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SAN ANTONIO
MEDICINE

BURNOUT:

Symptom of Moral Injury at the Workplace or Something More?

A Thought Analysis

By Rodolfo (Rudy) Molina MD MACR FACP

The word and concept of “burnout” is be- pational context and states it should not be jury”, defined as “a betrayal of what’s right by
coming better known and now more often applied to other experiences in other areas of someone who holds legitimate authority in a
written about in medicine. What is it? The life. It goes further by describing three high-stakes situation, so that there can be per-
Oxford Dictionary notes the first use of characteristics: sonality changes and complications in treat-

burnt out was in 1837 describing elder no- ing the post-trauma injury.” In the case of the
1. Feeling of energy depletion or
bleman. In 1926, the term burnt out was Vietnam vets, there were frequent complaints
exhaustion,
used to describe a young woman’s demeanor. 2. Increased mental distance from one’s of being issued M-16 rifles that malfunc-
So, I did a PubMed search using the terms job or feeling of negativism or cyni- tioned, or being sent out on patrols where
burn out or burn-out from 1926 through cism related to ones’ occupation, and they felt like sitting ducks in difficult and un-
2020. There were no references to burn out 3. Reduced professional efficacy. familiar terrain by commissioned officers
up until the early 1970s. From 1970 through corps. Moral injury has been applied to our
1979, there were a total of sixty-five articles The WHO recognizes these as symptoms medical profession as the root for burnout.
published that mentioned burn out. There- arising from the stress of one’s occupation. As I read through the literature, I thought
after, a steady increase in the number of arti- We have heard about burnout in other occu- the idea of moral injury should be expanded
cles mentioning burnout appear in our pations such as policing, fire fighters, as well to more completely address the issue of
literature. A sampling of the number of arti- as field and service workers during the pan- burnout. Over my last forty-one years (nine
cles published each in the following years demic. The stress of constant re-entry into a in the military and 32 in private practice)
gives us a sense of the continual increase and hazardous job is considered a factor that leads that I’ve been practicing medicine and hear-
interest in this subject. to burnout. ing my colleagues speak of their issues and
In 1980, 32 articles were published dealing If burnout is a description of a symptom problems with their practices, I’ve pondered
with burnout; in 1990, 161 articles; in the complex associated with one’s occupation, the idea of burnout. This has led me to the
year 2000, 329 articles were published; and then the root of the problem would be the following analysis of the problem. I believe
in 2019, 1,644 articles were published. The stressors of that particular occupation. there are three areas of activity that we have
concept of burnout has become so promi- Jonathan Shay began to talk about combat to be managed successfully to address and
nent, the World Health Organization stress in October 1991, comparing it to what prevent burnout. And if any one of these
(WHO) designated burnout with the ICD- was described in Homer’s Iliad and the sol- areas fails, burnout is eminent for the other
10 code of Z73.0. This code defines burnout diers who returned from battle. He then two cannot compensate. The three areas are:

as circumstances which influence the pa- wrote about the Achilles in Vietnam in 1994,
1. Resilience (self-motivation),
tients’ health status, but not a current illness discussing severe cases of Post-Traumatic
2. Life balance, and
or injury and one that is unacceptable as a Stress Disorder. These solders were trained 3. Control of the workplace.
principal diagnosis. The ICD -11 code, to commit legal criminal acts and after they
QD85, more clearly defines and characterizes witnessed horrific battle scenes, they then re- I’ll discuss each individually. I do want to
burnout as a chronic workplace stress that has turned to civilian life where they could no clarify that this analysis applies to the individ-
not been successfully managed. It refers longer trust their leaders. Why? They were ual who continues to try working at 100%, de-
specifically to this phenomenon in the occu- suffering from what he termed a “moral in- spite failing in any one of these three areas.

40 SAN ANTONIO MEDICINE • December 2020