Moral Injury in Healthcare
We have been calling it burnout for years. Clinicians leaving medicine, nurses leaving nursing, providers crying in their cars between patients, turning to substances, and overall feeling hollowed out by a career they once loved. We labeled it burnout, handed out resilience workshops, and suggested meditation apps. One time, I had a job ask us to take a burnout surveys every quarter. Nothing more happened except they just added double book slots for those “less” burned out, and then had us do active shooter drills in case our patient (whom we deeply cared for) showed up packing.
We got the diagnosis wrong.
What most healthcare providers are experiencing is not burnout. It is moral injury. The distinction matters enormously, because the cause and the cure are completely different.
Burnout vs. Moral Injury: Not the Same Thing
Burnout, as originally defined, is a state of emotional, physical, and mental exhaustion caused by prolonged stress. It implies that the worker is depleted, and that the demands of the job have exceeded their capacity to cope. The result - the person doesn’t care any more. The implicit solution is restoration: rest, self-care, better work-life balance. Self-care.
Moral injury is something different. The term was originally developed to describe the psychological damage sustained by military personnel who participated in, witnessed, or failed to prevent actions that violated their moral code. It was later applied to healthcare.
Moral injury in healthcare occurs when a clinician is repeatedly required to act in ways that violate their deeply held values about what good care looks like. It is not that the work is exhausting. It is that the system demands you provide care you know is inadequate and does so day after day, with no end in sight. We still care, and most of us feel like we care too much.
The difference is critical. Burnout says: I am tired. Moral injury says: I am doing harm, and I cannot stop it.
What It Looks Like in Practice
For most clinicians working in traditional healthcare settings, moral injury accumulates in the gap between the care they are trained and motivated to provide and the care the system allows them to deliver.
It looks like a 15-minute appointment with a patient who needed 45 minutes, and knowing you left without addressing what actually mattered (the reason I left traditional care).
It looks like ordering a test you know the patient needs but that they’ll get stuck with a bill so you don’t order the test - the other day I offered a patient 2 imaging tests I felt like she needed, then followed up and said but your insurance won’t cover either and out of pocket cost is XYZ, do you still want me to order this?
It looks like ordering a prescription that you spent time sharing all the risks, benefits, and alternatives and using shared decision making, you and the patient determined it was the best option - then spending hours you do not have fighting for it (oh like almost every testosterone I have sent in lately).
It looks like prescribing a medication because it is on the formulary rather than because it is the best option (oh hello off-label gabapentin for hot flashes).
It looks like watching a patient fall through the cracks of a fragmented system and knowing you did not have the bandwidth to catch them (for example an urgent referral to a specialist that gets missed).
It looks like caring deeply about doing right by your patients and being structurally prevented from doing so, repeatedly, indefinitely, without systemic relief.
Over time, the injury accumulates. We do not stop caring. That is the burnout narrative, and it is largely wrong. Most clinicians who leave medicine are not exhausted people who no longer care. They are deeply caring people who can no longer tolerate the moral cost of working within a system that prevents them from caring well.
Why This Matters for Women's Health Specifically
In women's health, the moral injury of traditional practice has a particular feel. Providers who care deeply about menopause, sexual health, and midlife women's wellbeing find themselves in a system that allocates 15 minutes to address concerns that require 45, that does not reimburse conversations about hormone therapy or personalized cancer screening or cardiometabolic testing, and that treats the complex, whole-person needs of midlife women as an afterthought. And frankly not important.
The women are not getting what they need. The providers know it. And the system does not change. This is the crux of my doctoral project.
That is moral injury. Watching patients leave your care inadequately served, not because you failed them, but because the structure you are operating inside failed them, and you did not have the tools or the time to bridge the gap.
Why I Left Traditional Practice
Building Camel City Women's Wellness as a direct primary care practice was not a lifestyle decision. It was a clinical one. It was an ethical one. And most importantly, it was one rooted in social justice for women.
In the DPC model, I have the time to actually practice the way I was trained to. I can spend an hour with a patient who needs an hour. I can order the tests that are indicated rather than the tests the insurance will approve. I can have the conversation about hormone therapy that takes 30 - 40 minutes to do correctly. I can follow up, be accessible, and know my patients in the way that good medicine requires.
The moral injury did not disappear overnight, but I did start to feel it dissipate over the first couple of years in this type of practice. However, my most humbling experience lately is the realization that over the last year, it is creeping back in. Hormone therapy shortages, never ending prior authorizations, lab pricing being 10-15 higher than just a few years ago, arguing with specialists about getting my patients in, fighting imaging centers for performing the actual test I ordered, the list goes on. My practice is based on evidence, guidelines, my experience, and patient preference. It is becoming increasingly more and more difficult to do the right thing - not because of me or the patient. Because of increasing red tape - everywhere.
What the System Needs to Hear
Moral injury in healthcare is not an individual problem with an individual solution. Telling injured clinicians to practice more self-care is like telling a soldier with PTSD to take more bubble baths. I have done it all - therapy, coaching, acupuncture, massage, vacations, meditating, and for crying out loud I am a yoga instructor! Telling us to do more self-care misidentifies the source of the wound and burdens the injured with fixing what the institution caused. We get told things like - oh you need thicker skin or you're not cut out for this.
The solution to moral injury is moral repair. This means changing the conditions that created the injury in the first place. It means healthcare systems that give clinicians the time to practice well (check, I did that). It also means reimbursement structures that value thoughtful, preventive, relationship-based care rather than volume and throughput. It means trusting clinical judgment over administrative protocols - not insurance formularies, pharmacy benefit managers, and preferred centers. It means building environments where clinicians can do what they trained for decades to do. It means providing care that women have not had access to, for centuries.
Until that happens at scale, many of the best clinicians will continue to leave traditional systems. But it is not because they burned out, but because they refused to keep sustaining the injury.
I am one of them. And I am not sorry. And I will continue speaking up and advocating for the handful of patients whom I have the privilege to care for.
[The other day my daughter said “mom, do you like taking care of people?” to which I responded, “yes, I love taking care of women, but there is other stuff that has nothing to do with them that makes my job very difficult.” To which she replied, “okay, I think I’ll stick to becoming a geologist then.” Good call, baby girl. Side note: she sticks a rock in my pocket every day before I leave for the office]
This post reflects the personal perspective of Christina Saldanha, PA-C, founder of Camel City Women's Wellness. It is intended to be part of an honest, ongoing conversation about how healthcare reform.
