Building the peer support physicians need

“In medicine we’ve been held to really unreasonable expectations of what it means to be a physician. Even the idea of ‘health care heroes’ during the pandemic, which came from wanting to honour providers, has actually had the reverse consequence – making health care providers feel they need to be superheroes.”– Dr. Jo Shapiro 

Dr. Jo Shapiro, surgeon, Harvard professor and founder of the US-based Center for Professionalism and Peer Support, is internationally recognized for her work in physician peer support. 

The program she helped create at Boston’s Brigham and Women’s Hospital pioneered the “reach in” approach, where trained peer supporters seek out medical professionals immediately after a serious medical error or other crisis events.  

In this episode, she talks with Dr. Caroline Gérin-Lajoie about the “reach in” approach, the “must-haves” for successful peer support programs and how she sees the COVID-19 pandemic affecting her colleagues and physician health programs in the long term. 

Want to learn more about physician wellness? Visit the CMA Physician Wellness Hubfor curated, clinically-based tools, resources, and research on all the topics covered in this podcast.

Transcript

Episode Five

Building the peer support physicians need
 
Dr. Caroline Gérin‑Lajoie:  Welcome to "Sound Mind," a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin‑Lajoie.

It should come as no surprise that during the pandemic, many health care professionals are turning to their colleagues for support. Research tells us that peer support is often the easiest support for physicians to access, but not all peer support is equal, and not everyone is comfortable seeking this type of help.

Dr. Jo Shapiro has spent more than a decade tackling these issues as the founder of the Center for Professionalism and Peer Support at Brigham and Women's Hospital in the US. The peer support program she helped create there has been the model for more than 25 similar programs worldwide.

Good morning, Dr. Shapiro and thank you so much for joining me today on this podcast.

Dr. Jo Shapiro:  Good morning, it's a pleasure to be here with you.

Dr. Gérin‑Lajoie:  Is it okay if I call you Jo?

Dr. Shapiro:  Please do.

Dr. Gérin‑Lajoie:  I've had the pleasure of seeing you present your work on peer support at several national conferences. Can you start today by explaining the peer support program that you founded?

Dr. Shapiro:  The peer support program that I and others founded, and I've really been working hard to help other organizations use, is based on data that we have that says, after stressors, certainly acute stressors, emotional stressors, physicians want to speak to a colleague. That's the core of why we call it peer support.

I believe that the reason for us wanting to speak to colleagues is the kinds of stressors that we experience, whether they're acute or chronic, in healthcare are really unique. It's so helpful to talk to someone who gets it, who's been there, who really understands the impact these events have on us emotionally and sometimes even physically.

Dr. Gérin‑Lajoie:  Your program initially focused on physicians' medical errors as the main trigger for peer support. Why was that an important focus?

Dr. Shapiro:  Well, as you know, it's certainly not the most common thing that we experience in our careers. But it is certainly something I believe we will all experience at one point or another. It's quite universal. There's a lot of published data about the negative emotional impact of errors on physicians and other health care providers.

We know that it's a time of, what I would say, is acute emotional trauma for us as healthcare providers. For that reason, we thought it's the most important time that we should be there for each other, because we have a lot of data showing what unsupported clinicians end up experiencing and that can be pretty devastating, including suicidal ideation and even actual suicide.

We know that having made a medical error is associated with both burnout and depression, independent predictors. We know that if you've made a medical error, you have a higher chance of becoming burnt out.

We also know that if you're burnt out, you have a higher chance of making medical errors, so that it can affect patient care, and then beyond that there's multiple, sometimes long‑lasting negative effects on job confidence and job satisfaction, relationship with colleagues, those sorts of things.

Because we know this is a particularly vulnerable moment for physicians, we felt it was important to start at least with that. Then, of course, as rapidly as possible broaden it to other reasons for peer support.

The other reason that I usually train for supporting after an error is because it's the hardest thing to do. The model for how you do peer support is the same regardless of what you're peer supporting for. The bones of it are the same, the framework, but doing it for errors is hardest, and the reason it's hardest is because it carries the most stigma. That having made a medical error carries the most stigma of pretty much anything that we do.

It requires a certain way of offering the support and being there during the support for the physician to be able to open up and be vulnerable and be able to benefit from this support.

Dr. Gérin‑Lajoie:  Can you give us a sense of the common emotions that physicians can feel after a medical error has occurred?

Dr. Shapiro:  I want to say before I do categorize some of them that it's always important when we're doing peer support to remember that we all experience even similar events in a different way. That said, we do know that there are very common emotions that people feel.

One of them is just feeling sad that someone suffering, the patient suffering.

Then I think very, very commonly we feel this deep sense of shame, and shame is where you go from saying, "I feel really bad about this," to "I feel bad about this and it happened because I'm not a good enough physician, resident, nurse practitioner, etc." You question your own worth. It's a very tough emotion to bear.

Another emotion, which, again, is almost universal is fear. We do have a fair amount to be realistically afraid of. For one thing, we're afraid of, what the patient and family will think. Will they lose their trust in us?

We're certainly afraid of what will our colleagues think. We tend to be judgemental, we jump to conclusions about other people's motivations and competence without necessarily understanding the full story.

We do worry that our colleagues will jump to conclusions about our worth, about our competence. There are some studies to support that that is a realistic fear. We also worry about what the internal processes will be, in terms of both investigating the event, and then what will the consequences be for us, personally and professionally.

Then there are external processes, which are things like litigation that tend to be extremely stressful for physicians, and we worry that we'll become ensnared in that.

We are, in medicine, moving away from shame and blame, which is how we have for decades handled adverse events. We have found that shame and blame is not just not effective, but it undermines patient safety because the goal should be, after something happens, let's make sure it doesn't happen to another patient.

Obviously, the immediate goals are taking care of that patient, but beyond that, it's our obligation to learn from the event and prevent its happening again.

When you use shame and blame, which I grew up with [laughs] as far as being trained, where my senior supervisors felt like that's what you're supposed to do, because we'll just make her a better surgeon, or we'll make him a better a generalist. Just make sure you know how bad that was, and don't do it again. We honestly thought that was good enough, and that would be effective. As it turns out, we have safety science showing us that shame and blame is very undermining of learning, growth and prevention of future safety lapses.

That said, our processes, both internal and external, sometimes contain remnants of or even full force of shame and blame, even though we say we've moved to a just culture or safety culture.

That's the context in which we're providing peer support, which is that people are worried about the shame and blame culture that we haven't been able to completely shed. Just because we've said we want to.

Dr. Gérin‑Lajoie:  Jo, what do you think prevents physicians from seeking peer support when they're going through difficult situations?

Dr. Shapiro:  I think there's a myriad of both structural and actual cultural barriers. Culture is a very powerful driver, for anybody. We are all part of a culture, whether it's a micro‑culture of a team, whether it's an organizational culture, whether it's the culture of medicine in general.

We have a culture that has taught us, and that continues to reinforce the idea that we are supposed to be strong, we signed up for this work. Being strong means denying our own needs. Being vulnerable means you're weak. We are taught, either explicitly or implicitly, that self‑care is selfish. The idea of being caring for ourselves, being compassionate towards ourselves, is anathema because of our culture.

I think also, in medicine, we've been held to, and hold ourselves to these unreasonable expectations of what it means to be a physician.

Even the idea of healthcare heroes which is came up in the pandemic, and has meant to be...It comes from a lovely place of wanting to honour all healthcare providers, who've just been amazing and stepped up to take care of very sick patients. It has had some reverse consequences, which is it's made the healthcare providers feel that we're supposed to be heroes in the sense of like superheroes, and therefore not subject to this workload impact, or emotional impact, that we're supposed to just tolerate this and be strong and strong, of course, means not feeling things.

Now, what I've just said, of course, I don't believe. I think actual strength is being able to admit your vulnerability. Many people have written and spoken beautifully about this. Yet, that's just not part of the culture in medicine.

I saw a lot of this when the pandemic started - of people being expected to and then lauded for being insanely sleep‑deprived, and soldiering on. Lots of war metaphors. And yes, in the moment, we need to be able to tolerate some physical and emotional discomfort, absolutely, but forever, never processing those emotions, never getting the sleep that we need, that's just not sustainable.

Our culture has told us that's the standard we're supposed to be meeting. Those are the cultural barriers to saying, "You know what, I need to take a break. This really is getting to be overwhelming for me."

With physicians, in particular ‑‑ and I'm just most familiar with this ‑‑ there'd been structural barriers to asking for time off, to saying, "I need some help here." A very concrete example is that in the US, some of the state licensure boards, in the past, they almost all asked this question, some still do. Although that's not recommended by the Federation of State Medical boards, they ask, "Have you ever sought help for mental illness?" Now, that's none of their business. [laughs] Does it stigmatize? Number one, does it stigmatize mental illness? Number two, more important, it absolutely has prevented people from saying, "I need help." That's just an example of a structural barrier.

Another one is if you want time off, you then end up, because the way our teams and our healthcare is structured, harming your colleagues, because there's no flexibility. Someone else is going to have to in a sense suffer because you're taking time off. We structured things in a way that says to people, "We don't have room for you to have an emotional impact, have a physical impact of any of this incredibly challenging work you're doing."

In the short term, that's great, because then you have everybody working full steam, but in the long term, it's completely unsustainable and terribly costly both on an organizational level for your workforce, and then on a personal level for ourselves, and our colleagues.

Dr. Gérin‑Lajoie:  What would you say are the key success factors in the peer support program you help to develop, Jo?

Dr. Shapiro:  There are two factors that are the most prominent and important in my mind. One is that we don't wait for people to show signs of distress, because we know, we have data.

First of all, we have data for acute stressors like errors, and there's developing data for more chronic stressors like COVID where we know there are going to be a significant amount of people who are affected emotionally by the kind of work they've been doing.

There are programs that are there for people who are exhibiting already signs of distress. My thought about peer support is let's not wait. Let's offer this support when we know there are stressful circumstances, whether there are acute events or more chronic events, or chronic circumstances, chronic stressors.

That's one hallmark of a successful peer support program. The other one, which is challenging for us to conceive of, because of our culture, is let's not wait for people to reach into a program. We know that there can be wonderful programs whether they're built on the mental health model or any kind of support model that are very poorly accessed by certain groups, again, especially physicians, because of all those barriers that we spoke about earlier. What we found is that if you have a support program and it is reach‑in only that is someone has to self‑identify as, "I'm hurting and I need help. Let me get help from this person or this program." Then you will serve some people, and you should always have a reaching component, but you will miss a lot of people who need, want, and deserve the help.

A hallmark of a good peer support program is one that has a reach‑out component where there's a pro‑active reach‑out, "Hey, we know you were involved in such, and such event, or we know you are working in this COVID unit, and we are proactively...we're reaching out to each of our colleagues to offer support because some of us find it really helpful. Is that something you'd like to do?"

I would say there's another component of peer support that needs to be integrated. That is a formal peer support program should be trained. The reason I say this is that informal peer support, most of us do, and it's wonderful. I always say it's necessary, but it can be insufficient. It's insufficient for a couple of reasons. One is, it's not meant to do a deep dive with a colleague. It's more of, "Hey, I just want you to know I'm thinking of you. How's it going? I heard you've been working really hard, or I heard there was this event."

The other thing is untrained frontline clinicians we use for peer support. We can be wanting to, out of the goodness of our hearts, but in a misguided way, minimize our colleague's pain if we're not trained. I ask you, "How's it going?" When you say, "I feel so bad that this happened, or I've had to do all these things during COVID, and because I don't want you to feel that pain, and I'm untrained, I might say, 'Oh, you know what, you shouldn't feel that way. You're doing your best, great job. Don't worry about it, it's not on you.'" It turns out, we know this, that's not well‑received by people. Having your emotions minimized, this is not a great way to move through them. That's one reason that we need training for peer supporters.

The other is we're dealing with people like me, surgeons. I like to fix things. I do. I'm trained to fix things. When you do peer support, you can't fix your colleague's pain in the same way I can maybe fix your symptoms from a Zenker's diverticulum. It's just very different. We need to train peer supporters to help and give specific tools for how to help, but not in that mode of, "I will take your pain away," because it's just an ineffective framing of the way to support people.

That third component of training and having an actual organizational program, versus, "Let's just ask everybody to support their peers," which is lovely. I wouldn't be against that in any way shape or form, but again, that may not do it for people. There'd be a problem. Many people need more time and focused to process their emotions with someone who's trained to help them do that.

The last thing is a formal peer support program needs to be integrated with what are the further professional resources that the peer could have access to? Our job in doing peer support, and this is part of the training that I offer, is to destigmatize and facilitate connections with further resources. Not everybody will need or want that, but there are going to be people who do need and want it. Our job is to help them get that help to overcome the barriers to seeking more longitudinal help than we offer in peer support.

Peer support is a psychological first aid. It is not long‑term coaching. It isn't mental health or behavioral health, stress reduction, long‑term treatment, those sorts of things. Facilitating that access, I think that's key.

Dr. Gérin‑Lajoie:  Here in Canada, we're in the third and most challenging wave of this pandemic. What supports do you see physicians needing during this time? Do you think peer support is an effective intervention in the pandemic?

Dr. Shapiro:  I think it is effective. Again, peer support, whether the trigger is an acute event or more chronic, which I think we'd have to call COVID right now, the principles are very much the same. We know how grateful physicians are to have time to process emotions. Certainly we know that there is an ongoing emotional fallout from COVID.

The difference is not so much how to provide peer support for COVID versus an acute trigger, but how do you actually get that peer support offer to the peers? That's the challenge with more chronic stressors like COVID.

I've had the wonderful opportunity to provide a lot of peer support to my colleagues, both locally and nationally and some internationally, since the pandemic began, specifically around the emotional stressors of being a health care provider during COVID. What I found is that people really do value, like I said, the opportunity to work through and process what they're feeling. It's quite helpful. Again, I have no proof of that, but I have certainly a lot of feedback from people to whom I and others have provided peer support during COVID to make us think that this is helpful.

That said, the organizations who were offering peer support programs and who reached out to me when the pandemic started, saying, "We were thinking of doing a peer support program, but we haven't set one up. Can you help us set it up now, because now we really need it?" 

There was a lot of that need and so I've been working with programs of how to set it up, which is actually the same as before COVID, except for how do you reach out? There's been a lot of creative solutions to that problem, because there isn't one acute trigger, one of which is doing a rolling offer that you have a peer supporter who is going to check in with certain group, maybe a certain group in a unit or division, and will do it periodically saying, "Can you give me a call when you get a chance? I'm reaching out as a peer supporter.” Then say, "I want you to know that I am checking in with and I'm reaching out to offer peer support to colleagues. Every several weeks I'm checking in on different people and I'd like to offer that opportunity to you if that's something you'd like to do." There are absolutely ways of doing this.

The other thing I think is important and I work with a group from the Center for Medical Simulation, who developed this framework of what's called Circle Up. It's this idea of integrating process improvement and check‑ins in the briefing period before shift, and then support during the shift, and then a debriefing afterwards.

In that process the team leader can say, "I just want to acknowledge that I personally found this very stressful," or "I want to open this up for anybody to acknowledge what they're going through," and then refer them to or make sure they have more of a deep dive, which formal peer support would be.

I think to the extent whether we're using Circle Up or other ways of doing debriefings and briefings is to how people acknowledge the emotional component.

After COVID, you are going to do a debrief where you're going to look at what went well, what could be done differently, but also to say, "Let's take a deep breath here. We just went through something that was tough."

I think we can do a lot to destigmatize this and you can't do formal peer support every day for every person. That's unrealistic and not necessary.

You can start to change the culture where people start to say, "Oh, actually yeah, even that senior person felt something after this event or after this shift in the ICU with these COVID patients that we've all been caring for."

To see somebody say, "Wow, I found that really hard, especially when we couldn't have the family be with the patient who was dying." Those kinds of acknowledgments will change the culture.

Dr. Gérin‑Lajoie:  As a follow‑up to that, have you noticed if the issues or feelings that arise in the context of the pandemic, are different than the issues or feelings that were coming out when the peer support was more focused on medical errors, any observations there?

Dr. Shapiro:  Yes, there are some similarities, but also some differences. I don't think, for example, that with COVID, the shame part hasn’t come to pass, which is great, shame is a tough one. There's been a lot more grief. There have been a lot more losses, that people have experienced, patients they couldn't save keeping family members separate from their loved ones. Loss of how we used to do things. Loss of the kind of contact that we've had with our team. We can't take our masks off. We can't hang out and eat together, the same way we did. Losses produce grief often, and that's been very salient for many people.

Guilt, it's a different kind of guilt, or I guess it's triggered by different factors with COVID versus errors, but the guilt of these unreasonable expectations, like I'm supposed to work extra shifts without be saying, "I'm tired, I can't, or I'm not supposed to have family issues."

This has been a huge, huge component of stress for physicians, and I'm going to say, especially women physicians, is now, managing their home life with their children at home, out of school, that's hugely stressful. It isn't only for women physicians, but women physicians definitely, have felt it more so because, of course, the unreasonable expectations we place upon ourselves and are placed upon each other, that we're supposed to be managing both of these worlds beautifully.

Feeling guilty, first of all, for what you're not doing for your family, and then feeling guilty for what you're not doing for patients. People are fearful and anxious. That's been a lot that I've heard when I've done peer support. I'm just so anxious about so many things, obviously, we know them all, but some of them are very much about your own...Am I going to get sick now? I think with the vaccine, there's obviously less of that, but there was so much anxiety about getting ill and then getting our family members ill.

While there's financial anxiety for people whose practices have been very much changed by this pandemic. There is certainly anxiety about, for example, trainees who haven't had the same training opportunities, because of COVID.

There's anxiety about people being deployed to do work in other domains that they don't feel comfortable doing. I'm going to say anger, and maybe this is more in the US.

We've had a reckoning with how unfair our healthcare system has been towards vulnerable populations, with healthcare disparities. They were there way before the pandemic, but of course, they've been shown to be even much worse during the pandemic.

A lot of us feel angry about how society, how our leaders, government, has responded to this, both in the past and currently. That's a healthy emotion, honestly, and I hope the anger leads to change and recognition of our colleagues, who come from communities of color, and also our patients. Anger is there.

I'll say the last one that ‑‑ There are others, of course, but these are the ones I've heard most about ‑‑ is gratitude. We all have things to be grateful for. I'm grateful for having survived COVID with no long‑term complications, and just survived it, period.

I got pretty sick, although I was just short of having to be hospitalized, but I still wake up every morning grateful that I didn't die. I gave it to my husband, unfortunately, and then he got a more mild case, and neither of us has any significant long‑term effects from it.

I'm not the only person who's grateful. We're all grateful for many different things, including the beautiful work our colleagues have done through all of this and how much caring, and outpouring of caring has come during the pandemic. Those are some of the emotions that I've seen, and heard, and felt myself as well.

Dr. Gérin‑Lajoie:  Thank you for sharing that personal experience with us, Jo. As the case numbers rise in Canada, physicians are worried about having to ration medication, having to triage patients. Making these life and death decisions can cause moral distress. Do you think we can use the principles of peer support to help doctors cope with moral distress?

Dr. Shapiro:  Absolutely. We can, and we should. I think of moral distress, that's such an important concept. There are so many compromises in healthcare that we've been asked to make. It has eroded our sense of purpose and well‑being. I think of it as a cause of burnout, as something that drains our sense of well‑being. Just like acute events, like errors, or patient aggression, or lawsuits, I would say moral distress is more often a chronic, huge stressor.

The principles should be the same around support which is, first of all, naming that this is happening, that someone is experiencing this or giving others an opportunity to recognize that they're experiencing this.

Just talking about it, even on this podcast is really important. Talking about peer support, talking about any support is important because we're going to start to normalize it.

The reason we feel these emotions and with regard to moral distress, certainly true, is because we care. If you didn't care, you wouldn't have moral distress. We have a moral compass. When we feel that it's being disturbed, then it's going to be stressful. I always want to note that the distress is good. We should be distressed. It's even good after adverse events and taking care of COVID patients. With moral distress, it means we're paying attention to and caring about what we're seeing.

What I don't want to happen is I don't want people to have that stress be chronic and not addressed and not processed. People need to move through these emotions. You can't go around them.

Moral distress is a great example of something that people didn't even recognize was a thing. Just understanding that it is a thing and then giving people the opportunity to process when they're feeling it. This is such an important thing.

Processing it is one thing, but where is the organizational responsibility for addressing the global concerns around things like moral distress, around COVID, around errors? The organization also has a responsibility to address and, to the extent possible, mitigate these from happening or recognize that sometimes moral distress, for example, will happen, but what can we do as an organization to lessen those chances that it will happen?

I think of peer support, it is one well‑being initiative. It isn't the only one, obviously. I think of it sitting in the intersection of three Venn diagram circles. One is individual personal resilience. That's important to help people process and move through things.

The second and very important circle is relational work and collegiality. Medicine is much more isolating, the way we practice it, even before the pandemic but certainly since the pandemic. Peer support is very relational. 

The third is organizational responsibility.

Peer support isn't just about you should meditate. [laughs] It's about having people process what they're going through. For example, if I were doing peer support for moral injury, the conversation would be, "What's causing that? What are the circumstances that are having you feel this way?" because there are so many that can happen in healthcare.

Let's think about what's the organizational responsibility for addressing this, and then bring that to the organization. Now, it's not always possible to fix things as an organization. I understand that. I've had leadership positions too, but boy, there are many things we could do better. We need to hold our leaders accountable for doing those things.

Dr. Gérin‑Lajoie:  As a final question, Jo, many doctors say that they're in crisis mode right now. They're basically focusing on getting through the day.

Based on what you've seen in the United States, what do you think we need to have in place now to support physician wellness focused at a later time when maybe the crisis has diminished but when the psychological impacts may still be lingering?

Dr. Shapiro:  I'd like to challenge one premise. That is the idea that we just have to tolerate this until we have time to deal with it. We are good in medicine at putting off dealing with things. Maybe if we reframe that and said, "You know, actually, if you spent an hour once every two weeks with a group of colleagues, hearing each other on Zoom or something, just processing what you're going through. Maybe the leaders could meet together. Maybe the people or the team could meet just 20 minutes." We have time for that. The reason I think we have time for that is because at the end of the day, it saves time. If you keep putting it off, then the distress gets so built up, that the time you're going to need to take to mitigate that stress is going to be way more than if you'd done smaller things more frequently.

I think we could, but it is also true that...Just using an analogy, you're not going to process your emotions nor should you during the code, right? The questions is sort of when.

What I would say about what can we do, thinking more long‑term about things, people are writing a lot about the fact that suffering is happening, and that it may affect certain people adversely going forward. Make sure people understand that that's normal, that we expect that there will be some fallout. We want to make it very easy for people to get help.

I still think if we structure support as just a reach‑in for those who've self‑identified as being incredibly stressed and miserable, we're not going to do as good a job. I would still say that we should look to having support offered now but also going forward. Let's keep structuring that, so when the pandemic's, over that whole idea of, "You weren't going to be offered support periodically," that's what we do. We're not singling you out. We're doing it because that's what we do. We've integrated it into our day‑to‑day processes. Then we're going to have these beautifully built programs where behavioral health people get a chance to, in addition to us, help people through mental illness but also help people through chronic stress.

All of those things could be done in parallel and should be done now and then absolutely continued as we move forward.

Dr. Gérin‑Lajoie:  Thank you, Dr. Jo Shapiro, for joining us today in the Sound Mind podcast on peer support. It was truly a pleasure. Thank you so much, Jo, for speaking with us today.

Dr. Shapiro:  It's been my pleasure. I want to thank you for inviting me to talk with you and also for your leadership.

Dr. Gérin‑Lajoie:  Dr. Joe Shapiro is an Associate Professor of Otolaryngology‑Head and Neck Surgery at Harvard Medical School. In 2008 she founded the Brigham and Women's Hospital Center for Professionalism and Peer Support, where she served as the director for over 10 years.

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