), both with no prior acquaintance with those participants, conducted those interviews. Participation was voluntary. Participants provided verbal consent and received a $20 Starbucks coffee gift card as compensation for their time.

Ethics

The Institutional Review Boards at all participating institutions approved the study.

Data management

Interviews were digitally recorded, assigned an identification number, professionally transcribed verbatim, and spot-checked by interviewers to ensure data integrity. Every effort was made to maintain participants’ confidentiality during data collection and manuscript preparation. Below, quotes are identified only by role (R = resident, H = hospitalist) and participant identification number.

Data analysis

Transcript data were uploaded into Dedoose (version 7.0.23, SocioCultural Research Consultants, Los Angeles) for coding. We utilized an inductive approach to thematic analysis (as described by Braun and Clark) while working within a constructivist paradigm.²⁸ We chose this method and paradigmatic orientation because thematic analysis can illustrate how a concept such as moral distress is socially constructed through the process of analyzing a wide range of data.²⁹ JB developed the initial version of the codebook based on review of the first two transcripts. As a team, we independently coded 2 transcripts, clarified definitions, and identified new codes. All transcripts were coded by pairs of research team members (JB and SC; KO and CF) first coding independently and then comparing coding and reconciling differences through discussion consensus. Data analysis occurred concurrently with data collection. After a few interviews, we made minor changes to our interview guide to enable theoretical sampling of the themes that emerged from our data. The entire research team met frequently to conduct axial coding of the data, whereby we identified relationships between codes in order to categorize them into themes with associated quotes.^28,30 During this process, we returned to the raw data as necessary to review our themes, their relationships to one another, and to ensure each theme had adequate supporting data.²⁸

Results

We interviewed 40 physicians (18 residents and 22 hospitalists) for approximately 60 minutes each (range: 42–123 minutes). Most respondents were female and non-Hispanic white. Demographic characteristics of the sample are presented in Table 1. We identified 2 major themes that describe factors which contribute to physicians’ experience of moral distress: (1) norms of medical education and the practice of medicine (3 sub-themes), and (2) corporatization of our healthcare system (5 sub-themes). Themes and sub-themes are organized in Table 2. Overall, both residents and hospitalists shared similar perspectives about these themes.

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

Theme 1: Norms of medical education and the practice of medicine

Interviewees described how the norms of medical education in the U.S. and medicine, including the hierarchy among doctors-in-training and hospitalists as well as preference for action over restraint, created an environment that prompted moral distress. We identified three sub-themes (below) related to how the norms of medical education and the practice of medicine lead to moral distress.

1.1. Hierarchy defines trainee expectations of learning and professionalism

Both residents and hospitalists emphasized that the hierarchical nature of medicine, from training through practice, teaches physicians to defer to those perceived to have more clinical decision-making experience, knowledge, expertise, or seniority. This expectation of deference caused moral distress when a physician’s wish to advocate on behalf of patients was precluded by the hierarchy. Multiple residents commented that, within the educational environment of medicine, learners are expected to agree with their superiors and discouraged from freely expressing their own concerns, values, and ideas. As a resident explained,

The culture of medicine is such that the way we learn is to propose something to our superiors and then get feedback about it. [This]does not leave a ton of room for having trainees feel empowered to express when they feel like their team is doing something that is wrong. R16

Some residents discussed a pressure to conform, wherein deference to hospitalists was expected and rewarded; residents questioning hospitalists’ decisions may be considered unprofessional, and asking questions or suggesting alternative plans may result in negative trainee evaluations.

1.2. Hierarchy can drive overuse

Residents believed that overuse of diagnostics and therapeutics could be driven by the hierarchy entrenched in medical training, where hospitalists are ultimate decision-makers for the team. Overuse was described as tests or therapies for which potential for harm exceeded possible benefit. Residents reported situations in which they experienced moral distress related to deference to the attending-on-record, especially in cases where overuse was more rampant.

…we have a subspecialty team that tends to do a lot, order a lot, intervene a lot…. that team causes distress to residents, because you’re ordering tests and doing things that you necessarily don’t agree with, but you’re the work horses who are putting in all the orders and are doing it all. R50

This was exacerbated when residents observed and compared different practice patterns between both individual providers and consulting groups or service lines during their training.

Some attendings order a lot of tests and they ask us to order a lot of curbside consults. As residents we know we can’t say no, but secretly we all hate curbside consults. They tend to result in a lot of extra tests and labs, which most patients don’t really need…Some attendings have a pretty bad reputation amongst us residents and we have learned to just let it go and do what they want. R2

1.3. Favoring action over restraint

Both residents and hospitalists described that, in the high-resource setting of the U.S., the prevailing medical norm is to “do everything we can.” One hospitalist explained:

I feel we get into this mode of, we’re the doctors, we have to keep doing things. I feel like we never quite get out of that mode, especially when it comes to taking care of children. H6

The normative expectation and pressure to act made participants reticent to refrain from action (e.g., ordering diagnostic studies or therapies with questionable benefit) even when inaction might better align with their own values or with patient or family values.

Theme 2: Corporatization of the U.S. Healthcare system

Participants described 5 sources of moral distress related to the “corporatization” of the U.S. healthcare system that has become profoundly and increasingly characterized by standardization protocols, metrics, incentives, and cost-control measures, resulting in steep declines in physician autonomy and associated moral distress. The term corporatization is meant to represent the way in which administrators dictate how frontline physicians are able to practice medicine.

2.1. Incentivizing wasteful spending

Participants described how, in general, the U.S. has a profit-focused healthcare system that incentivizes wasteful or unnecessary spending on patients. Many residents and hospitalists discussed a constant and inherent conflict between doing what they believed to be right by patients and maximizing revenue. One hospitalist reported:

Increasing revenue is what we are asked to be doing, rather than doing what’s best for our patients. We have a healthcare system in this country that is about making money and not about keeping people healthy as its core objective and providers are suffering moral distress because of it. H43

Participants suggested that procedures, laboratory work, or interventions that produced increased organizational revenue are valued even when offering minimal patient benefit. In addition, this unnecessary spending potentially saddles patients with increased out-of-pocket expenses and leads to incidental findings that spur further investigation. This disconnect between profit, appropriate care, and potential harms to the patient resulted in physician moral distress. One resident described the emotional consequences of increasing throughput in the emergency department setting via frequent inappropriate and unnecessary diagnostic tests:

“In our ER we have triage nurses who order a bunch of tests without a physician laying hands on the kids to help with throughput, and it’s distressing to people not just me that we are having to do these sorts of things.” R9

2.2. Prioritizing hospital growth over physician capacity

Participants described an increasing burden of patient volume, and thus higher productivity expectations, driven by revenue goals without adequate staffing to cover additional patients. Participants believed that this suggested that hospital leadership had inadequate understanding of the limitations of clinical medicine, which led to unreasonable expectations of increased clinician productivity. This focus on profit contributed to moral distress through excessive workloads, long hours, increased call duties, working from home after hours, and a resultant decline in the ability to provide optimal patient care. One resident shared:

More is not always better. We do not have the base to support the huge structure of our hospital which is accelerating at an extraordinary rate. And that is driven by people who are at the top, who are looking at the bottom line and trying to grow bigger, and faster, and wider. And they are not looking at how are staff supported? Are staff happy and competent, and confident in their skills? Are their staff overworked? Are residents carrying a ridiculous number of patients, so much so that they don’t have time to stop and think about the kids’ pathology, or families’ needs? R43

2.3. Rvu-based reimbursement models lead to inferior care

A subset of participants discussed how incentives driven by relative value units (RVUs) can encourage high-volume care, influence medical decision-making, and result in less patient-centered care. Such a situation can prompt moral distress, as these pressures conflict with residents’ and hospitalists’ commitment to meeting the needs of their patients. For example, one interviewee described how they considered admitting patients to increase RVU’s which are often tied to physician incentives:

I think that subconsciously this impacts many of us frequently, in areas where we think that there is not a definitive right answer. For example, when we instinctively think that maybe it’s better to not admit a patient, but if we admit them, our census stays higher, and our RVU’s go up. H43

2.4. Implementation of protocols and policies

Participants described how those not “on the frontline,” such as hospital administrators, sometimes set unrealistic expectations by implementing new policies and protocols without understanding unit workflow and/or frontline patient care. For many participants, the complications resulting from compliance with these rules, such as shifting resources away from true patient needs, led to feelings of decreased autonomy and increased distress. As a hospitalist described,

It was one of those things that you felt helpless and angry that we have a system that is designed the way it is. It’s frustrating. We’ve let folks who aren’t physicians decide how physicians should practice medicine. So much of what we do is now protocolized. Whether its pre-op labs that we are asked to do, or the MRSA nasal swabs we have to obtain before a kid goes to the OR. H25

Perceived clinical care-related values or goals held by hospital leadership, reflected in certain quality and performance measures (e.g., length of stay), fail to recognize the nuances of medicine and clinical bedside judgments and thus lead to distress for frontline providers. One participant shared an example which illustrates a misalignment of professional values with hospital values that leads to a loss of autonomy:

Our administration is looking at length of stay on our newborn unit because the rest of the hospital is at capacity, daily. … so I’m being asked, as the medical director, to kick out a baby who needs to stay for 48 hours observation, at 24 hours. Transfer the baby to the NICU and have the mom to sleep at the bedside on the chair. Things like that, where I was being asked to do things to serve their purpose. H11

2.5. Resource constraints and allocation decisions

Many residents and hospitalists shared that resource allocation decisions made by administrative bodies (without input from frontline physicians) led to gaps in care and negative impacts on patients; in some cases, policies and decision-making were aimed at preserving limited resources at the organization level while other decisions reflected scarcity across the entire healthcare system. Residents and hospitalists described four specific examples of constrained resources contributing to moral distress: limited weekend services, interpreter shortages, shortages in home nursing care, and limited psychiatric services (Table 3).

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

Discussion

We identified two culturally embedded system-level factors that contribute to moral distress among physicians: (1) longstanding and deeply entrenched norms of medical education and the practice of medicine and (2) the corporatization of medicine. Participants’ narratives about experiencing moral distress most often involved recollections of specific previous clinical encounters; however, details of those narratives frequently indicated the distress resulted from a broader system-level issue inherent in the U.S. healthcare system. Our results suggest that efforts to minimize moral distress by focusing on individual mitigation strategies and personal attributes, such as resilience, likely risk putting misplaced and undue burden on the individual. Such efforts absolve the system of responsibility and simultaneously do not solve the actual problem because they focus only on downstream factors. Interventions to improve physician well-being may benefit from an integrative approach that considers broader systemic factors such as educational norms and corporatized incentives. At the same time, given how long it takes to make systemic changes and influence culture in medicine, individual strategies may be part of a temporary solution. Acknowledgement and more in-depth understanding of systemic sources of moral distress, such as the ones identified here, are necessary to develop effective interventions and appropriately reform organizational health policies to improve physician well-being.

To our knowledge, our study is the first show that medical hierarchy and corporatization link directly to moral distress. This is consistent with findings from related studies describing drivers of burnout, which are part of a recently skyrocketing literature on physical wellness and burnout.³¹ For example, Wong described how the culture of medicine, standardized workflows, and billing rules contribute to physician distress. Considered together, the two primary system-level sources of moral distress that we identified imply a conflict between the autonomy of physicians to make decisions consistent with their core professional values and the constraints put upon physicians by multiple facets of the U.S. healthcare system.

Recognizing that a physician’s decisions are “embedded in a cultural milieu influenced by national policy, financial incentives, and resources pressures,” Dzeng and colleagues argued that socio-cultural factors may influence moral distress.^{32(p. 767)} Although culture is widely defined in medical education,³³ a recent analysis demonstrated that most definitions include the values, norms, beliefs, and attitudes of a particular organization or context. Shanafelt and colleagues defined culture as something that is “preserved over time (passed from older members to younger members.)”^{19 (p. 1557)} Our findings suggest that certain norms are passed on from hospitalist to resident over generations and made implicit as they become embedded within the culture of medicine.

The hierarchical power structure in which residents and hospitalists are embedded is relatively unchanged since the 19th century.³⁴ Researchers from the United Kingdom have previously described learners’ reticence to challenge authority due to the power structure of medicine.^35,36 This was also noted in our participants’ narratives, in which residents described not feeling comfortable questioning the decisions of hospitalists based on their lower position in the hierarchy. Nurses, who often feel compelled to implement treatment decisions over which they have little authority, have similar experiences.^37,38 This hierarchy and power differential, a “natural derivative” of the apprenticeship model, has some utility.^{39(p. 229)} A ranked structure in medicine may at times contribute to patient safety, with experienced attendings guiding and teaching trainees. At the same time, if hierarchy prevents residents, nurses, and other health care providers from raising concerns about patient safety, it may also be counterproductive. Therefore, a major question remains: How can the hierarchy of medicine be restructured or reframed to protect the safety of patients while balancing the learning and well-being of trainees? In its current form, the hierarchy discourages learners from freely expressing their concerns, which creates conflicts with their values about acting in the best interest of their patients.

The other primary theme we identified in this exploration of cultural system-level sources of moral distress—the corporatization of medicine⁴⁰—encompasses numerous recent changes in the way healthcare is delivered in the U.S. that contribute to moral distress. Although there is significant heterogeneity within the U.S. healthcare system, there seem to be pressures and responses across organizations within this disparate system that are similar: in response to cost-containment pressures from payers, organizations have adopted business principles from other industries designed to increase productivity and optimize revenue. Our results suggest that these principles are often adopted with limited vetting by frontline clinicians, so their appropriateness for the clinical setting is sometimes questionable. Furthermore, our results suggest there may be inadequate communication, lack of transparency, and fragile partnerships between clinicians and hospital leadership. The corporatization of medicine may represent a new characteristic of our healthcare system culture, and therefore a potential pervasive driver of moral distress among physicians. Our results are consistent with findings from other studies demonstrating that performance metrics leave many physicians feeling “micromanaged and demoralized.”¹⁹ This type of incentivization inappropriately pits a physician’s patient-focused priorities against the healthcare system’s corporate-focused priorities and precisely represents the misalignment of values that creates moral distress.

Reflecting a healthcare system under strain, challenges due to inadequate staffing and lack of resources were highlighted by participants from all our study sites as sources of moral distress. This finding builds upon the results from a study in the nursing literature. In that study, Morley determined that due to resource constraints such as lack of acute care beds and sufficiently skilled nurses, nurses were forced to provide suboptimal care and leave tasks undone, which led to moral distress.⁴¹ While our study population included only pediatricians, other studies have demonstrated that the lack of appropriate staffing and services, is not limited to pediatrics.^42–44 Our results extend existing literature highlighting that, while resource constraints may be part of the medical culture both in the U.S. and around the world, this issue demands attention if we are to improve both patient care and providers well-being.⁴⁵

Future directions for research

In order to ultimately generate comprehensive approaches to address moral distress, more research in this area is needed among physicians in other specialties (i.e., beyond pediatrics) to confirm and advance our findings, or to determine the role of specialty-specific systemic influences. For instance, although residents across all specialties train in a hierarchical structure of decision-makers, there may be differences in the recognition of autonomy between specialties which exacerbate or mitigate this as a component of moral distress. Additionally, while resident and hospitalist perspectives are crucial for understanding this topic, cultural systemic factors cannot be addressed by considering those perspectives alone. Future research should involve other stakeholders, including medical students, fellows, interprofessional health care team members, education leaders, administrators, and policymakers to better understand how socio-political forces co-exist and influence moral distress. Ultimately, future research will be needed to explore and critically evaluate interventions that aim to alleviate moral distress and improve physician well-being.¹³ Though our findings have the potential to inform the development and implementation of specific interventions, we agree with Bynum and colleagues’ assertion that the “rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine.”^{46(p. 16)}

To avoid rushing to “solution-ism,” which was recently described as accepting “simple solutions, to dive headlong into strategy before understanding the problem,”^{47(p. 2)} and based on the results presented here, we suggest the following two priority areas for essential future research to address moral distress.

1. Determine ways to “re-frame” the hierarchy among physicians in order to discourage patterns of obedience and submission. We should consider how the hierarchy can be reshaped so that all members of a team can contribute more equally to the care of patients by being encouraged to question, and even contradict, those with more real or perceived power (e.g., attendings). This paradigm shift would potentially allow residents to more meaningfully contribute to patient care in the event they have an insight not known to, or considered by, their attendings. While hospitalists (and other supervising physicians) have more experience, they may not always be right about every aspect of their decisions and orders. The hierarchy—as it is currently operating and perpetuated—assumes the supervising physicians is always right, and when there is a difference of opinion with a resident, the resident is always wrong. This may be a faulty assumption. Future research should therefore determine how trainees can learn and practicing physicians re-learn, while evaluating communication patterns and other aspects of interpersonal interaction that permit authentic inquiry, value professional curiosity, and still recognize and respect the wisdom of experience. Such a shift in culture may benefit all members of the health care team.

2. Identify collaborative system-level initiatives to foster the well-being of everyone on the healthcare team, including physicians, other clinicians, patients, and families. Individual-level physician well-being initiatives (e.g. resiliency training, healthy lifestyle support) may help some physicians. But, as demonstrated, moral distress also stems from system-level challenges. Therefore, healthcare administrators, system leaders, and policymakers who build organizations responsive to clinician feedback are most likely to effectively address workforce distress. Successful initiatives will appreciate the roles and responsibilities of varied stakeholders while simultaneously establishing a shared vision for physicians’ autonomy to put patients’ needs first.³¹ Traditional initiatives of information sharing, such as administrative town halls and yearly physician wellness surveys, are not enough to provide the robust, detail-driven collaboration necessary to address the systemic causes of moral distress.

Limitations

First, most hospitalists were faculty at the rank of assistant professor. Though this distribution is representative of pediatric hospital medicine as a whole, given it is a relatively new subspecialty, hospitalists with more experience may have other perspectives on the system-level sources of moral distress. Future studies should purposefully solicit senior faculty participation. Second, we recruited only residents and hospitalists, and the sample was predominantly female and white, which may have provided an incomplete picture of systemic drivers of moral distress and may limit transferability to other affinity groups. The somewhat homogenous nature of our participants may have led to interesting perspectives on the impact of hierarchy in medicine that should warrant more exploration in future studies. Nonetheless, since our participants described general systemic issues within the healthcare and medical education systems, the concepts synthesized and presented here may apply to other disciplines and physicians from other countries.

Conclusions

Our findings support the emerging understanding that moral distress is a complex social problem and offer new insights suggesting that, in the U.S., this problem is highly impacted by the culture of medicine, including norms and economic features of the current healthcare system. While individual-level interventions may be useful in mitigating moral distress, system-level changes impacting the culture of medical education and the practice of medicine, as well as the byproducts of the corporatization of medicine, will also be needed to address primary causes of moral distress.

Acknowledgements

We thank Julia Wignall for her assistance conducting participant interviews.

Funding

This work was supported by a Seattle Children’s Hospital Academic Enrichment Fund Grant. The funding source had no involvement in study design, in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Notes

1 * Recognizing that the U.S. does not have a uniform healthcare system or a single nationwide system of health insurance, for ease, and consistent with our participants’ words, we use the term “healthcare system” to describe the hybrid approach to health care delivery and payment in the U.S. This “system” includes a collection of health care organizations, private insurance companies, government payment mechanisms, and state and national policies.