From Moral Injury Vulnerability to Protective Equity: The Voyage Every Surgeon Must Take.

Objective: To examine the relationship between moral injury and surgical practice, further explore the concept of protective equity, and understand its role in mitigating the impact of morally injurious events throughout a surgical career.

Background: Moral injury in healthcare settings has evolved from Jonathan Shay's original definition, modified by Brett Litz and others, to encompass the psychological impact of adverse patient outcomes on medical practitioners. Early career surgeons may be particularly susceptible to moral injury, yet the factors influencing this vulnerability remain poorly understood.

Methods: An analysis of existing literature on moral injury in healthcare, combined with an examination of surgical career trajectories and outcome reporting was conducted. The concepts of protective equity and vulnerability are introduced, defined, and theoretically extrapolated across a surgical career.

Results: Evidence suggests that surgical complications significantly contribute to moral injury, particularly among early career surgeons. We propose a model wherein protective equity accumulates over a surgical career, whereas vulnerability follows an M-shaped curve with peaks in early and late career.

Conclusions: Early career surgeons face a precarious imbalance of low protective equity and high vulnerability, especially immediately post-training. Strategies to address this dynamic include providing: specific education when onboarding faculty, and longitudinal peer support by senior, trained surgeons.