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

2021; Elsevier BV; Volume: 134; Issue: 9 Linguagem: Inglês

10.1016/j.amjmed.2021.04.020

1555-7162

Steven M. Southwick, Leonard A. Wisneski, Patricia L. Starck,

Optimism, Hope, and Well-being

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 Meaning1Frankl VE Man's Search for Meaning: An Introduction to Logotherapy. Pocket Books, New York1985Google Scholar and The Doctor and the Soul.2Frankl VE "The Doctor and the Soul" From Psychotherapy to Logotherapy. Vintage Books, New York1977Google Scholar In a study of 465 academic physicians,3Shanafelt TD West CP Sloan JA et al.Career fit and burout among academic faculty.Arch Intern Med. 2009; 169: 990-995Crossref PubMed Scopus (414) Google Scholar 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,4Tak HJ Curlin FA Yoon JD Association of intrinsic motivating factors and markers of physician well-being: a national physician survey.Gen Intern Med. 2017; 32: 739-746Crossref PubMed Scopus (65) Google Scholar 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.5Alimujiang A Wiensch A Boss J et al.Association between life purpose and mortality among US adults older that 50 years.JAMA Netw Open. 2019; 2e194270Crossref PubMed Scopus (114) Google Scholar Meaning and purpose is also strongly associated with resilience,6Southwick SM Charney DS Resilience: The Science of Mastering Life's Greatest Challenges. Cambridge University Press, Cambridge, England2018Crossref Scopus (84) Google Scholar 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 paper7Press Ganey2018 White Paper, Burnout and Resilience. A Framework for Data Analysis and a Positive Path Forward.2018Google Scholar 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 Education8Hipp HM Rialon KL Nevel K Kothari AN Jardine LDA "Back to bedside": residents' and fellows' perspectives on finding meaning in work.J Grad Med Educ. 2017; 9: 269-273Crossref PubMed Scopus (41) Google Scholar 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 Foundation9The Physicians Foundation2020 Survey of America's Physicians, Part 2 of 3: COVID-19's Impact on Physician Wellbeing.The Physicians Foundation. 2020; Google Scholar found that 30% of respondents reported feelings of hopelessness or having no purpose as a result of pandemic-related changes in their practice. In a qualitatitive study conducted at annual meetings of the American College of Physicians and the Society of General Internal Medicine,10Horowitz CR Suchman AL Branch WT Frankel RM What Do Doctors Find Meaningful About Their Work?.Ann Intern Med. 2003; : 772-777Crossref PubMed Scopus (122) Google Scholar 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. 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.1Frankl VE Man's Search for Meaning: An Introduction to Logotherapy. Pocket Books, New York1985Google Scholar,2Frankl VE "The Doctor and the Soul" From Psychotherapy to Logotherapy. Vintage Books, New York1977Google Scholar,11Shantall T The Life-changing Impact of Viktor Frankl's Logotherapy. Springer Nature Switzerland AG, Cham, Switzerland2020Crossref Scopus (6) Google Scholar 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. 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.12Starck PL. Theory of Meaning. In: Smith MJ, Liehr PR, eds. Middle Range Theory for Nursing. New York: Springer Publishing; 2014:87–108.Google Scholar With systems, Franklian interventions can help organizations build frameworks, structures, and supports to maintain a sense of meaning in the work environment. 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."13Wright AA Katz IT Beyond Burnout - Redesigning Care to Restore Meaning and Sanity for Physicians.N Engl J Med. 2018; : 309-311Crossref PubMed Scopus (146) Google Scholar 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.