May 23, 2024

Moral Injury and the Amis Fellowship

Ali Khader, MD

My mentor and friend, Jennifer Broder, MD, urged me to apply for the E. Stephen Amis, Jr., MD, Fellowship in Quality and Safety as a diagnostic radiology resident in order to peek behind the curtain of our profession and discover valuable insights within the ACR® Department of Quality and Safety.

Prior to visiting the ACR headquarters in Virginia as a 2023–2024 Amis Fellow, I had been grappling with the concept of moral injury, which occurs when we perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs.

In the context of my work as a radiologist, this deeply held moral belief is the oath I took during medical school in Bahrain: Prioritizing patient well-being and needs, first and foremost. We commit moral injury when we know what needs to be done for the betterment of our patients but are unable to carry it out due to constraints beyond our control.

For example, picture a nurse at an underfunded, underserved hospital unit caring for 10 patients, including a dying man on comfort care who is taking his final breaths. With no one else at his bedside, this patient’s last request is for the nurse to stay with him as he passes on.

The nurse, spread thin by roles and obligations, suffers moral injury when unable to perform this last act of kindness. Other patients also need care, and this exhausts the nurse, planting a feeling of ineffectiveness.

In the past, we would describe this phenomenon as “burnout.” The difference between burnout and moral injury is important because alternate terminology can reframe the problem and the solutions. The concept of moral injury is a shift from burnout, which puts the impetus on the individual rather than the overarching systems at play.

What does moral injury and burnout have to do with my Amis Fellowship? As radiologists, we have full access to the clinical sphere of our profession. However, during residency we are seldom exposed to the well-oiled machine behind the scenes that allows us to function as healthcare providers.

If we want to address moral injury, we need to bridge the gap between the two houses of healthcare: The clinical and the administrative/logistical sides. This includes understanding the accreditation process, billing, policy making, practice parameters and standards, DEI, and so much more — all outside the scope of our day-to-day practice.

By learning about these processes and systems as an Amis Fellow — and as a practicing radiologist — I gained a better understanding of the collaborative push needed to improve our practice and patient care, with the ultimate goal of preventing moral injury.