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Rediscovering Meaning and Purpose: An Approach to Burnout in the Time of COVID-19 and Beyond

      Rediscovering Meaning and Purpose

      Medicine is in the midst of a crisis, resulting in high rates of burnout. Over the past few decades there has been an erosion of meaning, largely caused by the de-humanizing commodification of medicine with its inattention to humanistic values, where the focus is on rapid throughput and profit, and where practitioners are forced to spend much of their time engaged in tasks and activities unrelated to what they find most meaningingful. This surge in burnout has been magnified by the ongoing Coronavirus disease 2019 (COVID-19) pandemic.
      We believe the current level of staff burnout is directly related to loss of meaning and purpose in daily work. In this viewpoint, we propose that medical institutions and health care providers embrace the meaning-centered teaching originally articulated by Viktor Frankl, MD, PhD and expanded by scholars around the globe and from various professional fields.
      Frankl (1905-1997), a Viennese neurologist, psychiatrist, and philosopher, proposed that the primary motivation of human behavior was not pleasure (Freud) or power (Adler), but the desire to seek meaning and purpose in one's life. He called his style of clinical practice logotherapy (meaning-centered therapy) and published numerous ground-breaking books, including Man's Search for Meaning
      • Frankl VE
      Man's Search for Meaning: An Introduction to Logotherapy.
      and The Doctor and the Soul.
      • Frankl VE
      “The Doctor and the Soul” From Psychotherapy to Logotherapy.

      How Important Are Meaning and Purpose in Medical Practice?

      In a study of 465 academic physicians,
      • Shanafelt TD
      • West CP
      • Sloan JA
      • et al.
      Career fit and burout among academic faculty.
      those who spent <20% of their time at work engaged in the activity they found most personally meaningful had significantly higher rates of burnout (53.8%) compared with those who spent >20% of their work time (29.9%) engaged in such activities. Further, the less time engaged in the most meaningful activity was the strongest predictor of burnout, followed by working more hours per week, younger age, and working as a generalist rather than subspecialist.
      In a series of publications based on a survey of 2000 full-time members of the American Academy of Family Physicians,
      • Tak HJ
      • Curlin FA
      • Yoon JD
      Association of intrinsic motivating factors and markers of physician well-being: a national physician survey.
      the factor most strongly associated with physician happiness was career purpose, which included career satisfaction, joy in work, spiritual purpose, and meaning in patient relationships. A sense of calling and having long-term relationships with patients were strongly associated with high life meaning. In most cases, extrinsic motivators, such as annual income or other work-related characteristics, were not related to well-being, life satisfaction, life meaning, or career commitment.
      That meaning, purpose, and calling are so strongly linked to physician well-being is consistent with a large body of research linking meaning and purpose to mental, physical, and spiritual health. For example, in the Health and Retirement Study of 6985 subjects who were followed over a 4-year period, stronger purpose in life was associated with decreased mortality.
      • Alimujiang A
      • Wiensch A
      • Boss J
      • et al.
      Association between life purpose and mortality among US adults older that 50 years.
      Meaning and purpose is also strongly associated with resilience,
      • Southwick SM
      • Charney DS
      Resilience: The Science of Mastering Life's Greatest Challenges.
      something that is essential for all medical practitioners.
      Recently, a number of institutions have recommended that a greater sense of meaning and purpose be re-infused into the practice of medicine. A Press Ganey white paper
      Press Ganey
      2018 White Paper, Burnout and Resilience. A Framework for Data Analysis and a Positive Path Forward.
      on burnout and resilience in medicine emphasized the need to “more reliably find meaning, pleasure and respect” in work; and the Accreditation Council for Graduate Medical Education
      • Hipp HM
      • Rialon KL
      • Nevel K
      • Kothari AN
      • Jardine LDA
      ”Back to bedside": residents' and fellows' perspectives on finding meaning in work.
      recommended that trainees have more direct contact with patients as a way to enhance meaning. The call to focus on meaning and purpose is even more pressing during the COVID-19 pandemic. In a 2020 survery of over 2300 physicians, the Physicians Foundation
      The Physicians Foundation
      2020 Survey of America's Physicians, Part 2 of 3: COVID-19's Impact on Physician Wellbeing.
      found that 30% of respondents reported feelings of hopelessness or having no purpose as a result of pandemic-related changes in their practice.

      What Do Doctors Find Meaningful About Their Work?

      In a qualitatitive study conducted at annual meetings of the American College of Physicians and the Society of General Internal Medicine,
      • Horowitz CR
      • Suchman AL
      • Branch WT
      • Frankel RM
      What Do Doctors Find Meaningful About Their Work?.
      3 major themes emerged: 1) experiencing a change in perspective about human nature, themselves, their roles, illness, or patient care after involvement in a profound or emotional event; 2) connecting with patients in moments of intimacy; and 3) feeling that they had made a difference in patients’ lives. The author's were “struck” that nearly all participants wrote about nontechnical humanistic interactions with patients rather than diagnostic and therapeutic successes.
      While the COVID-19 pandemic has resulted in a renewed sense of purpose for some health care workers, for others it has meant reduced time with patients in moments of intimacy. Further, some have had to wrestle with moral and ethical dilemmas including having to make life-and-death decisions based on limited resources and watching patients suffer and sometimes die alone. These issues can contribute to guilt, sadness, and burnout.

      How Can Franklian Principles Enhance Meaning at Work for Medical Professionals?

      Frankl advocated finding meaning through: 1) creative acts or what we give to the world; 2) experiences that we take from the world; and 3) attitude.
      • Frankl VE
      Man's Search for Meaning: An Introduction to Logotherapy.
      ,
      • Frankl VE
      “The Doctor and the Soul” From Psychotherapy to Logotherapy.
      ,
      • Shantall T
      The Life-changing Impact of Viktor Frankl's Logotherapy.
      Creative acts include tasks to be accomplished, one's career, making a difference in someone's life, and alleviating suffering. Experiential values include witnessing courage in the face of tragedy and experiencing deeply emotional encounters with suffering patients. Attitudinal values means choosing an attitude toward an unalterable fate such as chronic illness or imminent death, what Frankl called the last of the human freedoms.

      How Does Frankl's Philosophical Approach Differ from Other Teachings?

      Compared with other philosophical and psychological teachings, logo-philosophy sees life in terms of solutions rather than problems, focuses on goals rather than obstacles, emphasizes discovering rather than uncovering, and is holistic rather than reductionistic. It is future oriented, focuses on personal strengths, emphasizes individual values, and places responsibility for change on patients, practitioners, and institutions.

      Starck PL. Theory of Meaning. In: Smith MJ, Liehr PR, eds. Middle Range Theory for Nursing. New York: Springer Publishing; 2014:87–108.

      With systems, Franklian interventions can help organizations build frameworks, structures, and supports to maintain a sense of meaning in the work environment.

      Conclusion

      The practice of medicine has changed substantially over the past few decades, with an accompanying loss of meaning and purpose. As noted by Christine Sinsky of the American Medical Association, “At the highest level we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”
      • Wright AA
      • Katz IT
      Beyond Burnout - Redesigning Care to Restore Meaning and Sanity for Physicians.
      The cost is enormous. We must not forget the wisdom of of William Osler, who believed that the medical profession was not a business, but rather a calling.
      Based on a large body of psychological and organizational research, we believe that helping employees, trainees, and medical institutions rediscover meaning and purpose in their work will improve morale and motivation, reduce burnout and depression, lessen staff turnover, and improve health care outcomes. While numerous health care experts and organizations have identified the need to rediscover and foster meaning in medicine, practical approaches have been relatively elusive. The basic principles and teachings of Frankl's logotherapy have time-tested answers for discovering meaning and purpose in life.
      Health care, with its mission of service to patients, families, and communities, provides a unique opportunity for all health care employees to experience high levels of meaning in their work. It is up to medical leaders to create an environment with policies, procedures, and training opportunities that help all employees understand and connect with the organization's ultimate mission of service.
      Frankl believed that every crisis presents an opportunity for growth. We propose that teaching the principles put forth by Viktor Frankl to health care students, medical caregivers, hospital administrators, and patients would help to bring professional satisfaction and meaning back to medicine in the time of COVID-19 and beyond.

      Acknowledgment

      The authors acknowledge Robert Barnes, PhD and Bernadette Lowthert, MBA for their valuable contributions.

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        Association of intrinsic motivating factors and markers of physician well-being: a national physician survey.
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        Association between life purpose and mortality among US adults older that 50 years.
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