EDITORIAL:
Worse than Burnout – Moral Injury!
Many of my editorials in The Pharmacist Activist have addressed the understaffed and extremely stressful workplace environment in which many pharmacists practice, most often in chain stores. In addition to the increased risk of errors, harm, and death for patients, the continuing stress experienced by these pharmacists has a very harmful effect on their physical and mental health, as well as their quality of life. I wish I could say that my concerns have resulted in greater awareness of and improvement of workplace conditions for pharmacists, but they haven't and, if anything, conditions have worsened. Many of the executives/management of the companies having the worst working conditions only care about profits and stock value of their companies, as well as their personal wealth and well-being. They view errors and injuries of patients, health crises of pharmacists and other employees, and resultant lawsuits as costs of doing business.
Our profession of pharmacy and leadership must also accept responsibility for failing to effectively address and take actions to prevent the continuing deterioration of the workplace conditions in which so many pharmacists practice. We know which companies have the worst workplace conditions that place customers and employees at risk, but our profession (e.g., professional associations, colleges of pharmacy, boards of pharmacy) refuses to confront them, or even identify them. I would contend that some large chains and other employers who are most responsible for the present situation are destroying the reputation of our profession and threatening our professional survival. However, the primary responses of our profession focus on conducting surveys of pharmacists to gather statistics and other documentation, and suggest steps that pharmacists can take to reduce stress and burnout and increase resilience. Rather than directly challenging the companies that are the most egregious offenders in placing their customers and pharmacists at risk, some professional associations, colleges, and boards give a higher priority to avoiding conflict and requesting financial support from these same companies for educational programs and naming rights for programs, buildings, and institutions.
Moral injury
For some of the same reasons, physicians and nurses have experienced challenges and workplace stress that parallel those that have been so devastating and disillusioning for many pharmacists. Concerns about the economics of health care are being given a higher priority than the quality of services provided for patients by healthcare professionals. New and changing legislation affecting health care, the increasingly dominant role of health insurance companies, mergers, acquisitions, and increased competition of and among healthcare systems, and the implementation of electronic health records are among the important factors that have resulted in the reduction in the amount of time and personal attention that health professionals can provide for patients. The quality and comprehensiveness of listening to, caring for, and providing personalized instruction and counseling for patients have been greatly compromised by some well-intentioned initiatives, but primarily by the obsession of placing profit above the interests of people (patients, health professionals, and other employees).
This situation has worsened over the last decade and was then exacerbated during the COVID-19 pandemic. The additional workload, stress, and illness/harm experienced by healthcare personnel have resulted in many leaving these professions.
I have just read the book, "IF I BETRAY THESE WORDS – Moral Injury in Medicine and Why It's so Hard for Clinicians to Put Patients First," by physicians Wendy Dean with Simon Talbot (2023; Steerforth Press). The following statements on the cover and flyleaf of the book provide succinct messages of the concerns and challenges of the experiences discussed.
"For more than a decade, the term burnout, which suggests a lack of resilience, has been used to describe distress among medical clinicians. The concept of moral injury more accurately locates the source of an ongoing and increasing crisis in a conflict-ridden system."
"Moral injury occurs when a person perpetuates, bears witness to, or fails to prevent an act that transgresses their deeply held moral beliefs. The deeply held moral beliefs that physicians share is the oath they take when completing their lengthy training and embarking on their career: Put the needs of patients first.
In today's American healthcare system, doctors, nurses, and other healthcare providers are increasingly forced to consider the demands of other stakeholders – insurers, hospitals, even their own financial security – before the needs of their patients. Whenever they are forced to make a decision that contravenes their patient's best interests, they feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury. Moral injury and its causes help explain why healthcare workers started leaving the field in droves long before the COVID-19 pandemic exposed weaknesses in the US system, why a rich country has such poor outcomes in certain categories, why there is a shortage of young doctors training for critical areas, and why patients feel frustrated."
"If I ever break this oath, let my gods take away my knowledge of this art and my own health. Here speaks a citizen, a servant of people. May I be destroyed if I betray these words."
Wendy Dean concludes the Author's Note with these comments:
"The covenant we make is not simply how we will do a job, it is also about who we will be when we don the mantel of 'physician.' It prescribes our conduct, calibrates our moral compass, and entwines both with our identity. Betraying these words, then, forsakes our identity, which can unmoor us and threaten our dissolution.
In standing up to moral injury and fighting for our oaths, we are fighting for our patients as if our lives depend on it. Because, figuratively, and too often, literally, they do.
I am humbled by and grateful to all the medical professionals who have spoken up against their destruction, and to those who find the courage to do so in the future."
The book includes numerous experiences that describe the extent to which our healthcare system is broken, the financially-motivated obsession of some individuals and organizations that put profits before people, and the moral injury experienced by physicians. Readers will find many of the experiences to be very discouraging, and the suicide of a physician as a consequence of moral injury is heartbreaking. However, the authors also identify examples and model practices that put the patients first and permit health professionals to experience fulfillment and escape moral injury. Although these positive models may be isolated rather than typical, they provide hope and motivation that patient-centric health profession practices are still possible.
The situations and concerns identified in the book pertain to physicians and the practice of medicine. However, pharmacists, nurses, and others will quickly understand and relate to the moral injury described. If I still was a faculty member of a college of pharmacy, I would require my students to read this book, and follow that with encouraging and motivational presentations by alumni and other pharmacists who have been bold, innovative, and entrepreneurial in establishing practices that provide optimal care and services for patients, and are personally and professionally fulfilling for pharmacists. Because I no longer have the privilege of providing classroom instruction and guidance for pharmacy students, I hope that faculty who read this commentary will consider taking this step, and I will follow up with friends currently on the faculties of colleges of pharmacy with this recommendation. In discussions with students a delicate balance must be struck in recognizing the brokenness of the present healthcare system and the risk of moral injury, and providing a message and examples of encouragement, motivation, and opportunity. It is very important that students are aware of the realities of the healthcare system and the opportunities and barriers in professional practice – forewarned is forearmed. Ignoring and/or remaining silent about the realities, as well as the opportunities, is not responsible or acceptable.
It is noteworthy that the concluding chapter of the book includes the following comments from a presentation by Lina Kahn, Chair of the Federal Trade Commission, at a meeting last year of the National Community Pharmacists Association:
"There is nothing inevitable about the current structure of the market or the current business practices that occur and are permitted – these are all the result of policy and legal choices, that were made by public officials, and that can also be remade by public officials through the democratic process"The responsibility for how our healthcare markets work is divided among dozens of state and federal authorities who are ultimately accountable to elected members of local, state, and federal legislative bodies"I hope everybody here – the patient advocates, the pharmacists, the other healthcare providers, and the concerned citizens – will remain fully engaged to ensure your voices are heard at all levels of government."
In her book, Wendy Dean provides the observations noted below in response to Lina Khan's admonition:
"In other words, at every level of government we must choose our elected officials carefully, and we must invest the time to educate them about our experiences as clinicians and as patients. Those officials will decide whether healthcare corporations serve all their stakeholders, or continue to focus just on their shareholders"Regulation and legislation for the sake of patient safety are impossible to argue against. Yet the demands for documentation have gotten so unwieldy that meeting them can lead to inefficient and even inattentive care, and the consequent moral injury is driving people"out of medicine altogether."
The challenge of fixing a broken healthcare system or starting and building a new one are so formidable that some will view change as impossible. Yet, if we do nothing, the risks of errors, harm, and deaths of patients will continue to worsen, as will the number of health professionals who fall victim to moral injury and its consequences. The issues are too important to give up fighting for what we know can be a more effective and safer healthcare system for patients and society, and personally and professionally fulfilling practices for health professionals. We need to identify, listen to, and learn from those whose ideas and actions have been successful in attaining positive outcomes, embrace and communicate these ideas to legislative and corporate policymakers, and to commit more of our personal time and attention to decisions and actions that will result in positive change.
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EDITORIAL:
Perspectives on Workplace Culture and Policies
During much of my long career in pharmacy, most pharmacists enjoyed their professional responsibilities, were fulfilled by the services they provided and accomplishments to which they contributed, and were enthusiastic advocates for our profession who were pleased if our children and other young people were sufficiently interested and impressed by our responsibilities and opportunities that they also chose to pursue a career in pharmacy. We experienced important expanded opportunities such as the authority to dispense less expensive generic equivalents for brand-name drugs, using our drug therapy expertise in counseling patients and contributing to better therapeutic decisions and outcomes, and the authority for administering immunizations. Numerous other creative, specialized, and/or entrepreneurial initiatives have been successfully implemented by individual or groups of pharmacists that have extended the scope of opportunities for pharmacists.
In recent years, however, we have experienced circumstances that have had a severely negative influence on pharmacy, medicine, and certain other health professions. Political, legislative, corporate, and other mostly profit-driven interests have fractured what was already a weak healthcare system, and pharmacy has lost whatever previous claim we might have had to the control of our professional responsibilities and destiny.
Many more pharmacists are employed in community pharmacies than in all of the other opportunities for pharmacists combined. As a result, this is often the only area of our profession that is visible and known to the public and legislators. Community pharmacists were highly-respected, readily-accessible, and valued members of their communities even before the expansion of the professional responsibilities they can now provide. But this situation has dramatically changed in recent years as a consequence of the domination of corporate profit-driven chain stores, as well as the impact of mail-order pharmacies, pharmaceutical companies, and health insurance companies and pharmacy benefit managers that control and restrict the compensation for most prescriptions and services. The number of pharmacist-owned independent pharmacies has sharply declined because they could not financially survive, and many consumers have never been in one or even know they still exist.
Many pharmacists who are employed in the large chain stores are subjected to a toxic culture created by abusive management that imposes staffing restrictions, egregious metrics, and other onerous policies. These pharmacists are very critical of their companies and management, and the workplace conditions that result in more medication/dispensing errors and personal stress and moral injury. This is quickly evident to the increasingly impatient customers waiting in long lines in the store or drive-thru lanes, or on-hold on the phone, and to the larger public who become aware of the toxic workplace culture as a result of social media comments and increasing media coverage.
I have been blessed and fulfilled by my career in pharmacy but am very concerned by what I observe and learn about the current challenges experienced by many community pharmacists, which I also view as having a destructive impact on the reputation and survival of our entire profession. I do not feel that I have done enough to help prevent the destructive circumstances and moral injury experienced by so many pharmacists or to identify strategies to address the challenges. This is the reason for which I continue to write commentaries in which I voice my concerns and recommendations, although I would quickly acknowledge that my recommendations are ignored or rejected by the pharmacist leaders and our associations that are in the best position to accomplish positive changes.
My recommendations for our profession are based on what I have learned and experienced, and my attempt to apply reasoning in identifying ideas and strategies that will enable us to effectively respond to formidable challenges and plan for success in the future. However, I concede that my ideas may be incomplete or otherwise flawed, and I certainly can't claim to have expertise or vision that are better than that of others. I question whether there is value in continuing to write these commentaries or whether they have become a self-serving way to vent my concerns and frustrations.
As I continue to listen, read, and learn about the increasing complexity of drug therapy and the healthcare system and its challenges, it is my perception that pharmacy leaders and our associations/institutions (i.e., colleges, professional associations, boards) have not identified plans, strategies, and an organizational structure that provide optimism for success in the future. There have been well-intentioned ideas, concepts, and hopes that have not been fulfilled, such as Pharmacy's Vision for 2015 (see the March 2015 issue of The Pharmacist Activist). We can be encouraged by the accomplishments of innovative and visionary pharmacists who have developed excellent practice models (Amina Abubakar and her Avant Pharmacy in Charlotte, NC come immediately to mind). However, these examples of professionally and financially successful practices established by individual pharmacists are unknown to many within our own profession who are well aware of, discouraged by, and victims of the negativity, problems, and moral injury that are so widespread.
I appreciate and am encouraged by the supportive comments and ideas I receive from readers. However, our collective concerns have not been sufficient to attract the interest, support, and action of the leaders of our profession. I fear for the future of our profession and my motivation to continue to communicate my concerns, criticisms, and recommendations is the hope that we can better prepare student pharmacists and recent pharmacy graduates for the realities of many current workplaces and the risk of moral injury, and making them more aware of the opportunities for professional fulfillment from which so many of us have benefited.
Perspectives and recommendations
For young people considering a career in pharmacy, current student pharmacists, and recent pharmacy graduates, I provide the following thoughts for your consideration.
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A pharmacy education provides a foundation from which one can pursue dozens of different types of opportunities/responsibilities within and beyond the profession of pharmacy.
- There is no opportunity/position that will meet our expectations and be fulfilling all of the time. Identify several types of opportunities that you consider to be the best match for your interests and skills, and identify what you consider to be the benefits and limitations (i.e., the positives and negatives) of each. In evaluating the opportunities you consider to offer the most exciting and strongest potential, visit the practices/companies/organizations and speak with pharmacists currently holding those responsibilities.
- Seek the ideas and guidance of pharmacists, pharmacy faculty, and others in whom you have a high level of confidence for their views regarding the opportunities you are considering, or others that you may not have considered.
- You, in consultation with your spouse and/or others who are directly affected by your choice and location of a position, are in the best position to identify the specific opportunity that best meets your needs and expectations at this stage in your life/career. If subsequent changes become necessary and/or desirable, those opportunities/options should be available.
- The salary/compensation of a particular position should NOT be given a high priority. Enjoyment/satisfaction/fulfillment of your responsibilities, keeping stress to a minimum and having peace of mind, and avoiding moral injury are far more important.
- Learn as much as possible about as many opportunities for pharmacists as you can, and acquire diverse experiences in your practice rotations, summer and part-time employment, and volunteer service.
- Identify and maintain expertise in one or more specialty/niche practice areas (e.g., therapeutic management of a particular medical problem [e.g., diabetes], compounding, medical equipment and supplies, hearing aids). Even if your first full-time position does not involve responsibility in this area, it can serve as a head-start experience for a future opportunity.
- Establish a network of classmates and other pharmacy friends with whom you will regularly meet or stay in contact with following graduation. In addition to the value of the friendships, this will provide the opportunity to share experiences and increase awareness of available/future opportunities.
- Obtain personal malpractice insurance (separate from that of your employer) and long-term disability insurance. Identify a trusted financial advisor who can provide guidance on consolidation of debts and financial planning.
- Demonstrate and be recognized by others as a person of integrity in every personal and professional responsibility.
- In practice responsibilities, always place the welfare and safety of the patients first, even before the interests of your employer or your own.
There are many factors that influence the availability of employment opportunities for pharmacists, most notably the balance of supply and demand for pharmacists in a particular region, the number of positions available in a particular practice area of pharmacy (e.g., community, health-system, pharmaceutical companies, postgraduate residencies/fellowships), and the number of positions for pharmacists available at individual employers. Because the largest number of positions for pharmacists are in the community setting, and because there are fewer and more competitive employment opportunities in other areas of pharmacy, many new and recent graduates will be employed in the community setting
CVS, Walgreens, Rite Aid, and Walmart have the largest number of positions available, but these are the same companies that are considered by many to have the worst and most abusive workplace culture and policies, the highest risk of errors and harm for patients, and the greatest risk of stress and moral injury for pharmacists and other employees. Before accepting a position at one of these companies, I strongly encourage new and recent graduates to fully explore other possible options in the community and other settings. Although there are far fewer full-time positions available in independent pharmacies, one option to investigate is whether there are several part-time positions available in independent pharmacies in a particular area that the pharmacy owners could combine to provide a full-time position.
I recognize that the realities of the type and number of full-time opportunities currently available for pharmacists will result in many new and recent graduates accepting employment with one of these four companies. Some may enjoy and even thrive in these positions, but most will not. For the latter group of pharmacists, I provide the following suggestions for your consideration:
- Continue to actively explore other employment options through your own searching and engaging with your network of pharmacy friends and others.
- Put forth your best effort in serving your patients and employer including "off-the-clock" time in an amount you consider reasonable.
- Adhere to your personal professional standards of practice.
- Do your best to avoid multi-tasking (some will view this as naïve and impossible) so you can give your full attention to the individual task in the order of priority you establish.
- Do not exceed a work pace or flow with which you have confidence will protect the safety of patients and that will keep errors to an absolute minimum. It is your license, reputation, and livelihood that are at greatest risk if serious errors occur.
- Do not fear being threatened, disciplined, or terminated by management if you fail to meet their metrics and onerous policies. Although it is difficult to avoid succumbing to these threats and pressure, your best response is that your priorities are to avoid errors and protect the safety of your patients.
- Document for your personal files errors that occur, workplace conditions, policies, and examples that increase the risk of errors, and threats and other abuses by management.
- Closely monitor the stress you experience, your mental and physical health, the quality of your relationships with family and friends, and experiencing moral injury. Among the situations to be monitored are your emotions and sense of wellbeing at the end of a typical workday and your emotions and attitude at the start of the next workday. If you personally conclude, or if it is observed by family and friends, that your mental and/or physical health is impaired, immediately resign even if another employment opportunity is not available and, as appropriate obtain professional counseling and medical assistance. Continuing in this employment situation has far greater risk of permanent consequences than unemployment or future uncertainties.
- Actively explore working for an independent pharmacy, managing or opening your own independent pharmacy, establishing a concierge or other unique community practice, establishing a drug therapy consultant practice, or become a patient consultant or "coach" regarding their medications and the challenge of navigating the complexities of prescription drug plans. A large majority of individuals live in community settings and I continue to believe that this setting provides the largest number of professional opportunities for motivated, creative, and entrepreneurial pharmacists.
Neither I nor anyone else can fully understand the challenges of your personal experience. However, I hope it is a source of encouragement to recognize that there are pharmacists who have some understanding and serious concerns about the challenges you experience, and we wish to voice our support.
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