Peer Support Overview and Key Points Summary for Medical Students

Apply Skills from this Module:

Scenario: Jasmine R

Introduction

A need for support is clear among medical students:

• Depression: The rate of depression for physicians-in-training is fairly high and increasing each year. (Mata et al., 2015; Rotenstein et al., 2016). Compared to a depression rate of 13.1% in this age group in the general population (NIMH, 2019), research has found
  • 27.2% of medical students screened positively for depression or symptoms (Rotenstein et al., 2016). Rates for pre-clinical and clinical students were similar.
  • 20.9% to 43.2% of medical residents had depression (Mata et al., 2015).
• Suicide: Past year suicidal ideation rates were 10.2% for medical students (Mata et al., 2015).
• Anxiety: Anxiety is similarly high among medical students: A global prevalence rate for medical student anxiety is 33.8% in pooled data, which is also higher than the general population (Tian-Ci Quek et al., 2019).

Depression and Burnout in Medical Students

Symptoms of burnout are common among medical trainees. Burnout and depressive symptoms overlap (Wurm et al., 2016). Medical students and residents are more likely to have symptoms of burnout than the general population (Dyrbye et al., 2014). Burnout rates for medical students range from 44.2% (Frajerman et al., 2019) to as high as 50% (Liam Davenport, 2018) but vary widely (Erschens et al., 2018).

Stressors associated with the symptoms of burnout in medical students include:

• A high volume of material to learn
• A culture of competitiveness
• Less flexibility by school administration than many students experienced in undergraduate studies
• The importance of doing well in order to get into the specialty or residency that they want
• Pressures from the expectations of parents and community back home to do well

Stressors of clinical training include:

• Having to learn and perform administrative functions
• Challenges of working with patients as a medical student
• Learning to take critiques from a variety of sometimes challenging personalities
• Having to study after spending a full day in the clinic

Students often adapt to the heavy workload by sacrificing time spent on self-care and keeping a healthy work-life balance. Stressors add up to many medical students feeling exhausted emotionally, physically, mentally, and spiritually.

Peer Support: Part of the Solution

Discussing stresses with peers having similar experiences can help mitigate the associated effects (Shapiro & Galowitz, 2016). Communication skills that are important in patient-centered care, such as being able to listen well and show compassion and empathy (Patel et al., 2019), are also important in offering support to a peer (Shapiro & Galowitz, 2016). The skills that are most effective include listening, empathy, and compassion which can be learned (Patel et al., 2019).

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Peer Support Overview

What is peer support?

For individuals affected by a major stress, peer support offers a chance to talk freely and share worries and pressure with someone who has had a similar experience (NCI, 2006). Peer support is often used to deal with mental health or substance use problems (SAMHSA, 2020), but is also used in medical settings for physicians experiencing work-related distress (Shapiro & Galowitz, 2016).

The goal of peer support for mental health and recovery from substance use is to “promote self-efficacy and hope through sharing experiential knowledge and through modeling recovery and coping strategies” (Bagnall et al., 2015). For example, veterans help other veterans accept mental health or substance use treatment by modeling the benefits of engaging in treatment themselves (Chinman et al., 2020). They provide encouragement, instill hope, and teach skills.

A key element in peer support is that the person offering support often has been through similar problems themselves or is familiar with the context of the stressful event, such as the work environment, in which it happened. The peer’s similarity to the individual being supported provides a relatable model that facilitates change that may be needed (Bandura, 1977).

Dr. Cochran of the AMSA recently called upon medical students to support each other, especially when some mentors may be busy responding to other responsibilities (Cochran, 2020). Peers having the same status may opt to provide mutual support, in which case, it is important to take turns focusing on the concerns of each peer.

What is the evidence for the effectiveness of peer support?

• Several one-on-one peer support programs for physicians have been utilized successfully within medical centers. For example, the Center for Professionalism and Peer Support at Brigham and Women’s Hospital has operated successfully since 2009 (Shapiro & Galowitz, 2016), and served as a model for over 25 programs.
• Individuals providing support to peers may even experience a reciprocal beneficial effect (Bagnall et al., 2015; Chinman et al., 2020). Those who provide support are often better able to better: 
  • Empathize and show compassion
  • Access social services
  • Respond to clients’ strengths and desires
  • Be tolerant, flexible, patient, and persistent
• Peer support resulted in a decrease in suicide in a prison setting (Bagnall et al., 2015).

Near Peer Support

Support by someone who is a little ahead of you in training, who understands what you are going through but also can share with you the benefits of their experience is sometimes called “near peer” mentoring. This model of peer support has evidence in an educational setting that it can be effective for providing social support, learning, and motivation to persevere (Anderson et al., 2015; Destin et al., 2017).

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What’s Involved in Providing Peer Support?

The steps involved are ones that come naturally for most people trying to help someone. However, following a loosely structured protocol and knowing a few extra skills can help it go more smoothly and assure that the peer you are trying to help gets the help they need. The main steps are:

1. Make a connection with your peer.
2. Ask what is concerning them and then listen attentively.
3. Assess the situation and how it is affecting your peer. Offer empathy and compassion.
4. Provide an intervention, that is, something that helps address their concern, drawing from your experience if you have had a similar one.

Let’s look at each step one at a time:

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1. Make a Connection

Initial Connection

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2. Ask What Is Concerning Your Peer

Ask your peer what is concerning them. The answer to this question is often at the heart of most of your conversation. Using listening skills and just being present as a compassionate witness to hear their story can help ease their distress.

• Encourage your peer to tell their story, however, go easy on the number of questions you ask. Asking too many questions takes over the direction of how they tell their story.
• Be fully present as you listen to their story.
• Offer empathy and compassion.

Use Open-ended Questions to Elicit Information

Use open-ended questions, which are questions that cannot be answered “yes” or “no,” to draw out your peer. The advantage of using open-ended questions is that they (National Cancer Institute, 2006) :

• Allow for a broader and deeper discussion.
• Keep the momentum of the conversation going.
• Avoid steering the conversation in the direction of your biases and assumptions.
• Are non-judgmental.
• Let the other person think as they talk.
• Allow the other person to do most of the talking and say things in their own way.
• Keep the focus on the other person.
• Provide information on what motivates, concerns, influences, and impacts the other person, as well as what barriers they have to actions they may need to take.

Use Listening Skills

Listening skills that are often effective when trying to support someone include active listening and reflective listening.

1. Active Listening

• Give your peer your full attention.
• Use body language that shows you are open to listening to them (Patel, 2019; WA, 2009)
  • Face them, make eye contact
  • Have an open posture (e.g., without arms crossed) at the same level.
• Use short verbal and non-verbal responses to show you are listening and responding.
• Listen for the meaning and emotions behind the words your peer says.
  • Look for non-verbal cues of distress, such as tone, pitch, and pacing. Check with your peer for the accuracy of any conclusions you draw, however.
• Provide verbal statements of acknowledgment:

2. Reflective Listening

• Reflective listening is when you convey your understanding of what the other person said by briefly paraphrasing it in your own words. It is important to:
  • Emphasize their thoughts and feelings.
  • Focus on what seems most important to them.
  • Check with the other person for the accuracy of your understanding.
• The following opening words might help you get started. Be careful not to use them too often in the same way, or you’ll trigger a feeling of being in therapy, rather than of support:

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Express Empathy and Compassion

Expressing empathy and compassion with a peer involves the same skills that are important in patient-centered care. Most people already have some idea of what is meant by these terms. Becoming skilled at them involves refining your ability to express them in effective ways and avoid causing any well-intentioned harm.

Empathy

Empathy has been defined in medical literature as “the ability to sense, feel, and understand another’s emotions” (Patel, 2019)

Becoming skilled with empathy includes refining your ability to express it in effective ways, which is supported by using the skills described in this section.

View Examples of Empathy Statements

For some people, verbalizing empathy is a challenge, even when it is felt, so it can be helpful to be prepared with a few commonly used responses. The following 25 statements express empathy and might be appropriate, depending upon the situation (use left and right arrows to view):

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3. Assess the Impact on Your Peer

Assessment helps you understand how to focus the support you give. Assess your peer’s needs informally, not clinically, to understand the impact of their concerns on them. Identify what distress they are experiencing, so that you can help them talk about it and feel supported.

Although peers are typically screened by the peer support program to make sure that they do not need professional help, the individual may not have been forthcoming in the screening. Or they may realize they have more serious concerns during your interaction. So, repeating questions about their safety and ability to function is a good idea.

Ask Basic Questions

Ask several basic questions about your peer’s needs and functioning:

• Check on their safety.
• Do they have medical or health problems? Check on their sleep and appetite.
• Are their basic needs being met, both physical (e.g., childcare, food, housing, sleep) and non-physical (e.g., social support, mental health, spiritual)?
• Are they able to function well enough to complete activities of daily living and meet their responsibilities?

Examples:

Assess for Distress vs. Dysfunction:

A critical question at the heart of providing support is to determine the extent of your peer’s distress. Distinguish mild distress that is likely to resolve from dysfunction and more severe behavioral and psychological reactions that mean your peer needs further help.

• The majority of individuals involved in a disaster, including ongoing ones such as a pandemic, do well enough to handle their responsibilities and move on (Everly, 2020). They might benefit from talking with a peer never-the-less, to help mitigate some of the effects of daily exposure to stress. Social support is an important part of resilience.
• Depending upon the stressor and how long it continues, as many as half of the individuals affected may experience distress (Everly, 2020). Most individuals in this group will be able to manage, especially with informal support. However, some individuals will decompensate, that is, lose their ability to take care of themselves and meet their responsibilities. They will need further assistance.
• A smaller group will have severe impairment interfering with taking care of themselves and handling responsibilities (Everly, 2020). They will need further assistance.

Some individuals who seem okay when you first talk to them can worsen over time. For this reason and the beneficial effects of social support, contacting your peer for a follow-up check-in can be helpful.

Assess the severity

Assess the severity of your peer’s distress or dysfunction. Is the distress likely to go away on its own, and can the individual discharge their daily responsibilities? Or do they have dysfunction and need more help?

Remember, your role is social support and not clinical, so if there is any doubt about your peer’s stability, mental health, or functioning, recommend that they seek help from the school or professional help.

Assess the cognitive, emotional, and behavioral effects in terms of Distress vs. Dysfunction

Assess the effect of the stressful event on your peer’s cognitive, emotional, and behavioral functioning, looking for signs of distress vs. dysfunction. With dysfunction, a recommendation to seek evaluation and further assistance through appropriate channels in your school is indicated. The following descriptions are intended to help discern whether additional help is needed.

View more details:

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How to Assess

1. Allow the person to tell their story.
2. Ask what happened to get the context and learn how they are responding, but don’t push to delve deeply
3. Listen carefully for their reactions
4. Ask specific questions about their reactions to the event
5. Ask to clarify any ambiguous aspects

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Unhealthy Coping

“Some people use unhealthy coping skills, such as eating poorly, not sleeping, substance use, or things like that. These are the responses to stress, emotional pain, or fatigue that cause un-healthy consequences or get in the way of healthier ways of coping.  To cope with emotional pain, stress, or exhaustion, some people:

• increase their alcohol intake
• use drugs
• over eat or eat poorly
• smoke cigarettes
• sleep too much
• shop excessively
• gamble
• are rude or impatient with others, especially those less powerful
• withdraw from loved ones
• use social media to excess.

Let’s look at one common harmful way of coping:

Alcohol Use

Guidelines: The USDA Dietary Guidelines for Americans (2020-2025) has the following advice regarding alcohol for those who are of legal age to drink:

• Choosing not to drink is a possibility; drinking less is healthier.
• When consuming alcohol, drink moderately or less:
  • No more than 1 drink in a day for women.
  • No more than 2 drinks in a day for men.

Reference: US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2020-2025.

People often have more in a single serving than what is meant by a “drink” in these guidelines. Help a peer who is drinking understand that a “drink” is measured as shown in the following image: 

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4. Provide Interventions

Once you understand what your peer is going through, you can take some action to try to help. If your assessment of their well-being and the impact on them of whatever is concerning them has found that they are able to function and they seem stable, next focus on what you can do to mitigate their distress.

Responding Compassionately

Compassion has been defined as “an emotional response to another’s pain or suffering involving an authentic desire to help” (Patel et al., 2019) There is some overlap with empathy in that it involves recognizing the other person’s suffering and resonating with it (Cameron et al., 2015). Compassion goes further and also involves taking some action to address the suffering.

It’s important to avoid causing any well-intentioned harm. If you keep your attention on your peer’s concerns, avoid comparisons, and avoid solving problems for them, keeping their autonomy in mind, you are more likely to avoid hurting them when you are trying to help.

Basic Interventions

Some of the interventions you can use to respond to a peer’s distress include the following:

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More on the Peer Support Skills of Anticipatory Guidance and Mentoring:

Anticipatory guidance is often given in Pediatrics to parents a step ahead of their child’s developmental stage in which they will need it. In medical training, anticipatory guidance can ease the way for the medical student peers you wish to help. Just think back on what you wish you had known ahead of time when you were at their stage of medical training. Be sure to offer it as your opinion, based on your experience.

Mentoring support: Provide relevant, inside, up-to-date advice based on your experience that students cannot get other places. Share ideas for studying for exams, maintaining work-life balance, and making the transition to the next phase of training.

Share good resources for emotional support, helpful administrators, which groups to join, what labs are looking for researchers, what doctors provide the best shadowing experience, what carries the most weight in a residency application, etc.

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Additional Interventions

If everything is going well, you may want to try some of these more complex interventions.

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Sharing your own experience in a supportive way

Sharing your own stresses and ways of coping needs to be done in a way that it does not detract from your peer’s concerns being the focus of the conversation. It is most effective when an individual has dealt with the same problem as the peer in the past successfully (SAMHSA, 2020). Sharing experience in the spirit of inspiring someone can be effective. It can help people feel normal just to hear that someone else is going through the same thing at the same time. Be careful that it does not result in the peer feeling like something is wrong with them that they are not doing as well as you.

Sharing ideas for coping skills can be beneficial, but be sure to elicit your peer’s ideas first. Then ask if they would like ideas or suggestions. If you have used a coping skill that worked for you, you can check if it’s okay with your peer to share your story.

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Make sure your peer has resources

Make sure your peer is aware of resources that may help them. These may include information on relaxation, resilience, mindfulness, and counseling. Even if a resource is not needed currently, make sure that your peer has a source of resources should they find they need help later. Your school will likely have a list of such resources. Some students may not want to avail themselves of school-related resources in order to maintain privacy. Be sure to be prepared with a list of alternatives resources. (See list at the end of this module and more in the Resources tab for this website.)

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Follow-up

Follow-up contact with your peer provides additional social support, which is important in a crisis (Everly & Lating, 2018). Follow-up can help make sure that your original impression was accurate, your peer has not changed for the worse, and that your peer’s needs look like they are going to be met. Depending upon the circumstances, both yours and theirs, you may decide to continue with regular contacts in a mentoring type relationship. Peers who are offering each other support may opt to continue meeting regularly.

Some experts in peer counseling advise that if the peer support relationship continues, it might be misconstrued as a clinical one (Everly & Lating, 2018), so be careful that there is no misunderstanding. Also consider whether a clinical evaluation is needed. If boundaries are kept clear and you are available, the ongoing social support of providing periodic check-in may be important for a while, even if they do get professional support.

At follow-up, even more than at the initial contact, encourage your peer to come up with their solutions to problems, if possible. Make sure they are aware of resources, should they find they need help later.

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Volunteering Opportunities for Medical Students

Helping others is often a powerful antidote for individuals in distress. In the case of the COVID pandemic, for example, many medical students expressed frustrations about not being ready or allowed to help (Cochran, 2020). AMSA president, Isiah A. Cochran and representative Pamela Wible MD recommended channeling the desire to help into volunteering to help those in the frontline. These efforts included helping to get personal protective equipment (PPE) to frontline healthcare workers, helping healthcare workers who had their home lives disrupted by their work in the pandemic with family or house management.

Summary

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