Healing the Wounds of Moral Distress Through Storytelling

Aug 10, 2023

Repeated instances of moral injury in his work as a paediatrician in intensive care were having a severe impact on Dr Lalith Wijedoru's health
Counselling helped him make significant changes
If you're struggling with work-related stress or burnout, we have therapists who can help here

'Do you think this could be work-related stress?' my GP asked towards the end of my appointment. I was in the last two years of my specialist training to become a paediatric emergency medicine consultant. In the preceding two weeks I had gone from being a cheerful, loquacious, motivated junior doctor to a sluggish, brain-fogged zombie with marked headaches and slurred speech. I had a slight tremor of my hands which was affecting my ability to carry out practical procedures required for my job. Given my maternal grandfather had a brain tumour at a similar age, and that my personality change was completely out of character, I thought I had better get myself checked out.

I was arrogantly indignant with the GP's suggestion that my symptoms could be a stress reaction. I considered myself a very positive and resilient person. I had dealt with a lot of stress my whole life. Physical and emotional abuse as a child. Harassment and bullying, as well as racial discrimination in the workplace. Some very emotionally traumatic experiences working in low-resource settings in Cambodia, Laos, and Bangladesh as part of global child health work. Why would I react like this now? If this was indeed stress, what had tipped me over the edge?

I begrudgingly took my GP’s advice to seek a work-based counsellor. Truthfully, my agenda and expectation was a referral for a CT or MRI scan of my brain. I was reassured that my neurological physical examination was completely normal and that any imaging was not necessary.

The counsellor was a very good listener. She was a mystical cross between a police inspector and academic philosopher. She quickly steered her questioning to the highs and lows about my medical career thus far. Her careful probing when it came to the challenges of my work led to a number of lightbulb moments for me. Reflecting on my career journey in light of my then current symptoms pointed towards the strong possibility that my symptoms were a manifestation of moral distress or moral injury.

I was working on paediatric intensive care at the time where I had been looking after children post-bone marrow transplant with irreversible bone marrow failure. One particular patient was a 12 year-old girl with severe graft-versus-host disease, which is a serious complication of transplanted bone marrow being rejected by the recipient.

This particular girl was bleeding from every external and internal orifice: her brain, lungs, gut and more. She had little intact skin or hair, resembling a creature that had been dipped in volcanic lava. She was on maximal intensive care support in multi-organ failure. She was being sustained with very expensive haematological products in what I perceived to be a no-hope situation, prolonging her suffering. Even though I spoke up after every shift questioning the ethics of what we were doing and advocated for the child’s management to be to make her comfortable and let her go, this opinion was always over-ruled or ignored.

The counselling made me realise that I had similar feelings at other stages earlier in my training in parallel ethical situations, specifically on newborn intensive care looking after very pre-term infants, and in certain A&E resuscitation calls where the clinical situation was incompatible with life or very poor neurological outcomes. The common theme: patients being kept alive when their cases were clearly medically futile.

The real lightbulb moment was when I realised it was at those points in my career when my levels of moral distress/injury were so raised that I had seriously considered leaving my job. I became a paediatrician to advocate for children, and a doctor to do no harm. It was in these clinical scenarios where these core ethical principles and values of mine were challenged or violated.

The NHS counsellor made a game-changing suggestion to me. She suggested I attend the next hospital Schwartz Round, which is a confidential forum where staff could share the social and emotional impact of their work in front of other staff through stories. By some amazing co-incidence at the first Schwartz Round I attended, I heard an anaesthetist talk about his own moral distress at the other end of the healthcare spectrum where he worked in very low-resource settings in Afghanistan. He described how devastated he felt not being able to provide very basic life-saving care due to the limited resources he was working in.

During the session, I shared my own experiences about the opposite: doing too much in a highly-resourced London teaching hospital paediatric intensive care unit. The discussion and connection it generated among staff at that meeting made me feel that what I was feeling was normal and that I was not alone. One of the final thoughts of the session: just because we can, does it mean we should?

This is where I discovered first-hand the power of workplace-based storytelling. I made a commitment then and there to support the emotional wellbeing of staff using this approach for the rest of my career. I trained as a Schwartz Round facilitator with the Point of Care Foundation (UK), and facilitated storytelling sessions for NHS staff working in a children’s hospital for a number of years.

I left the NHS in 2021 to set up a wellbeing company called Behind Your Mask, and now work full-time as a storytelling facilitator who helps others craft and share their personal stories.

Crafting a personal story is essentially reflective practice. Here are some tips and pointers to help you tell your story.

Try and craft a story based on a theme e.g. fear (which could mean ‘fearful’ or ‘fearless’)
Think, what happened? The chronology, timeline, or sequence of events is important.
Set the scene (time and place) for your audience. Year, month, location, how old you were etc.
Don’t forget to describe the events from a sensory perspective i.e. how did it look, smell, sound?
Think, so what? Why was this particular event or series of events important to you?
Focus on the emotions you felt at the time about these events
Reflect on the emotions you feel now looking back at those events
Think, what the moral of the story that you want to convey to your audience/listeners/readers is

I discovered immense benefits from being open and telling my stories, I hope you can too.

Dr Lalith Wijedoru is the founder of www.behindyourmask.co