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“Peer support” is one of those phrases we think we understand until we encounter it in a very specific context. In this ASA Member Spotlight, Julie Crichton, MD, outlines the key principles of Peer Support as it relates to the practice of medicine and shares what physicians can do to help lighten each other’s load.

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What is Peer Support? What are its key principles?

Peer Support is a program built by trained volunteer physicians to support their peer physicians in a time of crisis, adverse outcome/litigation, or through a variety of other negative stressors. The key principles are the acronym CLAP: Connecting, Listening confidentially, Acknowledging and normalizing struggles and emotions, and Partnering with their peers on an action plan in order to use coping strategies, reframing techniques, and resources available to them. Peer supporters prevent isolation and create a space for people to feel comfortable, encouraged and not judged while they process their situation. Peer supporters are available at a moment's notice.

What is it not?

It’s not legally protected conversation. It’s not counseling, advice or fixes.

What could it evolve into?

Peer Support could become a routine proactive “check in” on every physician by every leader, providing a support system. This program could also be integrated into already established de-briefing, performance and quality metric systems like a Well Being Index, the 22 question Maslach Burnout Inventory Human Services Survey or a simple two question survey about whether or not the physician feels supported in his/her work environment and what could we do to increase his/her feeling of support. Peer Support could also lead to peer to peer on boarding, mentorship and coaching.

If we track physician well-being or survey scores over time, perhaps we could find more ways to enhance physician well-being and assess how and if system advances are helping.

Enhanced physician well-being could reduce medical errors, reduce physician burnout/ depression/suicides, improve overall patient care, patient safety and patient satisfaction.

Why is Peer Support important to you and in general?

Even in college, I was interested in psychology; what motivates people and what makes people tick. My chairman, the late (great) John Tinker, MD, at the University of Iowa once told me, “people only do things for three reasons; money, power or sex.”

I reframed that to mean most people need some substantial reward to do anything. Although there are many intrinsic and extrinsic motivators, overall people do need to feel valued, loved and rewarded. During this current time of COVID, we have had many of my anesthesia partners leave our practice, many nurses leave their posts, and we have over 1200 open positions in our hospital system. I fear that the reason for this is that people don’t feel supported or rewarded.

To talk about Peer Support, we should back up and briefly discuss a few of the problems entrenched in the culture of medicine:  the “God” complex, the “just do it yourself and be stronger” cowboy mentality, and applauding sleep-deprived physicians working post-call. All of these historical beliefs and behaviors led to the lack of self-care and lack of recognition of our own physical, mental and emotional needs. These issues only became intensified during the COVID pandemic. Even the airlines recognize you have to put your own oxygen mask on first in order to help others. We encourage others to live healthy lives -- get a good night's rest, daily exercise and excellent nutrition-- yet more often than not, we aren’t able to prioritize healthy behaviors or even recognize unhealthy triggers or symptoms in ourselves due to lack of self-awareness and increasing demands and expectations of our careers.

How can we beat physician burnout?

In the May 2021 issue of Anesthesiology, the cover article was “Burnout Among Anesthesiologists in the United States” and included the editorial “Burnout: The “Other” Pandemic.” Before COVID, many of us already felt like we were on a hamster wheel, with perpetual stress both at work and at home with more being asked from us and less support and financial compensation given to us in return. During the past 18 months, the COVID pandemic has shed a light on the inadequacies of our public health system, our workforce and resources, payment models and income avenues when elective procedures were halted, and evolving or even contradictory recommendations, guidelines and misinformation emerging across the world. These are all system or organizational problems, not individual problems creating stress on physicians. Physician’s stress levels have increased dramatically across the board with the addition of the COVID pandemic and has intertwined overwork issues with emotional elements such as grief, helplessness, anger, fear and isolation.

Tait Shanafelt, MD, the chief wellness officer for Stanford Medicine explains in the May 26, 2021 article, Organizations must lead in boosting well-being, reducing burnout among physicians,  “ A lack of personal resilience is not the reason for higher burnout among physicians… Incoming medical students have less burnout, lower rates of depression, and better quality of life than college students entering other fields, and practicing physicians have higher resilience scores than the general population…To address physician burnout, 80% of the change must come from organizations, with the remaining 20% coming from physicians.”

For organizations, Shanafelt discussed the Stanford WellMD Model of Professional Fulfillment, where organizations combine practice efficiency and a culture of wellness with the personal resilience of physicians to create better professional fulfillment. A culture of wellness and compassion includes leadership, team building by aligning the organization’s values with those of its employees, giving employees a voice, and creating a sense of community and collegiality. In practice efficiency, organizations should focus on such things as optimizing user-friendly electronic health records, instituting flexible scheduling, creating intuitive documentation, and employing team-based care with appropriate staffing.

We all hope for the ideal Goldilocks “just right” temperature of stress or workload. Reflect on the Starling curve or the Buddhist teaching: “A person has to be tuned like the string of an instrument: If it is too taut, it will snap. If it is too slack, it will not play.”

Each one of us will need repeated fine tuning to find our ideal tension and strength throughout our careers within our systems and during the dynamic ups and downs that life brings. With the help of compassionate proactive leadership and system changes, our organizations will also be fine-tuned, and adapt to these changing times, moving us closer to a more productive, safe, engaged, enjoyable, sustainable workforce with better financial and personal rewards and motivators.

What can leaders do to help with peer support and well-being, and to prevent burnout?

Leaders can start asking questions of their workforce (Example: What support do you need? How can we make this better? What are you missing in your daily routine?) or utilizing a good old fashion anonymous suggestion box to act and drive improvements. Leaders can provide resources and funding for distressed individuals to promote an overall culture of physician wellness. Leaders can make peer support a priority, send surveys with follow up results, make peer support training available, establish a formal Peer Support program and ensure that people feel valued and compensated. Leaders can also hire, train and retain leaders that lead by example, show gratitude in every email or correspondence, speak up and praise physicians for contributing to solutions to change burn out to burn bright.

Clinician well-being can also be fostered through helpful workplace onboarding, practice resources, clinical updates, mentorship programs, introductions to allies and promoting women in leadership. Leaders should promote gender equity and promote female leaders as female leaders tend to be transparent, seek feedback, foster belonging and inclusion and can provide mentoring opportunities for other women physicians who are more likely to experience burnout. Overall women physicians are at an increased risk for burnout and are 2.27x more likely to commit suicide than their male colleagues.

(Dr. Lorna Breen died by suicide in 2020. Please urge your lawmakers to pass the Dr. Lorna Breen Provider Protection Act, which aims to reduce and prevent burnout, behavioral disorders and suicide among healthcare professionals and urges governments and health systems to prioritize clinician well-being through education and awareness campaigns, grants and a comprehensive study of our health: https://drlornabreen.org/all-in/.)

Even among trainees, women physicians are more likely than men to report being burned out and dissatisfied with work. Women's place in the workforce has been even more disrupted by the pandemic with school closings and childcare needs soaring, highlighting the fact that we must all work together to face these great challenges.

Is it reasonable to rely on personal resilience and peers/friends to combat work related stress? How can we build up our personal resilience?

No, it’s not reasonable to ask physicians to travel this road alone. There is an abundance of literature showing the combination of personal and organizational responsibility and change needed. High risk groups tend to be younger, marginalized (LGBTQ), women and minorities due to the increased risk of lack of social support and isolation.

After tending to our personal wellness domains - emotional, psychological, social, contemplative and physical - we need to task our leaders and task our health care organizations to focus on better systems for higher quality care, improved efficiencies and enhanced teamwork.

As for building up personal resilience, be sure to foster your friendships, exercise, and take at least 5 minutes a day to reflect on something positive or enjoyable. Try a “news free” holiday by turning off your incoming media, or just switch to listening to the Calm app or The Happiness Lab podcast with Laurie Santos from Yale. Maybe volunteer to become a peer supporter at your institution!

Remember, the grass isn’t greener on the other side of the mountain, the grass is greener where you water it.

Julie Crichton MD, FASA practices anesthesia in a busy inpatient and outpatient setting in Scottsdale, AZ. She is a founding member and co-chair of the six-hospital-wide HonorHealth system Women Physician Leadership Council, bringing her multicultural background and over 20 years of clinical experience to the leadership team.

Holding numerous committee positions in anesthesia, education and collegiality over the years with Valley Anesthesia, now Envision Healthcare, Dr. Crichton is also president of the Scottsdale and Phoenix Women Physicians Group, a committee member on Diversity Equity and Inclusion and a member of the Arizona Chapter of the International Women’s Forum.

Additionally, Dr. Crichton is an active member of Innovation Care Partners Quality and Performance Committee, an HonorHealth Peer Support leader for caregivers experiencing burnout and exhaustion, and an Envision Wellness Champion.

To reach her please email: Julie.Crichton@EnvisionHealth.com