Souba, Wiley W. MD, ScD, MBA
Work can provide the opportunity for spiritual and personal, as well as financial, growth. If it doesn't, we are wasting far too much of our lives on it.—JAMES AUTRY 1
The shakeup of the health care industry over the past decade has generated an enormous amount of anxiety, frustration, and dismay. It would be difficult, if not impossible, to find another social issue directly affecting all Americans that has undergone as impressive and rapid a transformation and, perplexingly, one in which the chief protagonists (i.e., the patients and the doctors) feel short-changed. 2 This “new order” in health care, one governed by commercialism and free competition, presents academic medical centers (AMCs) and university physicians with unique challenges. Driven by pressures to reduce costs and increase reimbursement, academic physicians are spending more of their time seeing patients but less time with individual patients. All three AMC social missions—patient care, teaching, and research—are in jeopardy.
Many physicians have become disenchanted with their ability to serve as advocates for and provide care to their patients; changes in the structure of the health care system have strained the physician–patient relationship and led to cynicism and disillusionment. Today, physicians are often viewed as “employees” or “providers” in an industry in which health care is in danger of becoming simply a commodity. Financial success, the measure of the marketplace, has become the dominant standard of measurement or “value” for most AMCs and physicians. Many doctors report their work is less fulfilling. The noble profession of medicine, which once was regarded a vocation or calling, has for many become a paycheck, if not a chore. Dissatisfaction and frustration arise from unmet expectations. By and large, their source can be traced to an unpleasant workplace environment or a missing (or misplaced) sense of purpose (List 1).
The transformation of the health care industry into a marketplace governed by commercialism and entrepreneurialism challenges the doctrine that medicine is a profession valuing service rooted in unselfishness above financial reward. 3 The risk to the medical profession is that it may lose its sovereignty, becoming a passive rather than an active participant in shaping health care policy and choosing what it values in health care. The risk to our patients is that cost will take precedence over quality and access to care. The risk to individual physicians is that they may fall short of discovering true meaning and purpose in their work. Lacking a clear sense of how meaning in their work is grounded, they may lose touch with the values that drew them into the profession in the first place. Some physicians may experience the “anxiety of meaninglessness—anxiety about the loss of an ultimate concern, of a meaning which gives meaning to all meanings.” 4
Whether we like it or not, this commercial landscape, one governed by market forces, is here to stay. Powerful constituents argue rising health care costs require medicine be managed as a business, governed by the invisible hand of the marketplace and all the accompanying harsh realities. Here, the idea of a social contract becomes impractical and unrealistic. However, the corporatization of academic medicine comes with a heavy price. Today, the primary performance indicator is profitability. We approach patients as we would airline passengers, selectively seeking out business-class types who pay well and avoiding those in the super-saver category because the profit is not as high. We accept that medicine has become a commercial enterprise, subject to all the rules of big business. Most physicians try to cope with this, but they frequently feel overwhelmed. Troubled by the isolation of their core values from their professional practices, they often detach (sometimes even compromise) these beliefs from the workplace, even though such segregation is inconsistent with their deepest convictions.
In reality, medicine is not just another market. A difference exists between medical care and other marketable commodities. Physicians intuitively know medicine cannot be run like an auto repair shop—diagnosing and fixing patients as if they are machines that break down leaves much to be desired. The mitigation of human suffering is what gives meaning and purpose to the medical profession, a task that cannot be distorted by profit. Profiting excessively from illness is unfair. An exclusive focus on scientific knowledge of the body and disease hinders our ability to ameliorate suffering; bodies don't suffer, persons do. Illness is too directly a confrontation with the fundamental questions about the meaning of human existence to ignore this fact. As eloquently stated by a Boston Globe writer, “The rush to transform patients into units on an assembly line demeans medicine as a caring as well as curative field, demeans the respect due every patient and ultimately demeans illness itself as a significant human condition.” 5
Our health care system is losing direction and purpose and is in urgent need of renewal. AMCs can take the lead.
WORK AND OUR SEARCH FOR MEANING
“No need is so compelling,” said futurist and strategic thinker Willis Harman, “as the need we all feel for our lives to make sense, to have meaning. We will tolerate almost any degree of austerity or risk in this indomitable quest for meaning.” 6
The dictionary defines work as any physical or mental effort through which something is produced as a result of the effort. Meaning denotes the significance or importance of something. Accordingly, meaningful work provides a sense of purpose, a feeling the effort expended is worthwhile and makes a contribution (to the greater good). Most of us are motivated to work for reasons other than compensation. Clear evidence exists that happiness and well-being are directly linked to a commitment to a cause or purpose beyond oneself. As academic physicians, we hunger for meaning in our work, in part because of its nature but also because of the long hours we put in, not uncommonly twice the hours of the average workweek for non-physicians. 7 We long to put our ideals and values into practice, to “put them to work.” We seek an understanding of our world that gives us purpose and dignity. Work serves as a vehicle by which our lives make sense and can be expressed. Whether caring for patients, engaging in research, or teaching, we each seek to discover a worthy purpose that allows us to embody and embed our most passionate commitments at work.
Virtually every culture, race, and tribe looks to its fundamental core values, largely religious and spiritual, as the ultimate source of deep-seated purpose and meaning. Whether we acknowledge it or not, the allure of this ultimate truth appeals to each of us. In the final analysis, most people draw on this truth in making moral and ethical choices. We may with regularity smother this yearning, but as writer—attorney—executive coach C. Michael Thompson points out, “However dimly conscious it might be amid the chaos and complexity of our lives, there is a need in almost all of us for a sense of connectedness and purpose in the events of our outer lives, and a deeply rooted desire for our inner lives to have a harmonious connection to a higher source of meaning and value.” 8
This calling home is arduous and time-consuming. We often choose instead to attach meaning and fulfillment to the trappings of success measured by income, accomplishments, and title. This lure is not surprising—a health care system governed by market forces encourages obsession with material wealth and power. Clinicians begin to equate financial reward with service (according to Charles Dickens, “a good Samaritan is a bad economist” 9). Buyers look for the lowest-priced deals; the system promotes meaning in clout, achievement, and performance. When we think about health care, we often think of it as it relates to me, and the solution to its problems is from my viewpoint, encompassing my values. We may think the uninsured are without coverage because of their failings, not because of flawed health care policies, and they simply need to find jobs and adopt an attitude of rugged individualism.
THE ROAD TO RECOVERY—FINDING MEANING AND FULFILLMENT IN ACADEMIC MEDICINE
To recover from our disengagement, we must reexamine our purpose as academic physicians. Meaning is expressed in how we approach each day's activities of patient care, research, and educating and mentoring students, residents, and faculty.
Illness and suffering are threats to individual integrity and well-being; they threaten the patient's freedom, disrupt relationships, call values into question, and restrict choices. They are also enigmas, imponderables that we cannot fully fathom. We may understand the biologic basis of disease but we struggle with the pointlessness with which sickness seems to strike. The ultimate meaning of illness and suffering, observes author—psychiatrist—neurologist and WWII concentration camp survivor Viktor Frankl, “exceeds and surpasses the finite intellectual capacities of man; what is demanded of man is not, as some existential philosophers teach, to endure the meaninglessness of life, but rather to bear his incapacity to grasp its unconditional meaningfulness in rational terms.” 10
We frequently hear our faculty, residents, and students exclaim, “What a great case!” This statement, while a declaration that conveys the excitement of learning, is also an affirmation of thankfulness, an acknowledgement of the appreciation for the skills and knowledge allowing them to care for their patients. Such gratitude provides meaning and value because we share ourselves in caring for our patients. The fulfillment we receive from this giving is the greatest gift we can receive. Ultimately, our approach to and empathy with our patients and their illnesses are a reflection of our understanding of what it means to be human, of the meaning and value of human life. Although we cannot comprehend or experience the agony of our patients, we can display compassion and alleviate their suffering. In so doing, our values come to life and our work has meaning. “Real health,” note ethicists Pellegrino and Thomasma, “is found in coming to grips with our own mortality—the fact that we exist has no ultimate and self-righteous meaning that we can construct on our own. The unique impact of being ill on the person, the impact on the person's humanity, is the grounding that gives meaning to the whole of the physician's activities.” 11
That we live in a scientific age in which our knowledge of how the body works is continually growing seems to clarify and enrich the physician's work. But, while helpful in some respects, in other ways it promotes a sense of distraction. Advances in biotechnology permit health care professionals to treat patients with a stent, a laser beam, a vector, or an antibody. If we become more preoccupied with technology and neglect healing patients, medicine will become even more depersonalized. If we focus more on curing and less on caring, we will lose many privileges we have enjoyed as trusted professionals.
While it is widely acknowledged that biomedical research has enhanced our knowledge of how the body works and yielded great benefits to individuals and society as a whole, it cannot provide meaning in and of itself. Truth and meaning are distinct; science can supply truth but it does not confer meaning. Meaning comes from trusting and committing our lives to something larger than ourselves that is the source of all truth. Research helps us acknowledge and appreciate that there is more to this universe than meets the eye, something authentically divine about how it all fits together. Such appreciation produces meaning and value. In response to a sixth grader who wrote to Albert Einstein asking him whether scientists pray, Einstein replied, “Every one who is seriously involved in the pursuit of science becomes convinced that a spirit is manifest in the laws of the Universe—a spirit vastly superior to man, and one in the face of which we with our modest powers must feel humble.” 12
As physicians, our purpose can provide us with a reason for being, even as we acknowledge that we lack answers to many questions. Our belief in a coherent universe often complicates, rather than solves, our predicaments with meaninglessness and suffering. To accept suffering is the first step toward discerning it; to dismiss it and look solely to science for the answer is to fail to recognize that “while misfortune challenges faith, it is only faith that can give hope and meaning to human suffering and dying.” 11 Once we acknowledge and accept this, our understanding of ourselves takes on new meaning. We begin to see illness and suffering not merely as molecular derangements to be repaired but as an integral part of our being that can provide us with an appreciation of what it means to be human. This grasp, however tentative it might seem at times, gives meaning and worth to our work. When we recognize that in spite of our imperfections and vulnerabilities we reside not at the fringe of our universe's consciousness but squarely in its center, our call to serve those who suffer from illness is a call to greatness.
Education and Mentoring—Channeling Potential
One of the joys of academic medicine is unleashing dormant human capabilities in our colleagues, residents, and students. To unleash this human potential, a good mentor must be more of a coach than a chauffeur, someone who helps the mentee become a competent navigator in his or her own right. Teaching is one of the primary means by which we develop others. To foster a young person's career development, create an environment in which he or she can flourish, and be a catalyst for success by validating someone's values and solidifying his or her commitment are among the greatest rewards in academic medicine. They give us meaning, purpose, and value.
As academic physicians, we must be willing to share our fundamental values and convictions about medicine with our students and mentees. Our trainees will notice quickly whether we view the doctor–patient relationship as a commercial transaction or a covenant based on trust. We must encourage them to examine how their work gives them meaning: Do they see their purpose as being simply about achieving the next goal? Or, do they see it as about making a difference in the lives of their patients and helping others develop? This kind of mentoring works best when the gifts of time, wisdom, and self are free. Under these circumstances, it is somewhat ironic that the mentor usually discovers the personal return and feeling of fulfillment are enormous.
Teaching, then, like patient care, is first and foremost an act of care. We must be concerned with how much knowledge and experience our young people acquire but also how that experience is used to shape meaning and purpose in their work. In caring about them and what they learn from us, we help them gain key insights and, in the process, we encourage and support them in their struggle to connect their outer work to a higher source of inner meaning and commitment. We do this because we care about their development as competent physicians and their growth as human beings.
THE TASK OF LEADERSHIP IN ACADEMIC MEDICINE
Organizational Leadership and Personal Leadership
The function of leadership in enabling people to find true meaning in their work applies at the organizational and personal levels. At the institutional level, leaders rally and inspire others to do constructive work to create a better future, a better health care system, and in so doing they create a culture anchored in shared purpose and values. Personal leadership begins with discovering one's true purpose, a purpose far more gratifying than making more money or acquiring more power. To quote Osler, “You are in this profession as a calling, not as a business; as a calling which extracts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man. We must work in the missionary spirit with a breath of charity that raises you far above the petty jealousies of life.” 13 When people feel that they are part of and belong to something larger than themselves, they are much more likely to find meaning in their work, professionally and personally.
The similarities between organizational leadership and personal leadership remind us that our ability to mature as leaders is rooted in our ability to grow as persons (List 2). Regrettably, leadership development is often seen as an external process. We focus on achievements rather than the meaning and purpose behind those achievements; we emphasize what to do, not how to be. The journey of leadership begins on the inside by asking several fundamental questions: Where does my leadership come from? What is my purpose? To what must I commit myself? How we express who we are and how we lead depend substantially on how we derive meaning from our work.
Without this inner journey we cannot fully connect with the suffering of others, and we lack the wisdom and will to tackle the problems facing health care today. Yet, when our inner work is isolated from others, it implodes within itself, leading to futility and meaninglessness. Sadly, the commercialization of medicine has encouraged an external orientation—one that hinders the personal journey of transformation and contributes to the lack of meaning and direction permeating the workplace today.
Academic medical centers, by virtue of their intimate associations with colleges of medicine, universities, and teaching hospitals, are poised to take the lead in the renewal of our health care system. Organizations cannot change unless and until the people that work within them change first. In building a health care system that truly cares for its patients and fulfills its physicians, we must begin by conveying a clear sense of what we value in health care and what kind of medical profession we want to have.
The growth of modernism, preeminence of biomedical research, and dominance of a market-driven clinical enterprise will continue to pose obstacles to a health care system that sees the mitigation of human suffering as its special calling and privilege. Properly positioned as a foundation, the venerable tripartite missions of the AMC can serve as the vehicles and means through which we work to alleviate suffering and thereby find meaning in our work. Our overarching operating philosophy must be to help and serve others, not to become wealthy or famous. The motivation lies in that powerful desire within each of us to make our lives significant, to go to work each morning knowing that what we are doing is worthwhile and adds value—for others and ourselves. Real meaning must come from realizing illness is a significant human condition and our compassion is connected to something that transcends each of us, and is tied to a sense of purpose and commitment.
Renewal of our health care system must begin with more open discourse about the fundamental issues conveyed in this essay. This is unnatural for many physicians, but the call is there; it drew us into the profession in the first place and it needs only to be resummoned. This is why leaders who are clear and steadfast about the organization's guiding mission and values are so vital to the future of our AMCs. In leading by example, our best leaders encourage others to openly share their feelings, values, and convictions about key questions such as: What does it mean to be an academic physician? What gives my work meaning and purpose? What do we value the most?
This kind of conversation and role modeling could be easily built into the curricula for medical students and our residency training programs, but the faculty must take the lead. Visible, highly respected faculty who are keen to share the experiences of their own “inward journeys” will inspire and empower the young people to do the same, thereby unleashing the human spirit and validating the dialogue. A critical point here is the importance of creating time and space to reflect on what's truly important. With today's frenetic pace, especially in the workplace, introspection and self-awareness keep us mindful and help clear our heads of the clamor and clutter. It is not possible to make much progress along the path of personal growth without carving out the time for reflection to mull things over and without examining and cultivating the inner life. If our AMCs are to transform themselves sufficiently to meet the challenges they will undoubtedly face, we will surely need a whole slew of people providing the kind of leadership that only a personal journey of self-development can make possible.
The Department of Humanities at the Milton S. Hershey Medical Center of the Pennsylvania State University spearheads an annual off-site two-day retreat for senior and chief residents from all clinical departments that covers topics such as professionalism, spirituality and suffering, and the issues discussed herein. This is a powerful experience for the residents and it goes a long way in building teamwork and cooperation within the hospital. In my own experience, students and residents hunger for opportunities to explore these issues with faculty. They want very much for us, their mentors, to be compassionate as well as capable, good listeners as well as good advisors, and devoted as well as competent as we live out our values in our work. They want us to teach them how to care for patients as well as how to treat them.
Academic medicine is a noble profession. It offers incredible opportunities to let our true selves shine at work. When we let our light shine, it justifies life and gives it purpose. As it is discovered and rediscovered, this purpose gives us direction by revealing who we really are and what is truly important in life. We are not burdened by it as some sort of obligation, requirement, or duty. Rather, it becomes a source of freedom and joy.