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Support and trust among colleagues within an organization is a key component of professional well-being. In clinical medicine, this support and trust is most crucial during times of significant stress, such as being involved in a medical error, the target of patient aggression, or being named in a lawsuit. In response to such adverse events, organizations must move away from a culture of shame and blame to one of support.
Peer support is an essential component of this cultural change. It represents an organizational shift:
Away from a culture of silence towards one of sharing and acceptance
Away from a culture of expected perfectionism towards an acceptance of our human fallibility
Away from a culture of shame and blame and towards a culture of psychological safety where we can learn from our errors
Formal peer support, where non-mental health clinicians offer support to their colleagues after adverse events or other professionally stressful circumstances, is fundamentally different from informal peer support.
Informal peer support, where a colleague inquires how a peer is doing after an adverse event, can sometimes be helpful but can also be insufficient or occasionally even counterproductive. Oftentimes colleagues feel helpless and unsure of what to say in these situations. They may try to minimize the emotions of their peers with comments such as, “You really shouldn't feel that way,” or, “Why are you so upset? This is part of our job.”1
Furthermore, physicians are trained to “fix” patients' problems. Many are less comfortable in situations where they have to sit with others' pain. With peer support, it is important to learn to accept that physicians cannot “fix” their peers' pain. For this reason, peer support training is necessary in order to train physicians to offer support in a way that most are not accustomed to doing. Formal peer support programs provide such enhanced peer support to our colleagues in times of need.
The following 5 STEPS are the building blocks of a peer support program.2
Make the Case to Leadership that Peer Support Is Essential
Decide Which Health Care Team Members Your Program Will Serve
Form a Peer Support Team with Strong Communication Skills
Train Peer Supporters and Launch the Program
Activate Peer Support Interventions and Provide Additional Resources
While the importance of promoting physician well-being and preventing burnout is generally agreed upon, organizational leadership may need to be convinced that there are substantial benefits to developing a program specifically aimed at fostering peer support amongst physicians and other clinicians. This case can be made by showing leaders the data regarding negative outcomes experienced by many physicians after adverse events. Some of these outcomes include:3- 5
Increased physician burnout
Increased medical errors
Decreased quality of patient care
Increased risk of depression, substance abuse, and suicide
Studies have shown that in such times, most physicians prefer to receive support from colleagues rather than mental health practitioners, and talking with colleagues after medical errors has been shown to positively correlate with physician resilience.6,7 While some may also wish to seek professional mental health treatment, there may be cultural and sometimes structural barriers to receiving such services. Peer supporters can facilitate connections with mental health services by de-stigmatizing such services and facilitating access to them.
Use this PowerPoint presentation as a template for making the case to leadership to build a peer support program in your practice.
Depending on the organization's bandwidth and how the program will be resourced, you need to decide to whom the peer support interventions will be offered. Some organizations choose to offer the service to all members of the health care team, while others offer it only to physicians. Ideally, the program offers support to any team member. That said, many organizations are limited by funding and leadership support. They may decide, therefore, to begin by setting up the program to support only physicians and then expand the program to other health care team members as the institutional support allows.
To develop and sustain a peer support program, a peer support team must be formed. This involves selecting or appointing individuals to fill three essential roles: program director, program administrator, and peer supporter.
A program director should be appointed to oversee the peer supporter selection process and ultimately lead the peer support program with the help of an administrator. Like the peer supporters themselves, the program director should be a clinician who is well-respected professionally amongst his or her peers and has strong communication skills. Taking on the directorship of such a program may account for up to 10% to 20% of the person's full-time employment, so it is important to ensure the appointed director can dedicate this time before stepping into this role.
A program administrator should assist with logistics and provide administrative support to the clinician director.
Each peer supporter should be someone respected clinically and who has effective interpersonal skills. There should be as much diversity as possible in gender, race, age, and specialty within the peer supporter team. If the population you will serve includes other health care team members in addition to physicians, then having these care team members (eg, advanced practice providers, registered nurses) serve as peer supporters is important, as well.
Identifying Good Candidates for Peer Supporter Roles
While it may be tempting to have peer supporters self-nominate, all clinicians who believe they are qualified to become a peer supporter may not necessarily be a good fit for the program. Providing a description of the program and asking clinicians to nominate one or more colleagues to be trained as peer supporters may be more effective. A sample program description and a sample email request for peer supporter nominations are included below.
We've all had cases or circumstances that are challenging, sometimes because of difficult clinical situations and other times due to the accumulation of emotionally depleting events. Studies have shown that clinicians may initially want to get support from peers rather than mental health providers.
To create a culture of trust and collegiality, we are developing a peer support program for our [insert department/program/organization/clinic name here]. Colleagues trained as peer supporters will reach out to [insert whom your program will serve here, such as clinicians, care team members, physicians, advanced practice providers, etc.] involved in any critical event; they are also available at any time for [insert group served here, such as clinicians] to self-refer due to distress from any cause. This is not therapy. It is support from a peer who understands the pressures of navigating challenging circumstances and is trained with effective listening and responding skills to help others do the same. Peer supporters can also connect you with other organizational resources that may be helpful.
Email subject: Important: Please submit your nominations for peer supporters by [insert date]
We need to support each other in this challenging work we do. Our organization is creating a peer support program to help you weather difficult clinical circumstances. A description of our program can be found below. It is crucial that we train a diverse peer support team of apt communicators and listeners so that you have access to peers with whom you would be comfortable speaking. We ask that you share the names of up to 3 clinician colleagues from [insert department/program/organization/clinic name here] whom you recommend for peer support training. Please also let us know what qualities you feel these clinicians have that lead you to nominate them.
Please send your CONFIDENTIAL nominations to [insert email address] by [insert date].
Thank you for your participation,
[insert your signature]
Use this document as a model for drafting your own peer support program description and email request for peer supporter nominations.
How many peer supporters are needed?
How many peer supporters your program needs depends on the number of clinicians in the organization who might potentially be offered peer support. As a rough guide, in an organization with approximately 3000 physicians, one peer support program was well-served by approximately 30-40 peer supporters. There should be a large enough group so that each supporter is involved in approximately 5 peer support interventions per year.
Should peer supporters be paid?
While financial incentives can be helpful, this model of peer support does not depend on paying clinicians to support their peers. Peer support interventions can be quite rewarding for the supporters, as the peers typically express gratitude for the support and the time spent with the peer supporter. This model is also supported by the studies on behavioral economics: paying people for something they would do out of the goodness of their hearts can actually decrease their enjoyment of and inclination to do the generous act.8,9 The time commitment for peer supporters should not be excessive: after the training, they would be asked to provide support about 5 times each year, with each intervention being about 1 hour.
Quiz Ref IDPeer support training involves using empathetic listening, question-asking, and some sharing of personal experiences. Because peer support may be countercultural to your organization and challenging to some participants, the training should be done in a private setting, whether remotely or face-to-face. The videos in references 10-14 can be used to provide guidance on the process.10- 14
Regular peer supporter meetings provide an excellent opportunity for ongoing training. Quarterly meetings with food and drink should be held to give the supporters an opportunity to spend time together and support one another. If they choose, they can also practice peer support role plays during these meetings. An example of such an exercise would be:
Work in dyads
Person A plays role of peer supporter
Person B plays role of peer (colleague) who has already agreed to having peer support.
Person A opens up the conversation and then the conversation continues for 15 minutes
Then switch roles and scenarios
Implement a Referral and Outreach Program for Peer Support
Quiz Ref IDPeer support can be preventive, so it is important that peer support is offered early in the process of an adverse event. There is data to suggest that simply having peer supporters available may not be sufficient due to the barriers some clinicians feel in seeking help after adverse events.6 Thus, peer support should be actively offered after an adverse event or challenging circumstance rather than simply passively available. Your institution likely already has a process for reporting adverse events. Those who receive reports will be the primary referral source to trigger peer support outreach. It is critical that all those to whom events might be reported (eg, clinical leaders, patient safety leaders, risk management and legal) are on board with the peer support program so that everyone your program serves receives the active outreach from a peer supporter when they may need it.
For example, a process could work as follows:
An adverse event is reported to the appropriate person according to preexisting organizational protocol. This person then contacts the peer support program director by phone or email to refer all involved clinicians for peer support.
The peer support program director assigns a peer supporter to each involved clinician, considering specialty (trying to match the specialty of the peer supporter to the peer), rank (aligning the peer with a peer supporter who is of similar or higher rank), and the nature of the adverse event (eg, if the event is an interventional adverse event, trying to assign a peer supporter who is also an interventionalist). The director then emails each selected peer supporter with the name and contact information of the referred peer and a one-sentence description of the event.
The peer supporter reaches out to the peer with a brief message requesting a phone call at the peer's convenience (eg, “I'm reaching out as a peer supporter. Please give me a call on my cell when you have a moment”).
The peer calls the peer supporter, who then briefly explains the program and asks if the peer would like to speak with them as a colleague.
If the peer declines support, this should not be construed as a failure of the peer supporter or the program. The supporter's outreach to the peer is an intervention in and of itself. The peer supporter should ask if they can send the peer a list of further resources and invite the peer to contact them at any time in the future if the peer would like support.
Publicize Your Program
Once the program is established and peer supporters are trained, the program should be publicized so that, in the face of emotional stressors, clinicians will be more inclined to self-refer or refer peers for support, and peers who are offered support will be more inclined to accept. Examples of venues where the program can be promoted include:
Quality and safety conferences
Medical staff meetings
Clinical practice meetings
In addition, the program can be hard-wired into routine clinical processes such as on-line safety reporting, where there can be an option to click to receive outreach from a peer supporter. Peers can be given contact information for peer support during event analysis (eg, root cause analysis, peer review, risk management, or morbidity and mortality conferences).
It is important that peer supporters are recognized publicly within their clinical community. Once your program has taken off, consider initiating an event to celebrate peer supporters. Such an event will naturally promote awareness of the peer support program, as well.
Could physicians seek support on their own instead of actively reaching out to them?
Current experience and data suggest that physicians may not ask for help on their own.6 The most effective way of providing peer support is via a “push” strategy; a “pull” strategy to require reaching out for help puts an extra and unrealistic burden on physicians.
Is the peer support intervention protected in connection with litigation?
This depends on the state. In Massachusetts and many other states, the peer support is not peer-review protected (ie, it is discoverable). The reason that many organizations choose to provide peer support despite its lack of protection is that:
The risk of not providing such support can be sizeable. There is a plethora of data showing the serious negative impact on both clinicians and ultimately patients and families when clinicians are unsupported.
The risk of having peer support used against the peer in legal proceedings, in jurisdictions where no legal protection exists, can be mitigated by having the peer supporter not take any notes. In addition, medical liability cases are likely to focus on the appropriateness of the physician's diagnosis and treatment, in the clinical opinion of the defendant's colleagues, rather than emotional aspects that may not be relevant to the diagnosis or treatment. Physicians who have concerns about potential liability should seek the advice of a lawyer.
A typical intervention session will include the following topics of discussion:
Adapted from written communication with J. Shapiro, MD, FACS (March 2020)
What, if anything, is bothering you or worrying you about this event?
Is there anyone at work you trust to help you sort out these concerns? Who (eg, section chief, risk management)?
What are your coping strategies for stressful times? (Note to person facilitating the intervention: mention not to use alcohol or benzodiazepines as coping mechanisms)
Who is in your support network at home? At work? Have you shared with them?
Are you ruminating about the event? If yes, what aspects of the event and how often do you find yourself ruminating?
Are you experiencing any issues with:
Thoughts of self-harm?
Do you need or want time off from work?
What else are you are thinking about that we didn't discuss?
May I send you information about coping strategies and other resources?
May I check in with you by email in about a week?
This document addresses typical topics of discussion covered during a peer support session in question format.
Peer support interventions are typically offered just once or twice to a peer for a given event. Some peers will want or need further assistance. Formal peer support can normalize and facilitate access to other resources. The peer supporter might say, “Many times these emotions slowly fade away, but on occasion they get under our skin and we don't recover as quickly or thoroughly as we'd like. If you find that's the case for you, we have many resources available to support you. Please have a low threshold for letting me know if you'd like me to facilitate connection with any of these resources. In addition, I'll send you an information sheet with some contact information so you can also reach out on your own.”
Without this facilitation, peers may be reluctant to seek further help due to stigma and cultural expectations of being “strong” and unaffected.
Examples of other resources a peer supporter could recommend or help facilitate include:
Mental health counseling
Stress reduction resources, such as cognitive behavioral therapy or mindfulness meditation
Disclosure and apology coaching15
Administrative and leadership assistance in scheduling time off from work
In the course of our professional careers, each one of us is likely to experience events that are emotionally stressful. In the aftermath of such events, physicians most want to be supported by their peers. An institutionally organized peer support program provides a way to reach out to our colleagues in order to guide them through the process of recovery from such stressors.
Institutional peer support programs are needed to mitigate the emotional impact of emotionally stressful events on clinicians
Few resources are required for program development and sustainability
Key components of the program include champion leader(s) and training of peer supporters
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