American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes


Learning to Manage Well-Being through Transitions

More than one year after the start of the COVID-19 pandemic, we are on a journey of change yet again. In fact, we carry the trauma and experiences of the COVID-19 pandemic into this new phase of life.

As local, state and national communities roll back physical protocols that helped manage the risk of transmission, it is crucial to take stock of your well-being. One place to start is reflecting on how you will move from a place of fear and uncertainty back to a place of trust and certainty.

Well-being comprises physical, emotional, social, spiritual, occupational, financial, intellectual and environmental dimensions, and the COVID-19 pandemic affected each of these domains. The transitions you will make in each of these dimensions as we enter the next phase of the COVID-19 pandemic might feel easy in some areas and more difficult in others.

One place to start assessing your well-being is to explore your experience with Compassion Fatigue and recognize symptoms of Compassion Fatigue, Life Stress, and Empathy.

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Moral Injury in Surgery

By Anna M. Miller, MD, FACS, FAAOS, FAOA

More than 400 physicians die by suicide annually in the U.S; this amounts to more than one physician every day. Physician suicide rates are much higher than the general population, especially for women physicians, and almost a quarter of surgical trainees have had suicidal thoughts at some point in their residency. Many of us know or have been affected by partners, colleagues, mentors or trainees who have died this way or experienced other significant mental health issues.

Although these issues often are discussed in the context of burnout, especially recently during the COVID-19 pandemic, it is important to point out that many physicians are experiencing "moral injury." Burnout was described by Herbert Freudenberger in the 1970s as "severe stress in healing professions," and it is often easy to miss in "type A" physicians who are high-functioning people that may be showing only subtle signs.

In contrast, moral injury was first described in the military, where people in the line of duty may have seen, or failed to stop, events that went against their personal moral code. Moral injury is the response a person experiences after such events, which can be exceedingly difficult to overcome.1 This has more recently been applied to health care professionals and came to the forefront with the COVID-19 pandemic and the difficult patient care choices that many physicians had to experience.2,3 Specifically in the context of health care and moral injury, many believe that the issues physicians have cannot be attributed to burnout in and of itself, as physicians are generally a resilient, mindful. and optimistic group. However, when anyone is continuously put in situations where that person cannot take optimal care of patients due to limited resources, increasing electronic health record burdens, pay for performance and so on, moral injury occurs. I hope that we can continue to advocate through the ACS as well as our specialty organizations to push at a national level for improved work conditions for all our nation's physicians and health care workers, particularly regarding mental health.

Finally, I would advocate for us to all remember to take care of each other. In 2015, the Accreditation Council for Graduate Medical Education hosted a symposium on physician well-being where they specifically discussed the fact that physicians often are not helped by others around them, despite being surrounded by other physicians.4 They noted that the decision to help others involves a series of decisions that can waylay the process at any point, thereby making it easy to fail. Physicians regularly cited reasons such as "it was none of my business," "I assumed there wasn't an issue" or "I thought someone else would do something" as justification for not helping a physician colleague in need. This report specifically emphasized the need for all of us to take personal responsibility to help our colleagues and to reach out to someone who might be having an issue.

As we are hopefully getting to the light at the end of the pandemic tunnel, we should take care to continue to push for improved mental health resources at our institutions, support for physicians across health care environments and advocate for open dialogues with each other about mental health issues and moral injury. Per the Clinical Congress theme: Resilience in the Pursuit of Excellence!


  1. Griffin BJ, Purcell N, Burkman K, Litz BT, et al. Moral injury: An integrative review. J Trauma Stress. 2019;32(3):350-362.
  2. Campbell SM, Ulrich CM, Grady C. A broader understanding of moral distress. Am J Bioeth. 2016;16(12):2-9.
  3. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. BMJ. 2021;368(m1211).
  4. Accreditation Council for Graduate Medical Education. 2015 ACGME Symposium on Physician Well-Being. Available at: Accessed June 7, 2021.