While preparing yet another talk about burnout, I had a brainstorm. I created a counterpoint PowerPoint (or tongue-in-cheek complementary model) to The Stanford Model of Professional Fulfillment. Perhaps it was a particularly irreverent or flippant stage of my own stuttering burnout. Maybe it was passive-aggressive pent-up frustration. Whatever it was, I came up with a “new and improved” model for physician burnout. I’ve gotten rather burned out on burnout. The literature keeps expanding with types of health care workers who are affected, proposed causes, etc. So, although I find the Stanford Model inarguable, I tongue-in-cheekily whipped up my own model – the F Model.
If you are not yet familiar with it, The Stanford Model has at its center, the positive desired end state (professional fulfillment). The focus on a positive aim rather than a negative state (burnout) is a welcome start. Another pivotal concept in the Stanford Model is the recognition of three dimensions supporting professional fulfillment. Rather than focus solely on individual resilience, the model names both “culture of wellness” and “efficiency of practice” as essential institutional drivers of professional fulfillment.
Early physician wellness literature focused exclusively on the physician. The Stanford Model made clear that institutional-level factors are also at play. Rather than ascribing burnout solely to a lack of individual resilience, the model acknowledges the importance of workplace factors. There has been a growing shift to recognizing burnout to be an occupational condition not an individual failure of resilience. The group at Stanford, as well as researchers at Mayo, have been instrumental in bringing this to awareness.
While providing a more complex framework for professional fulfillment, the Stanford Model doesn’t cover it all. So, I whipped up the F Model. See figure. I am no graphic artist. Nor did I pay one. I used the most basic PowerPoint template to draw a crude Venn diagram. I named the three spheres comprising the F Model: inevitable suffering, extra junk, and moral distress. Pretty self-explanatory.
The inevitable suffering is what we signed up for. To be with people in times of great need. We witness sadness and grief regularly. People die, receive difficult diagnoses, grapple with addiction, and struggle to manage chronic disease. We bear bad news, long hours, and vicarious traumatization. By choosing medicine as a calling, we knew these truths were in store. This is where support for individual resilience is vital. Beyond the basics – sleep and food, there are many paths to coping. Coaching, therapy, Balint groups, exercise, mindfulness, journaling, solitude, community – let me count the paths. All that’s required is to acknowledge our needs, to find our preferred way(s) to meet them, and the will to pursue them. This is not easy for a bunch of altruists. Wellness offices and chief wellness officers frequently start here. I did this as the wellness person at my institution. Subsidizing mindfulness classes, creating peer support programs, and offering coaching, time management talks, and small group experiences – were all gratifying and useful. But none addressed the two other spheres in the F or Alternate Model.
The “extra junk sphere” is getting more attention, thanks to thought leaders and researchers in the field. Endless inboxes, “pajama time,” and the EMR are among the factors being evaluated as contributors to burnout. The AMA has launched a Practice Transformation Initiative. Their Steps Forward Modules are full of toolkits and time-saving strategies, as well as descriptions of workflow process improvements.
The third sphere, that of moral distress is now receiving increased attention thanks in part to a book by Dr. Wendy Dean. Knowing that 41 percent of U.S. citizens carry some medical debt and 24 percent of them are considering bankruptcy to solve the issue, generates moral distress. Hearing about inequities in access to health care by race, gender, employment status, and income – more moral distress. These are two examples. There are innumerable day-to-day examples when doing the “right thing” is impossible.
The F Model is not intended to supplant or compete with the Stanford Model. It’s a gentle poke to broaden attention. The Stanford Model broadened the concept of burnout to include institution-level factors. I hope the F Model will further broaden the discussion beyond any single institution. Many elements of the health care ecosystem (payors, pharmaceutical companies, etc.) must also be part of the conversation.
Claudia Finkelstein is an internal medicine physician.
