The physician leader as logotherapist. (Physician Executive Leadership).

VIKTOR FRANKL DIED AT THE AGE OF 92 ON September 2, 1997. At that moment, the world was occupied with the funerals of Princess Diana and Mother Theresa, but let us consider how Frankl's life and teachings offer American medicine perhaps the best solution to the angst that presently threatens it. Frankl coined the term "existentialism" and developed an existential form of psychotherapy which he called logotherapy. (1) American medicine needs a big dose of logotherapy right now, and the most likely "therapists" to administer it are physician leaders. This article will consider the spiritual and moral troubles of American medicine, Frankl's answer to that affliction, and the implications of logotherapy for physician organizations and leadership.

The emptiness of postmodernism

To understand ourselves, we must understand the world in which we live. Our times have been labeled "postmodern," but what does that mean? In its original context, postmodernism described a style of architecture. The term has achieved expanded use to describe the attitudes and perspective of the late 20th Century. Unlike The Enlightenment or Romanticism, postmodernism describes us for what we are not, rather than for what we are. That is to say, our times are more about the rejection of ideals and beliefs than the acceptance of them. 'Postmodernism tends to hold that there is no all-embracing, 'totalizing' viewpoint, no 'God's-eye view,' no pure 'objectivity.'.... (P)ostmodernist themes seem to have infiltrated the culture far more in the United States...(2) In short, postmodernism leaves us with no central belief or ideal to bring meaning to our lives.

Professor Rick Roderick asserts that our postmodern culture is getting perilously close to Nietzsche's nightmare of nihilism (a society that exists in a moral and aesthetic vacuum and whose citizens believe in nothing) through the agents of mass communication and mindless materialism. (3) In a world where many of us get our personal philosophy from Nike ads and Howard Stern and Jerry Springer have considerable commercial success, nihilism is almost here. This is not a slam on all popular culture, but even jazz great Wynton Marsalis sees our culture sliding into nihilism when he considers the meaning of the more violent parts of rock and rap music. (4)

We hate to admit it, but at its core our society accepts that someone like Donald Trump is "worth more" than someone like Mother Theresa. As such, we have lost touch with the nonmaterialistic meaning of worth. The most alarming part is that, as a society, we don't even understand this is happening to us. Worse, these same conditions affect us in our professional lives. The nihilism that has captured our social institutions has hold of American medicine as well. We feel helpless in its relentless grasp; and, yet. we must hold on to something.

What fills this postmodern vacuum in our personal and professional lives? One answer comes from the world of business:

* The defining fact of American life in the 1990s is its complete reorganization around the needs of the corporation. (5)

* Corporations are the dominant institutions of our time, exercising the sort of power wielded by the church during the Middle Ages or the nation-state in more recent times....

* (The corporation is) a superhuman creature of the law, superior to you and me, because it has civil rights without any civil responsibilities. It is legally obligated to be selfish; it cannot be thrown into jail; it can deduct from its tax bill any fines it gets for wrong doing: and it can live forever. (6)

Corporations have become the dominant entity in American medicine as well. Large hospital chains, physician practice management organizations, pharmaceutical manufacturers, etc--the list of corporate medical giants is long, and the power of these corporations is incredible. It really does not matter if they are investor-owned or not-for-profit, the effect of these giants on the practice of medicine in our country has been profound, and that influence is growing.

Absent any government interference at all, corporations have radically changed the face of American medicine in less than a generation. This impact has not gone unnoticed; consider these two recent quotes:

What irony For years the companies that financed "Harry and Louise" ads have flapped their arms wildly to scare us about that old bugaboo, "socialized" medicine, while they blindsided us with something even harsher: Corporatized medicine, a new form of "care" in which the Hippocratic Oath has been displaced by a bottom-line ethos. (6)

It is 1998, and patients feel powerless and betrayed by providers. Physicians are frustrated with a loss of control and the nagging temptation to make treatment decisions based on cost. HMOs are admitting they can't confidently predict medical costs or keep up with the doctor bills. Well, what is it they manage? (7)

Bottom line concerns and little else drive our corporate, postmodern world, including the realm of medicine. (8) Quarterly profits and stock price appreciation dominate the psyches of executives in investor-owned corporations. Yet, the pervasive materialism of our postmodern condition leaves us with no philosophical or moral underpinning to buoy us through life's difficulties. "Postmodernism isn't a philosophy. It's at best a holding pattern, perhaps a cry of despair." (2) We hear this cry of despair from physicians all over the United States.

The angst that generally afflicts American physicians today was clearly articulated by an anonymous doctor who recently wrote to "Dear Abby," defending doctors who do not listen to their patients anymore:

Managed care, which is what the majority of doctors work under, means a lot of managing and very little care. I don't even dare to ask patients how they are anymore-for fear they will really tell me. Under managed care I'm given no time to listen to their answer anyway.

I doubt you heard from many doctors on this issue because most are too busy trying to keep their miserable lives afloat. I pity those carrying big mortgages and supporting kids in college, because they probably can't afford to leave these "factory jobs" behind. I, myself; plan to eventually change careers.

Abby, the medical profession is falling apart in this country It's a tragedy.

A Doctor, Telling It Like It Is (9)

This one physician's lament becomes a collective roar in the doctors' lounge at the hospital, in clinics, and in the hallways at medical meetings. Yet, who, if anyone, is effectively addressing the problem? In considering the plight of today's physicians, Pfifferling notes, "The massive literature on burnout and health care professional stress and impairment indicates either pandemic denial or short-sighted dehumanization." (10) Doctors are falling into a funk of self-pity and anger against managed care because "the system" won't let them practice good medicine anymore. But is this really the case? Are we now victims of a situation in which we have no choices? Are we really living out "a tragedy?" Let us turn to Viktor Frankl's life and work for some comparison.

Viktor Frankl

Viktor Frankl was a Jewish psychiatrist who had the misfortune of living in Vienna during the Nazi take-over of Austria. He lost everything: The Nazis murdered his wife and parents and confiscated all his belongings. Frankl was shipped to Auschwitz, where he endured an unspeakably horrible existence doing slave labor until the American Army liberated the death-camp in 1945. Frankl wrote of his experience in Man's Search for Meaning, which was first published as From Death-Camp to Existentialism in 1946. This is the best known of Frankl's many books and has sold more than nine million copies in 23 languages since its original publication. (1) The interested reader should start with this book for a further understanding of Franki and logotherapy.

One of the most amazing aspects of Frankl's story is that he tells it with no anger or self-pity. Horrible things were done to him, but he found no excuse to become bitter or defeated. Indeed, one of Frankl's greatest insights was that only those Auschwitz inmates who were able to find some existential meaning in their lives--even in a death-camp--survived. He wrote about what the Auschwitz survivors learned:

What was really needed was a fundamental change in our attitude toward life. We had to learn ourselves and, furthermore, we had to teach the despafring men, that it did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead to think of ourselves as those who were being questioned by life- daily and hourly Our answer must consist, not in talk and meditation, but in right action and in right conduct. Life ultimately means taking die responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual. (11) (*Bold highlights the author's emphasis).

Compare Frankl's attitude to the doctor who wrote to "Dear Abby" and we begin to understand the lamentable state of American medicine today. On one hand, the "Dear Abby" correspondent is correct: The medical profession is falling apart In this country and it is a tragedy. But he is wrong when he contends that doctors have no choices anymore. He is wrong when he blames outside forces--managed care, HMOs, or what have you--for the condition of our profession. "A Doctor" accurately distills the essence of our professional crisis. Yet, his sense of helplessness is not just exaggerated; It is pathetic.

Let us face the ugly truth: If American medicine is falling apart, we physicians have no one to blame but ourselves. We must be brave enough and honest enough to face this disquieting fact. It is far easier to blame others than to accept responsibility ourselves. The solution to medicine's plight will not come from more laws or restrictions on HMOs: it will be a moral and spiritual awakening among physicians from all modes of practice. This is not a call for a return to the "good old days" of unrestricted, fee-for-service medicine as much as it is an acknowledgment of the power physicians still have, if we choose to wield It. When we compare our current situation to Frankl's, we can only feel ashamed about our dispirited surrender, let alone the dishonesty to cast the blame elsewhere.

In an excellent article recently published in this journal, (The Physician Executive, volume 24, issue # 1), William C. Mohlenbrock, MD, asserts: "Now is the time for physicians to reestablish their legitimate right to make clinical decisions by eliminating the intrusive utilization management techniques of managed care 12 Mohlenbrock is on the right track here. He goes on to say, "Physicians are the only constituency capable of creating this revolution." But what will spark such a revolution? Whining and selfpity? Of course not. The industrialization of medicine and our own personal bottom line concerns have conspired to undermine our moral authority. We can't help ourselves or our patients unless we recognize the situation for what It is and reverse these trends at all possible cost. Medicine needs something to grasp, something to re-center our professional lives.

Existentialism and logotherapy

As a philosophical movement, existentialism pretty much died in 1980 along with its last proponent, Jean-Paul Sartre. Yet, American medicine needs the lessons of existentialism to rescue itself from its quagmire of self-pity and despair. Professor Robert Solomon summarizes existentialism as having three tenets:

1. Each of us has a very important role to play in life.

2. Each of us is responsible for his or her actions.

3. Each of us does, in a way, control his or her own destiny--whatever other influences or forces may be involved.

Thus, existentialism calls us to live passionately, live responsibly, and live in such a way as to feel positive about life, rather than in despair. (13)

Logotherapy applies the tenets of existentialism to help individuals discover meaning in their lives. Frankl said, "Logotherapy focuses rather on the future, that is to say, on the assignments and meanings to be fulfilled by the patient in his future."" He speaks of a will to meaning in contrast to Freud's will to pleasure or Alder's (and Nietzsche's) will to power.

This is the essence of logotherapy: Finding or creating our own meaning of life even in tough situations. We must find a meaning for our existence that has sustaining importance. Ultimately, postmodern materialism will not fill the bill. Frankl neatly summarized his philosophy as "Get to work!"' He would tell us that our work is not merely being "productive" in the hospital or clinic, but, rather, reestablishing a moral and spiritual dimension to our profession that brings us the satisfaction of lasting value. If Viktor Frankl could find meaning in Auschwitz, can we not reclaim control of our professional lives today? The answer is: We can, but we must want to do this more than anything else. And there's the rub.

When a physician insists that under managed care he or she does not have time to talk with patients anymore, this is a choice regarding personal practice style. That doctor chooses to put personal needs ahead of patient needs. A doctor can chose to see fewer patients, do better work, and make less money or work longer hours. We can work to connect with our patients in such a way that we become their advocates and make a highly confusing health care "system" function properly for them.

In fact, many physicians do just that, regardless of whether payment is by fee-for-service or capitation--or even when there is no payment at all. But the social environment of today's medicine does not nurture or encourage such choices. Doctors who choose to emphasize patient needs over personal rewards often feel ashamed of themselves because they have fewer "bragging rights" in the doctors' lounge when the discussion turns to luxury cars, fabulous vacations, college tuition, and the like. So does postmodernism make cowards of us all.

Change starts at the top

If the moral and philosophical environment of medicine has any chance of improvement, that change must start at the top. There is much sadness in acknowledging this; one could only wish that a renaissance of moral strength and commitment to the primacy of patient needs would be a grass roots phenomenon of our profession, but such does not seem to be the case. Thus, physician leaders--in medical groups, organized medicine, and, perhaps, even in investor-owned, for-profit HMOs--must lead us out of our postmodern wilderness.

One could rightly ask: If physician leaders won't or can't lead such a change, what other, better purpose will they serve? If physicians with MBA degrees are going to be beholden to the bottom line above all else, they become identical to all other corporate business people. In such a case, the rest of us in medicine are no better off having physician executives in the board room than we are without them. We expect something more from physician executives; we expect them to promote the core values of medicine. They must advocate for patients first and foremost, and for all other physicians and the profession of medicine as well.

Patient care comes first; This has been American medicine's traditional core of meaning in the past. Dedication to patient care has been the true center of greatness for American medicine in this century. The primacy of patient needs must be reestablished as the preeminent value of our profession. Almost all physicians will give lip service to this ideal, but our actions tell another story. Both our patients and the HMOs know that too many doctors do not put patient needs ahead of personal desires today. Our patients resent it, and the HMOs use it against us. When "A Doctor" complains to "Dear Abby" that he can't listen to patients anymore and it is not his fault--he is wrong. He has made his choice. Nobody put a gun to his head.

An ancillary problem is physicians' sense of entitlement--the idea that the world owes us a living, and a very good one at that, simply because we are hard working physicians. This attitude has got to go. Viktor Frankl was undoubtedly entitled to better than he got from the Nazis. Yet, let us read his words again: "It did not really matter what we expected from life, but rather what life expected from us." When was the last time any of us has heard this sort of notion expressed in the doctors' lounge? Who among us would even dare to speak such idealistic rhetoric? Meanwhile, more and more physicians are suffering from burnout (14) as they lose touch with the humanism and joy of service that has always made medicine the best of professions. Perhaps idealism is not so nonsensical after all.

The impact of postmodern angst goes far beyond materialism and defeatism among physicians. Physician leaders must feel growing concern as their most experienced doctors are giving up and dropping out. Syndicated columnist, Charles Krauthammer, sounds the alarm to the general reader about physicians leaving practice at the height of their careers because they don't enjoy medicine any more: "Declining income. Lost independence. Confiscatory malpractice insurance. Put them together and you've got pediatricians and surgeons and orthopedists who have had enough." (15) Krauthammer makes a compelling case for changing the direction that medicine is going, but he doesn't tell us how this should be done. Stanford medical student, Jeffery Towson, muses, "While I question whether it was such a golden age, I am beginning to understand the longing, if not for fee-for-service, then for a system where I can focus on care and not money." (16)

A better vision for medicine

The existential cure for what ails American medicine today can be summarized in four phrases:

1. Patient care comes first.

2. Right action and right conduct.

3. Focus on care and not money.

4. Discover what life expects of us.

Both experienced physicians and medical students long for a return to a world where these ideals would be the center of our profession once again. Do we have physician leaders with the moral backbone and philosophical insight to move us in this direction? Can such a movement stand up to the rapacious needs of a bottom line driven, investor-owned medical marketplace? Perhaps it cannot. In his recent PBS special, "Surviving the Bottom Line," Hedrick Smith documented how industries such as manufacturing and banking are sacrificing their employees and the needs of their customers in the quest for stock price appreciation and bigger dividends. (8) In such a world, how can medicine have a chance?

Some cause for hope exists, Medicine is different from most other businesses in that its most highly trained "workers" are not in the board room and the executive suite (with the exception of physician executives, of course), but rather on the front lines of service. This difference creates a situation in which medical leaders can appeal to the humanistic side of physicians and challenge them to take Frankl's existential step of accepting choice and rejecting excuses. Physician leaders could push us to recapture the dedication to putting patient care first, come what may. In doing so, these leaders and executives would really make a change for the better in how medicine is experienced by its customers (our patients) and its practitioners (ourselves.)

Logotherapy for American medicine

Let us consider two different situations in which physician leaders have the opportunity to apply Frankl's lessons of logotherapy in their daily lives. For this discussion, we will consider two different groups: (1) Physician leaders in close contact with practicing physicians (medical directors of clinics, VPMAs of hospitals, etc.): and (2) physician executives isolated from practicing physicians by their daily tasks (medical directors in large HMOs or very large corporate systems, etc.) This is admittedly an artificial separation, but these two settings can define two different ways that physician leaders can become logotherapists.

A medical director of a clinic or hospital would have to be truly out of touch from the physicians on his or her medical staff not to be concerned about escalating anger and demoralization among the troops." Just exhorting physicians to put patients first will not change anything. The physician leader must live a professional life in which patient needs are always paramount. The physician leader must hold all organizational decisions to the test of what is best for the patient while supporting the professionalism of physicians. One has to do more than "talk the talk." One has to lead by example. How this plays out in each individual situation will be different, but it starts with developing an unassailable moral center in the physician leader.

Just as a psychiatrist must undergo psychotherapy to develop personal insight, so must a physician leader develop inner moral fortitude and will before trying to lead others in the direction logotherapy would take us. Frankl can serve as a role model for courage and resilience in the face of daunting troubles. When we compare our problems with Franki's, we start to realize how manageable our current conditions are. Nevertheless, it takes courage and conviction to put patient needs ahead of personal desires. The payoff can be recapturing the "joy of medicine" and professional pride for all involved.

The more isolated physician executive lives and works in a world that is quite remote from the culture of medicine. Unlike a clinic director, the physician executive must maintain his or her commitment to the highest ideals of medicine in an environment that is often antithetical to those ideals. The physician executive needs a special form of courage to stand up in favor of patient care needs above corporate needs. As Hedrick Smith detailed so well, even those corporations that try to develop a long-term strategy based on better service face many problems. Large shareholders, such as aggressive mutual fund managers, often will not allow anything to interfere with short-term profit considerations. (8)

Investor-owned corporations have a legal duty to put shareholder considerations ahead of everything else. Even a very enlightened corporation would have to justify improving patient care as being ultimately in the best interests of its shareholders. This can be difficult when patients' needs are very expensive. Such an organization would need to have a solid commitment to a long-term strategy and would have to be able to sell this vision to its shareholders. This calls for a lot more than just good public relations or a strong advertising campaign.

The physician executive is the only person in the board room able to articulate a vision of commitment to patient care from the traditional medical view point. If the physician executive is not completely committed to the core value of the primacy of patient care, the task will be impossible. In such a setting, the physician executive must become his or her own logotherapist.

Conclusion

In closing, this article challenges physician leaders and executives in every situation. Are you willing to be logotherapists for a profession in need? Rank-and-file physicians are demoralized and dejected. Medicine must recapture the joy of practice and the love of patient care. We must somehow rediscover Franki's will to meaning in our lives and in our profession. The power and economic might of huge medical corporations seem invincible as we watch our professional standards sacrificed in the name of shareholder equity.

Yet, our patients want what we crave: A return to those values and attitudes that made American medicine great. Physicians need and want leaders who will work to restore what we are losing little by little, day after day. We front line physicians must learn once more that we have the freedom to act in our patients' best interests regardless of anything else. We still have the choice to do right by our patients and our profession. You, the leaders in the business side of medicine, must teach us this lesson.

References

(1.) Scully, Matthew, "Viktor Franld at Ninety: An Interview." First Things, 52 (April 1995), pp. 39-43

(2.) Solomon. R and Higgins. K., A Short History of Philosophy, Oxford University Press, 1996, pp. 299-304.

(3.) Roderick. Rick, "Nietzsche and the Post-Modern Condition," (recorded lecture series). The Teaching Company.

(4.) Marsalis, Wynton, "Talking With David Frost," PBS, Feb. 27, 1998.

(5.) Frank. Thomas. "Let Them Eat Lifestyle," Utne Reader, 84. (Nov.-Dec. 1997). pp. 44-47.

(6.) Hightower, Jim, "Chomp," Utne Reader. 86. (Mar-Apr. 1998). pp. 57-61. 104.

(7.) "Private sector has stumbled on promises for self-healing," Modern Healthcare, 28. 9. (March 2, 1998), pp. 52.

(8.) Smith, Hedrlck. "Surviving the Bottom Line." Frontline, PBS. January 16. 1998.

(9.) Dear Abby column. The Sacramento Bee, Feb. 6. 1998. Scene, pp. 2.

(10.) Pfifferling, John-Henry, "Provider Satisfaction = Patient Satisfaction," Group Practice Journal, 47, 2 (Feb. 1998). pp. 13-20.

(11.) Frankl, Viktor. Man's Search For Meaning, Beacon Press. 1962, pp. 77 and 98-99.

(l2.) Mohlenbrock. William. "Part 1: Physicians Reestablishing Clinical Autonomy." The Physician Executive, 24 (Jan.-Feb. 1998). pp. 26-29.

(13.) Solomon. Robert, "No Excuses: Existentialism and the Meaning of Life," (recorded lecture series). The Teaching Company.

(14.) Olden. Megan. "Physician Burnout--Stemming the Epidemic Among Us," California Physician, 14, 9 (Sept. 1997), pp. 26-31.

(15.) Krauthammer. Charles, "Cost-conscious medicine isn't what some doctors bargained on," The Sacramento Bee. Jan. 13, 1998, pp. B7.

(16.) Towson, Jeffery, "Becoming a physician in a managed care age," California Physician, Jan. 1998. pp. 14.

Earl R. Washburn, MD, FAAP, is an Administrative Physician at El Dorado Pediatric Medical Group, Inc., in Placervile, California. He can be reached by calling 530/626-1144, via fax at 530/626-3335, and via email at [e-mail].