Moral distress among residents in neurology: a pilot study

Medical progress, economization of healthcare systems, and scarcity of resources raise fundamental ethical issues. Physicians are exposed to increasing moral conflict situations, which may cause Moral Distress (MD). MD occurs when someone thinks he or she might know the morally correct action but cannot act upon this knowledge because of in- or external constraints. Correlations of MD among residents to job changes and burn-out have been shown previously. There are, however, hardly any quantitative studies about MD among physicians in Germany. The aim of this study was to investigate the frequency of occurrence, the level of disturbance, and reasons for MD among neurological residents in German hospitals.

1st qualitative phase: Open interviews on workload and ethical conflicts in everyday clinical practice were conducted with five neurological residents. Ethical principles of medical action and potential constraints that could cause MD were identified and a questionnaire designed. 2nd quantitative phase: A preliminary questionnaire was tested and evaluated by five further neurological residents. The final questionnaire consisted of 12 items and was conducted online and anonymously via e-mail or on-site as part of an unrelated resident training event at 56 sites.

One hundred seven neurological residents from 56 university/acute care and rehabilitation hospitals throughout Germany were examined (response rate of those requesting the questionnaire: 75.1%). 96.3% of the participants had experienced MD weekly (3.86, SD 1.02), because they were unable to invest the necessary time in a patient or relative consultation. Errors in medical care, which could not be communicated adequately with patients or relatives, were rated as most distressing. The most common reasons for MD were the growing numbers of patients, expectations of patient relatives, fears of legal consequences, incentives of the DRG-system, and the increasing bureaucratization requirement. 43.0% of participants mentioned they considered leaving the field of inpatient-care. 65.4% stated they would like more support in conflict situations.

MD plays an important role for neurological residents in German hospitals and has an impact on participants' consideration of changing the workplace. Important aspects are rationing (time/beds) and incentives for overdiagnosis as well as lack of internal communication culture and mentoring.