Emilie Couchman is an NIHR Clinical Lecturer in general practice with the Division of Primary Care, Palliative Care and Preventive Medicine at the University of Leeds, and a salaried GP in Wiltshire.
What exhausts me in clinical practice is not the intellectual demands of medicine, nor the emotional burden of bearing witness to people’s traumatic life events. It is the quiet, relentless heartbreak of listening to patients articulate what good care looks like, knowing I agree with them, and having to tell them the system forces me to deliver care in ways that fall short of what I know is right. This kind of protocol-driven, “Computer says no,” rigidity is not unique to healthcare, but here the stakes are higher: inflexibility does not simply delay a process, it undermines the very conditions that make safe, humane care possible. Moral injury climbs on the backs of clinicians who must repeatedly listen to patients describe what they want and need from a doctor, and must apologise that the system makes this increasingly difficult to provide.
Moral injury climbs on the backs of clinicians who must repeatedly listen to patients describe what they want and need from a doctor, and must apologise that the system makes this increasingly difficult to provide.
Well-intentioned friends and family sometimes tell me that I need to be less caring, less involved. I have reflected on this advice for some time, trying to articulate the unease it provokes. To accept it would be to accept that there is something wrong with me: with how I practise medicine, and with how I care for patients. I am a clinical academic; I thrive on evidence. In the clinical context, feedback from patients and colleagues is the most meaningful evidence available, and it consistently affirms the way I practise medicine. My approach cannot be the problem, and I am angry that I am even led to question this. My clinical experience and the confidence that comes with age allow me to resist such pressure, but my junior colleagues and trainees, who have not yet had the chance to build their self-certainty, are more vulnerable to taking personal ownership of systemic failings, and to the moral injury that follows.
I do not need to be a less compassionate practitioner. That would not help me to do my job. Detaching and disengaging might allow me to survive superficially in an environment that is in constant tension with my values for a little longer, but the damage would still be inflicted. I would lose the core of what makes my work meaningful, and would be acting in direct opposition to my own moral code. The term ‘burnout’ is often used as a surface expression of a deeper moral injury; the distress that arises when clinicians know what good care looks like but are repeatedly constrained in their ability to provide it.1
Resilience discourse has fallen out of favour, not because clinicians became less resilient, but because the concept was increasingly recognised as a way of individualising systemic harm.
Stockholm syndrome describes how a victim can develop emotional attachment to the person harming them.2 Though widely recognised in popular culture, the concept is met with scepticism in psychological academia. Some argue that it is better understood as a ‘coping mechanism under extreme stress’, than as a distinct syndrome.3 I am acutely aware that my experience as a doctor bears no resemblance to the realities of abuse or trauma, and I use the term only to illustrate the psychological adaptation that occurs when a person tries to function within a system fundamentally misaligned with their values. I recognise the strange tension of being deeply loyal to a system that is simultaneously breaking me, and of continuing to advocate for the NHS even as it erodes the very conditions that make compassionate care possible.
In the NHS, resilience was briefly treated as universal remedy; a buzzword that implied clinicians could withstand any degree of structural dysfunction if only they were personally robust enough. Resilience discourse has fallen out of favour, not because clinicians became less resilient, but because the concept was increasingly recognised as a way of individualising systemic harm. As Oliver argued, no amount of personal resilience can compensate for working conditions that are chronically misaligned with professional values.4
This is the paradox at the heart of contemporary healthcare: a system that demands emotional withdrawal and then calls it resilience, while clinicians know that connection is the mechanism through which care works. Moral injury is not a personal deficit but a predictable consequence of practising in a structure fundamentally misaligned with the values that make medicine meaningful. Harm is borne by patients who still know what good care looks like, and by a profession asked to survive by abandoning the very values that define it.
A system that demands that clinicians distance themselves emotionally from patients and then applauds that distance as strength is not cultivating resilience; it is manufacturing moral injury. A system that insists on emotional withdrawal, even though connection is the mechanism through which care works, cannot claim to prioritise patient care or staff wellbeing. A system that requires clinicians to survive by caring less, asking them to become people they do not recognise, turns survival itself into a form of loss. Detachment is not resilience.
References
Linzer M, Poplau S. Eliminating burnout and moral injury: Bolder steps required. EClinicalMedicine. 2021 Aug 19;39:101090. DOI: 10.1016/j.eclinm.2021.101090
Namnyak M, Tufton N, Szekely R, Toal M, Worboys S, Sampson EL. ‘Stockholm syndrome’: psychiatric diagnosis or urban myth? Acta Psychiatr Scand. 2008 Jan;117(1):4-11. DOI: 10.1111/j.1600-0447.2007.01112.x
Cantor C, Price J. Traumatic entrapment, appeasement and complex post-traumatic stress disorder: evolutionary perspectives of hostage reactions, domestic abuse and the Stockholm syndrome. Aust N Z J Psychiatry. 2007 May;41(5):377-84. DOI: 10.1080/00048670701261178
Oliver D. When “resilience” becomes a dirty word. BMJ. 2017 Jul 25;358:j3604. doi: 10.1136/bmj.j3604. DOI: 10.1136/bmj.j3604
Featured Photo by Luis Villasmil on Unsplash
